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   Table of Contents - Current issue
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July-September 2020
Volume 14 | Issue 3
Page Nos. 357-544

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EDITORIAL  

Fundamental guidelines and proper application of protective gear and equipment for health worker safety during caring for COVID-19 patients p. 357
Farah Maani Takrouri, Ragad Mani Takrouri, Mohamad Said Maani Takrouri
DOI:10.4103/aer.AER_17_21  
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REVIEW ARTICLES Top

Cardiovascular complications related to COVID-19 disease p. 359
Raed A Alsatli
DOI:10.4103/aer.AER_105_20  
Coronavirus disease-2019 (COVID-19) is a world epidemic disease and is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In addition to the respiratory manifestations, it may also cause cardiovascular complications, such as, myocarditis, arrhythmias, myocardial infarction, heart failure, and venous thromboembolic events. This review article will discuss in detail pathophysiology, manifestations, and management of these cardiac complications. A literature review was performed, it included meta-analyses studies, cohort studies, publications, and case series from the largest COVID-19 outbreak centers around the world. Cardiac complications of COVID-19 disease can lead to significant cardiovascular morbidity and mortality. It is important to recognize and treat these complications as early as possible.
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Preparing intensive care unit in resource-constraint setting amid COVID-19 pandemic: Our experience and review Highly accessed article p. 366
Kamal Kajal, B Naveen Naik, Ajay Singh, Shiv Lal Soni, Amarjyoti Hazarika, Kulbhushan Saini, Sanjay Jaswal, Shyam Charan Meena, Naveen Pandey, GD Puri
DOI:10.4103/aer.AER_86_20  
COVID-19 pandemic is an emerging, rapidly evolving public health emergency where a nation's health-care system can face a marked surge in demand for intensive care unit (ICU) beds and organ support. In regions with insufficient medical resources, it may further aggravate the existing shortage, limiting an ICU's ability to provide the normal standard of care. It can present ethically or legally demanding questions about how to prioritize the allocation of life-saving medical resources. In developing countries like India, still many hospitals are challenged by competing priorities and remain underprepared. In the wake of COVID-19 pandemic, to guide the intensive care disaster planners in regions with low resources and to ensure ICU readiness, this review shares our experience and strategies for preparing ICU with existing and alternative resources, focusing on space, equipment, and health-care workers' safety and training.
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ORIGINAL ARTICLES Top

A cross-sectional study on knowledge, attitude, and practices of donning and doffing of personal protective equipment: An institutional survey of health-care staff during the COVID-19 pandemic Highly accessed article p. 370
Kamakshi Garg, Anju Grewal, Rajesh Mahajan, Samriti Kumari, Aashita Mahajan
DOI:10.4103/aer.AER_53_20  
Background: Personal protective equipment (PPE) is used to protect the health-care professional from bacterial, viral, or other hazards during this COVID-19 pandemic, and they should be made aware of proper usage of this equipment. Aims: The aim was to evaluate how adequate knowledge, attitude, and practices (KAP) of health-care worker toward the appropriate use of PPE, which can prevent them and the community from virus contamination. Methodology: This study was conducted in a tertiary care hospital during the COVID-19 pandemic in a span of approximately 50 days. This cross-sectional questionnaire-based survey was done in 155 health-care providers posted in the COVID-19 area. Statistical Analysis: Data were described in terms of range; mean ± standard deviation, frequencies (number of cases) and relative frequencies (percentages) as appropriate. Results: Health-care workers (HCWs) were aware of the importance and criticality of donning and doffing procedure, but they lack the knowledge about dispersion of virus as 62% responded that virus dispersion occurs more during donning than doffing. Gaps were found in attitude as 51% of HCWs found it inconvenient to don PPE that they sometimes think of compromising their own safety. Nearly 33.5% of HCWs move out of the doffing area without removing gloves and N-95, which needs serious correction in their practice. Conclusion: There were major gaps in KAP at institutional level among the health-care providers with regard to donning and doffing of PPE during the beginning of this pandemic.
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Ultrasound-guided intercostal nerve block and subcostal transversus abdominis plane block for postoperative analgesia in patients posted for open cholecystectomy: A randomized controlled trial Highly accessed article p. 376
Srivastava Swati, Naaz Shagufta, Ozair Erum, Asghar Adil, Yadav Urvashi
DOI:10.4103/aer.AER_100_20  
Background: Effective postoperative analgesia leads to early mobilization, fewer pulmonary complications, and shorter hospital stay. Aims: We compared the analgesic effects of ultrasound-guided intercostal nerve (ICN) blocks, subcostal transversus abdominis plane (SCTAP) block, and a control group in open cholecystectomy. Settings and Design: This was a prospective, randomized controlled, double-blind, multi-arm and parallel study. Materials and Methods: The study was conducted on patients of American Society of Anaesthesiology Physical Status Classes I and II, either sex, 18–60 years of age, and body mass index 18–30 kg.m−2. Exclusion criteria were infection at the injection site, coagulopathy, thrombocytopenia, and allergy to the drugs used. Group I (n = 41) received ICN blocks, Group T (n = 41) SCTAP block, and Group C (n = 41) no postoperative block. The duration of analgesia was the primary outcome, and the analgesic consumption, the pain intensity, adverse events, and patient satisfaction were the secondary outcomes. Statistical Analysis: For the continuous data, analysis of variance was used for multiple group comparison and intergroup data were analyzed by Student's t-test. Kruskal-Wallis and Mann-Whitney U tests were applied for ordinal data. P = 0.05 or less was considered statistically significant. Results: The duration of postoperative analgesia was significantly longer in the ICN (mean = 441.6 min; 95% confidence interval [CI], 407.71, 475.49) and SCTAP block (mean = 417.6 min; 95% CI, 390.94, 444.26) as compared to control (mean = 33.98 min; 95% CI, 26.64, 41.32) (P = 0.00) with no significant intergroup difference between the two intervention groups (P = 0.278). The cumulative analgesic consumption was not significantly different between the intervention groups but was significantly reduced in the study groups when compared with the control group (P < 0.001). No notable adverse events were observed. Patients with both the techniques were very satisfied in comparison with the control group (P = 0.00). Conclusion: Both the ICN and SCTAP blocks have similar results in terms of analgesia and patient satisfaction for cholecystectomy.
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Comparison of intranasal dexmedetomidine and midazolam as premedication in pediatric surgical patients: A prospective, randomized double-blind study p. 384
Gayendra Diwan, Alok Kumar Bharti, Kapil Rastogi, Pramod Kumar Gupta
DOI:10.4103/aer.AER_102_20  
Introduction: To relieve anxiety and fear is a major concern for pediatric anesthesiologist, and intranasal dexmedetomidine seems to be better alternative to midazolam to provide sedation and allay anxiety in children. Aims and Objectives: We compare the sedative effects, anxiety level, successful child–parental separation, and hemodynamic parameters of either intranasal dexmedetomidine or midazolam as a premedication in children undergoing pediatric surgery. Setting and Design: This is a prospective, randomized, double-blind study conducted on 60 patients belonging to the American Society of Anesthesiologists Physical Status Classes I and II, undergoing pediatric surgical procedures with the use of intranasal dexmedetomidine and midazolam as premedication. Materials and Methods: Sixty children were randomly allocated into two groups of 30 each: dexmedetomidine group received intranasal dexmedetomidine (1 μg.kg−1), and midazolam group received intranasal midazolam (0.2 mg.kg−1), 30 min before induction. The sedation score, anxiety score, and successful child–parent separation were recorded till 30 min of drug administration, and then, the child was taken to the operating room (OR). Statistical Analysis: The Statistical Software, namely Statistical Package for the Social Science 17.0, was used for the analysis of the data. A P < 0.05 was considered statistically significant. Results: Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation score (P < 0.001), lower anxiety levels (P = 0.001), and easier child–parent separation (P = 0.003) than children who received intranasal midazolam. Conclusion: Intranasal dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child–parent separation at the time of transferring patients to the OR than children who received intranasal midazolam.
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Parturient controlled epidural analgesia with and without basal infusion of ropivacaine and fentanyl: A randomized trial p. 390
Garima Choudhary, Kriti Chaudhary, Ravi Shankar Sharma, Shobha Ujwal, Jagdish Kumawat, Rashmi Syal
DOI:10.4103/aer.AER_116_20  
Introduction: Parturient controlled epidural analgesia (PCEA) is an established method of providing safe and effective labor analgesia. Objective: The aim of this single-blind, randomized controlled trial was to compare the efficacy of PCEA with or without basal infusion (BI) of ropivacaine and fentanyl for the effective management of labor pain associated with normal vaginal delivery. Materials and Methods: A total of 78 nulliparous parturients with vertex presentation at term and with cervical dilatation of 3–5 cm demanding for epidural analgesia (EA) were enrolled in the study. EA was initiated and maintained with ropivacaine 0.125% and fentanyl 2 μg/mL. Following an initial epidural loading volume of 8–10 mL, parturients were randomly allocated in two groups of 39 each. PCEA group received bolus of 5 mL at 200 mL/h with lockout interval of 15 min and with maximum volume of local anaesthetic was 20 mL/h and PCEA + BI group – receiving added BI rate of 5 mL/h along with same programmed parameters of PCEA pump. Results: No statistically significant difference was observed between the groups in terms of demographic characteristics, duration of labor, delivery methods, maternal satisfaction as well as Apgar score. Mean demand bolus in group PCEA + BI was 0.39 ± 0.59, whereas in group PCEA was 3.31 ± 0.77 (P < 0.05). Mean volume of drug used in group PCEA + BI was 25.57 ± 2.75 mL, while in group PCEA was 22.42 ± 4.56 mL (P = 0.0005). In PCEA + BI group, Visual Analog Scale (VAS) score was 0.07 ± 0.35 at 60 min and 0.06 ± 0.33 at 120 min, whereas in PCEA group, VAS was 0.32 ± 0.62 at 60 min and 0.26 ± 0.50 at 120 min (P = 0.05), respectively. Conclusion: BI when added to PCEA, it significantly reduces breakthrough labor pain and demand boluses without prolonging labor duration but at the cost of increased requirement of drug volume when compared to PCEA only group.
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Comparison of conventional technique versus modified tube first technique of awake nasotracheal fiber-optic intubation: A randomized control open-label trial p. 395
Rashmi Syal, Mohammed Parvez, Nikhil Kothari, Haider Abbas, Rakesh Kumar, Surjit Singh, Garima Choudhary
DOI:10.4103/aer.AER_104_20  
Background: Although the conventional awake fiber-optic nasal intubation is most commonly used in anticipated difficult tracheal intubation, it has several potential difficulties. Aims: The aim of this study is to compare another technique modified tube first (MTF) technique with the conventional one in terms of time taken, ease of glottis visualization, number of attempts needed, and complications. Settings and Design: This was a prospective, randomized, open-label trial conducted on 60 patients with an anticipated difficult airway undergoing oromaxillofacial surgery at a tertiary care center. Materials and Methods: The patients were randomized into the MTF and conventional technique groups. Times from insertion of the fiber-optic scope into nares till vocal cord visualization (T1) and from T1 to complete intubation (T2) were measured and compared. Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21. Results: Time taken to visualize glottis was significantly less in the MTF technique as compared to the conventional method (mean ± standard deviation = 108.6 ± 43.1 vs. 142 ± 49.2 s, respectively, P = 0.007). Similarly, the total time taken for nasotracheal intubation with modified technique is significantly less as compared to the conventional technique (P = 0.004). Furthermore, there is significantly better ease of glottis visualization (P = 0.001), higher success in minimal attempts (P = 0.02) with significantly lesser incidence of desaturation in MTF technique (P = 0.026). Conclusion: The alternative technique (MTF) is a quicker, easier approach with higher success rate and lesser complications for the placement of an endotracheal tube in a difficult airway scenario.
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Effect of two different doses of dexmedetomidine on the hemodynamics of “Hypertensive Patients” undergoing laparoscopic cholecystectomy p. 401
Shefali Gautam, Vijay Prakash, Neelkamal Mishra, Ravi Prakash, Sanjeev Kumar, Shobhna Jafa
DOI:10.4103/aer.AER_14_21  
Context: In laparoscopic cholecystectomy, pneumoperitoneum results in tachycardia, hypertension, and increased myocardial oxygen demand. These changes are more pronounced in hypertensive patients. The intravenous administration of dexmedetomidine attenuates sympathoadrenal response and provides better hemodynamic stability intraoperatively. Aims: To evaluate the hemodynamic stabilizing and sedation properties of two different doses of dexmedetomidine including 0.7 μg.kg−1.h−1 and 0.5 μg.kg−1.h−1 in hypertensive patients undergoing laparoscopic cholecystectomy. Settings and Design: This was a randomized, prospective, double-blind controlled trial. Subjects and Methods: A total of 60 controlled hypertensive patients of either sex, aged 30–60 years, and ASA class 2 without any other serious comorbid conditions who were undergoing laparoscopic cholecystectomy under general anesthesia were randomly assigned into three groups of 20 each. Group A and B received loading dose of dexmedetomidine 1 μg.kg−1 over 10 min and maintenance dose at 0.7 and 0.5 μg.kg−1.h−1, respectively. Group C received normal saline infusion only. Hemodynamic parameters (heart rate and systolic, diastolic, and mean arterial pressure) and sedation score were compared at different time intervals among groups. Statistical Analysis Used: The Chi-square test, ANOVA, and Tukey Post hoc Test. Results: Fluctuations in the hemodynamics of hypertensive patients are effectively attenuated by dexmedetomidine and there is no difference in the attenuation of these hemodynamic changes by maintenance dose of 0.5 or 0.7 μg.kg−1.h−1. However, maintenance dose of 0.5 μg.kg−1.h−1 causes lesser sedation. Conclusions: Dexmedetomidine administered as infusion in a maintenance dose of 0.5 μg.kg−1.h−1 serves as an ideal anesthetic adjuvant in hypertensive patients undergoing laparoscopic cholecystectomy.
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A study to evaluate intrathecal 1% chloroprocaine and 0.5% levobupivacaine in perianal surgeries: A prospective randomized study p. 406
B Bhaskara, S Shruthi, R Ramachandraiah
DOI:10.4103/aer.AER_2_21  
Background: With increasing focus on outpatient care, there has been an increased demand for short-acting spinal anesthetics, facilitating early recovery and mobilization of the patient. Aims: The aim of the study was to compare 1% chloroprocaine, characterized by short latency and short duration with 0.5% levobupivacaine, which has shown to preserve motor function at low concentrations, with recovery from motor block as the primary objective and recovery from sensory block and hemodynamic stability as secondary objectives. Settings and Design: A prospective study to evaluate newer isobaric chloroprocaine and levobupivacaine intrathecally in a cohort of patients using randomization and double blinding. Materials and Methods: Sixty American Society of Anesthesiologist physical status Classes I and II patients undergoing perianal surgeries were randomly divided into Group C (n = 30) receiving intrathecal 1% chloroprocaine 3 mL and Group L (n = 30) receiving 0.5% levobupivacaine 1.5 mL. Patients were assessed for sensory and motor block characteristics, hemodynamic changes, period of analgesia, time for ambulation, and urination. Statistical Analysis: Qualitative data were analyzed using Chi-square test and quantitative data using Independent t-test. Results: There was no significant difference in highest sensory level, onset of motor block, maximum Bromage scale achieved, and hemodynamic changes between the two groups. There was a significant difference in mean Time for Maximum Bromage scale, Time for Sensory regression (Lumbar-L1), Duration of Motor Block (Group C 50.7 ± 5.7 min and Group L 181 ± 27.8 min), Time for rescue Analgesia, Time for 1st void, and Time for ambulation (Group C 88.3 ± 9.1 min and Group L2 06.7 ± 27.2 min) between chloroprocaine and levobupivacaine group. The above duration was shorter in chloroprocaine group than in levobupivacaine group. Conclusion: Thus, chloroprocaine provides good surgical anesthesia and early motor recovery than levobupivacaine and is well suited for day care surgeries.
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Comparison of oral clonidine and gabapentin premedication for attenuation of pressor response to laryngoscopy and endotracheal intubation p. 412
Vaishali Sharma, Kamal Fotedar, Ravi Goel
DOI:10.4103/aer.AER_114_20  
Background: During the administration of general anesthesia, direct laryngoscopy and endotracheal intubation cause an increase in heart rate, arterial pressure, and dysrhythmias in upto 90% of patients. These changes can be particularly hazardous for patients with cerebral or coronary diseases. Both clonidine and gabapentin have been used for anesthetic effects, but a better drug for controlling hemodynamic parameters is being investigated. Aims: The study was done to evaluate and compare the efficacy of oral clonidine 0.3 mg and oral gabapentin 900 mg as a premedication for attenuation of pressor response to laryngoscopy and endotracheal intubation. Materials and Methods: After obtaining approval from the ethics committee, 75 patients, American Society of Anesthesiologists physical status classes I and II between the ages of 18 and 60 years scheduled to undergo elective noncardiac surgical procedure were enrolled in the study. Patients were randomized into three groups of 25 each who received 0.3 mg clonidine, 900 mg gabapentin, and placebo. The hemodynamic parameters were recorded at various time intervals along with any adverse effects. Statistical Analysis: Quantitative variables were compared using unpaired t-test between the two groups and ANOVA for three groups. Qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: In our study, we found that both clonidine and gabapentin are effective premedicants by oral route 2 h before induction of anesthesia to blunt the hemodynamic response to laryngoscopy and intubation as compared to placebo. Between clonidine and gabapentin, clonidine was found to be more effective with respect to blunting of systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), although found to be statistically significant only at 15 min with respect to SBP and DBP. Conclusion: Using clonidine or gabapentin, one can effectively provide stable hemodynamic conditions during laryngoscopy and endotracheal intubation, but more so with clonidine.
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Comparison of propofol–Dexmedetomidine-based intravenous and sevoflurane-based inhalational anesthesia in patients undergoing modified radical mastectomy p. 420
Nitesh Goel, Rupam Jha, Manoj Bhardwaj, Rajiv Chawla
DOI:10.4103/aer.AER_13_21  
Background and Aim: Total intravenous anesthesia (TIVA) has proven advantage over inhalational anesthesia in terms of stable hemodynamic, eco-friendly, and good recovery profile, but apprehension regarding adequate depth of anesthesia and intraoperative recall is still pertaining. This study aims to compare propofol–dexmedetomidine-based TIVA with sevoflurane-based inhalational anesthesia in modified radical mastectomy in terms of depth of anesthesia, intraoperative recall, recovery profile, and hemodynamic status. Settings and Design: This prospective randomized controlled study was conducted at a tertiary care center over a time frame of 1 year. Methodology: In this randomized controlled study, 100 patients were randomly distributed into two groups: TIVA (Group T) and inhalational anesthesia (Group I). Group T patients received injection dexmedetomidine: 1 μg.kg−1 over 10 min followed by 0.7 μg.kg−1.h−1 and injection propofol: 25–100 μg.kg−1.min−1. Ventilation was maintained with oxygen–air gas flow. In Group I, patients were ventilated with nitrous oxide–oxygen (50:50) and sevoflurane. Rest of anesthesia for both the groups was same. Primary objective was to achieve adequate depth of anesthesia as monitored by intraoperative bispectral index value (BIS, 40–60). Hemodynamic variables, recovery profile, and amount of individual anesthetic agent consumed were recorded for comparison between two groups. For comparison of scale variables between two groups, independent sample t-test for significant difference between two sample means has been followed. Results: Intraoperative BIS and hemodynamic variables were comparable (P > 0.05). Emergence time was 5.10 min in the TIVA group versus 8.38 min in the inhalational group (P = 0.00). Modified Aldrete score was comparable in two groups (P > 0.05). Cost of TIVA agents consumed per patient was 40% lesser than inhalational agents. Conclusion: TIVA maintains adequate depth of anesthesia along with stable hemodynamic and good recovery profile, at low cost in an eco-friendly manner.
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A retrospective analysis of outcome in malaria patients admitted into a multidisciplinary intensive care unit of a tertiary care teaching hospital p. 425
Bharath Cherukuri
DOI:10.4103/aer.AER_12_21  
Introduction: Malaria is a significant public health problem with people worldwide at risk for the disease. It is a mosquito-borne disease causing high-grade fever, chills, and flu-like illness. The World Health Organization (WHO) recommends the case with severe malaria should be admitted in the intensive care unit (ICU). Severe malaria is a medical emergency and often managed in ICU with regard to the definition of hyperparasitemia. The WHO amended the criteria for definition of severe malaria in 2006, 2010, and 2015. Methods: All patients had a full workup for fever that included three smears for malarial parasites, serology for dengue, leptospirosis, scrub typhus, enteric fever, blood, urine, sputum or endotracheal cultures, and other tests as clinically indicated. A diagnosis was made when a patient is tested positive for malarial antigen with a rapid diagnostic test and other causes of fever excluded. Patients were treated with intravenous Artesunate along with enteral Doxycycline. Results: Of total patients, the vasopressor requirements being Dopamine (7.40%), nor adrenaline (7.40%) and vasopressin (3.70%). None received packed red blood cell transfusions, whereas 14.81% had platelet transfusions. 66.66% required Noninvasive ventilation, none required invasive mechanical ventilation (IMV) and both noninvasive and IMV. None of the patients had received hemodialysis. The mean duration of ICU and hospital stay was 4.14 and 6.26 days, respectively. No deaths were observed during the study period. Conclusion: In our study, we hereby conclude the incidence of clinical features is in agreement with other studies with no in-hospital mortality.
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Comparative evaluation of efficacy of preventive analgesia with diclofenac and buprenorphine patch versus single diclofenac patch for postoperative pain following general anesthesia for laparoscopic cholecystectomy p. 428
Ananya Nanda, Kalyani Surya Dhanalakshmi Sangineni, Vandana Pakhare, Gopinath Ramchandran
DOI:10.4103/aer.AER_109_20  
Background: Acute postoperative pain is managed with parenteral and oral medications requiring skilled personnel for administration and vigilance. Previous studies have been done either with transdermal buprenorphine or diclofenac patch separately in mitigating postoperative pain. Aims: The primary aim was to compare pain scores and rescue analgesia requirement. The secondary aims were comparison of side effects, time to mobilization and oral intake start, sedation scores, and satisfaction scores of surgeons and patients receiving transdermal patches of buprenorphine and diclofenac versus placebo and diclofenac patches following laparoscopic cholecystectomy. Settings and Design: This is a randomized double-blinded (1:1), case–control study. Materials and Methods: One hundred patients undergoing laparoscopic cholecystectomies were enrolled for the study. Patients were allocated into two groups by computer-generated randomization: those receiving dual patch of buprenorphine and diclofenac (DP) and those receiving patches of diclofenac and placebo (SP). Outcomes were measured after extubation and at 4, 8, 12, 24, 36, and 48 h after surgery. Statistics: Analysis was done using the Statistical Package for the Social Sciences version 22.0, R environment 3.2.2 for data analysis, and Microsoft Excel to generate graphs and tables. Results: The pain scores and rescue analgesia requirements were significantly higher in group SP compared to group DP. Patient satisfaction scores were better with group DP. No significant difference was found in both the groups concerning sedation scores, side effects, and time to patient mobilization and start of oral intake. Conclusions: Concomitant use of transdermal patches of buprenorphine and diclofenac for postoperative pain in laparoscopic cholecystectomy provides adequate analgesia and patient satisfaction without compromising postoperative recovery.
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Comparative evaluation of the role of nonbronchoscopic and bronchoscopic techniques of distal airway sampling for the diagnosis of ventilator-associated pneumonia p. 434
Abhinav Agarwal, Deepak Malviya, Mamta Harjai, SS Tripathi, Anupam Das, Samiksha Parashar
DOI:10.4103/aer.AER_5_21  
Background: The diagnosis of ventilator-associated pneumonia (VAP) remains a challenge, with clinicians mainly relying on clinical, radiological, and bacteriologic strategies to manage patients with VAP. Aims: To compare the results of non-bronchoscopic and bronchoscopic techniques of distal airway sampling for the diagnosis of VAP. Settings and Design: This was a single-center prospective diagnostic accuracy study done in the 14-bedded intensive care unit of a tertiary care referral hospital. Materials and Methods: Patients aged ≥18 years, on mechanical ventilation for ≥48 h, and with clinical suspicion of VAP (fever, leukocytosis, and increased tracheal secretions) either on admission or during their stay were included. Every patient underwent both procedures for sample collection, first non-bronchoscopic protected bronchoalveolar lavage (NP-BAL) and then bronchoscopic BAL (B-BAL). Clinical Pulmonary Infection Score (CPIS) was calculated for each patient and the collected samples were evaluated in laboratory using standard microbiological techniques. Statistical Analysis Used: The sensitivity, specificity, positive predictive value, and negative predictive value of NP-BAL and B-BAL for the diagnosis of VAP were calculated taking CPIS score of >6 as index test for the diagnosis of VAP. Results: Sixty patients were included in the study. Both NP-BAL and B-BAL had concordance with the CPIS at 69.1%. The concordance between NP-BAL and B-BAL was better at 67.6% with a kappa coefficient of 0.064 (P = −0.593). The yield and sensitivity of NP-BAL were comparable to that of B-BAL. Conclusions: The blind NP-BAL is an equally effective method of airway sampling and could be a better alternative to replace more invasive B-BAL for microbiologic diagnosis of VAP.
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Comparison of superior vena cava and inferior vena cava diameter changes by echocardiography in predicting fluid responsiveness in mechanically ventilated patients p. 441
Vishal Upadhyay, Deepak Malviya, Soumya Sankar Nath, Manoj Tripathi, Ashish Jha
DOI:10.4103/aer.AER_1_21  
Context: Resuscitation of critically ill patients requires an accurate assessment of the patient's intravascular volume status. Passive leg raise cause auto transfusion of fluid to the thoracic cavity. Aims: This study aims to assess and compare the efficacy of superior vena cava (SVC) and inferior vena cava (IVC) diameter changes in response to passive leg raise (PLR) in predicting fluid responsiveness in mechanically ventilated hemodynamically unstable critically ill patients. Methods: We enrolled 30 patients. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax − Dmin)/Dmax for collapsibility index of SVC (cSVC) and (Dmax − Dmin)/Dmin for distensibility index of IVC (dIVC), where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and 1 min after PLR. Patients were divided into responders (increase in cardiac index (CI) ≥10%) and nonresponders (NR) (increase in CI <10% or no increase in CI). Results: Among those included, 24 (80%) patients were R and six were NR. There was significant rise in mean arterial pressure, decrease in heart rate, and decrease in mean cSVC from baseline to 1 min after PLR among responders. The best threshold values for discriminating R from NR was 35% for cSVC, with sensitivity and specificity of being 100%, and 25% for dIVC, with 54% sensitivity and 86.7% specificity. The areas under the receiver operating characteristic curves for cSVC and dIVC regarding the assessment of fluid responsiveness were 1.00 and 0.66, respectively. Conclusions: cSVC had better sensitivity and specificity than dIVC in predicting fluid responsiveness.
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Comparison of ultrasound-guided thoracic paravertebral block using ropivacaine and balanced general anesthesia in breast surgeries p. 448
Ujjwal P Singh, Sumit Kumar, Shilpi Mishra, Manoj Tripathi, Virendra Kumar, Deepak Malviya
DOI:10.4103/aer.AER_113_20  
Background and Aims: Despite the latest advances in breast surgery, the procedure is frequently associated with postoperative pain, nausea, and vomiting, which leads not only to increased patient's suffering but also to a prolongation of hospital stays and related costs. Thoracic paravertebral block (TPVB) has been successfully used to provide analgesia for multiple thoracic and abdominal procedures in both children and adults. Methods: Forty patients were allocated for this observational, comparative study and divided into two groups of 20 each, namely thoracic paravertebral group (Group P) study group and general anesthesia (GA) group (Group G), control group, and observations made for duration of procedure, visual analog score, rescue analgesia, surgeon and patient's satisfaction, postoperative complications, and duration of postanesthesia care unit (PACU) stay in both the groups. Results: We found that there was a statistically significant difference in duration of procedure, more time was taken in performing TPVB. Pain was better controlled in Group P and requirement of rescue analgesia was higher in Group G patients, postoperative complications such as shivering, nausea, vomiting, and duration of PACU stay were more in patients receiving GA. Conclusion: Hence, we conclude that ultrasound-guided TPVB appears to be safe, reliable, and effective technique for breast surgeries with several advantages over GA in terms of long-lasting pain relief, fewer complications, and shorter hospital stay.
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Incidence of device associated-healthcare associated infections from a neurosurgical intensive care unit of a tertiary care center: A retrospective analysis p. 454
Gokuldas Menon, Avanthi Subramanian, Poornima Baby, Nimesh Daniel, R Radhika, Mathew George, Sajesh Menon
DOI:10.4103/aer.AER_112_20  
Background: Deviceassociated infections (DAIs) increase the morbidity and mortality in the intensive care unit (ICU). Studies from the neurosurgical ICU in developing countries are sparse. Aims: The aim of this study was to assess the incidence of device-associated healthcare associated infections, pathogens isolated, antibiotic resistance, and mortality in neurosurgical ICU. Settings and Design: A retrospective study was conducted in the neurosurgical ICU of a tertiary care center Materials and Methods: This study was done by analyzing data of patients admitted in a neurosurgical ICU with one or more devices during the period from January 2011 to July 2017. Statistical Analysis: Quantitative variables were expressed as mean and standard deviation; qualitative variables were expressed as frequency and percentage. Results: During this period, 6788 patients with devices were admitted in the ICU, and 316 patients developed DAI. Two hundred and forty-eight patients had catheter-associated urinary tract infection (CAUTI), 78 had ventilator-associated pneumonia (VAP), and 53 had central line-associated bloodstream infection (CLABSI). The incidence rate for CAUTI was 17.83, VAP – 16.83, and CLABSI – 4.39 per 1000 device days. The device utilization ratio was highest for urinary catheter – 0.76, followed by central line – 0.66 and ventilator – 0.25. Predominant pathogens were Klebsiella – 90, Escherichia coli – 77, Pseudomonas – 40, Candida – 39, Acinetobacter – 30, and Enterobacter – 21. Carbapenem resistance was found in Acinetobacter (73.4%), Pseudomonas (45%), and Enterobacter (38%). S. aureus isolated in six cases; four being MRSA (66.7%). Multidrug resistance was found in Acinetobacter (80%), Pseudomonas (60%), Enterobacter (52.3%), Klebsiella (42.3%), and E. coli (33.7%). No colistin resistant Gram negative bacilli or vancomycin resistant enterococci were isolated. During this period 124 patients with DAI died, of which 52 patients had sepsis. The crude mortality rate was 1.83%. Conclusion: The DAI with the highest incidence was CAUTI, followed by VAP and CLABSI. With the implementation of insertion bundles and adherence to aseptic precautions, the DAI rate had come down.
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Supraglottic airway devices for elective pediatric anesthesia: I-gel versus Air-Q, which is the best? p. 461
Rami Mounir Wahba, Milad Zekry Ragaei, Ayman Anis Metry, George Mikhael Nakhla
DOI:10.4103/aer.AER_107_20  
Objectives: The objectives of the study were to compare the insertion facility, the effect on hemodynamic parameters, and effective ventilation using I-gel versus Air-Q supraglottic airway devices (SADs) for pediatric patients undergoing short-duration surgical procedures. Patients and Methods: One hundred and fifty children aged 3–10 years were randomly divided into two equal groups: Group I received I-gel and Group Q received Air-Q SAD. All patients were anesthetized by sevoflurane inhalation using a face mask without neuromuscular blockade. Study outcomes included SAD insertion success rate (SR), insertion time, anatomic alignment of the SAD to the larynx as judged using fiberoptic bronchoscope (FOB) inserted through the SAD, and tidal volume leak, and incidence of postoperative complications. Results: Total and first attempt SRs were 97.3% and 85.3% for I-gel and 94.7% and 82.7% respectively, for Air-Q with nonsignificant differences. However, I-gel insertion time (12.3 ± 3.6 s.) was significantly (P = 0.034) shorter than Air-Q (13.7 ± 4.2 s). FOB grading of laryngeal view through SAD was better with I-gel but without significant difference for patients who had view Grades 1-2. Percentage of tidal volume loss was significantly decreased at 5 min after insertion than immediately after insertion, in all patients, with a nonsignificant difference in favor of I-gel. Intraoperative hemodynamic changes and postoperative complications showed a nonsignificant difference between both the groups. Conclusion: Both Air-Q and I-gel SAD provided advantages for pediatric anesthesia during short-duration surgical procedure with nonsignificant differences. However, I-gel SAD required a shorter insertion time and provided a high SR which is satisfactory for trainees and during an emergency. I-gel SAD allowed minimization of tidal volume leak and gastric inflation and is associated with infrequent complications.
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Effect of two regimens of fluid administration on airway edema in prone-position surgery p. 467
Ravees Jan, Ayman Alahdal, Parmod Kumar Bithal
DOI:10.4103/aer.AER_89_20  
Background: Surgeries in prone position expose a patient to multitude of complications including laryngeal edema which may be related to the volume of fluid administered. Administering larger volumes of fluid intraoperatively may contribute to significant tissue edema, leading many anesthesiologists to practice a restrictive fluid infusion strategy. Although previous studies have compared fluid infusion strategies, changes in airway dimensions leading to airway edema have not been extensively investigated. Here, we compared two fluid infusion regimens in patients undergoing spine surgery in the prone position, and assessed their association with airway edema by means of the cuff leak test (CLT). Aims: The aim of this study was to test the hypothesis whether a larger volume of crystalloid administration in spine surgeries performed in prone position would result in greater chances of airway edema, than would a restricted infusion policy, utilizing the CLT. Materials and Methods: After ethical committee approval, thirty patients, aged 21–60 years, American Society of Anesthesiologists Status I or II, scheduled for elective spine surgery in the prone position, were selected. Group 1 (restrictive group) received 3 mL.kg− 1.h− 1, whereas Group 2 (permissive group) received 5 mL.kg− 1.h− 1 of crystalloids plus urine output replacement. The airway edema was assessed by CLT which was performed soon after intubation (T1) and before extubation (T2). Cuff leak volume (CLV) was calculated from the difference in tidal volumes before (VTi) and after cuff deflation (VTe). Airway edema was evaluated by calculating the differences in the CLV at T1 and T2 (ΔCLV); the more the value of Δ CLV which means greater difference between these two points, the more the decrease in laryngeal lumen, signifying an increased risk of airway edema. Results: Decrease in laryngeal lumen was observed in patients who received permissive fluid regimen than that of the restrictive group, signifying more chances of airway edema in the former group. In addition, a poor correlation was found between the duration of anesthesia and development of airway edema in our study group. Conclusions: Because surgeries in the prone position are at risk of airway edema, restrictive fluid regimen strategy should be preferred over the liberal one as there are more chances of reduction in laryngeal lumen dimensions with permissive fluid infusions.
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A study of Vitamin D level in critically ill patients and effect of supplementation on clinical outcome Highly accessed article p. 474
Subhransu Sekhar Padhy, Deepak Malviya, Mamta Harjai, Manoj Tripathi, Pravin Kumar Das, Shivani Rastogi
DOI:10.4103/aer.AER_83_20  
Background: Supplementation of Vitamin-D in Vitamin-D deficient patients may reduce morbidity and mortality in critically ill patients in ICU. Aims and Objectives: The aim of this study is to investigate serum level of Vitamin-D in critically ill patients and supplementation of vitamin-D in deficient patients and finally to compare clinical outcomes between two groups. Settings and Design: Randomized, prospective and comparative study. Materials and Methods: In this study, serum vitamin-D level was investigated in recruited patients and vitamin-D deficient patients were randomly allocated into two groups viz; group-1, group-2. Vitamin-D (sachet CALCIROL 60,000 IU) supplementation was done once a week and twice a week in in group-1 and group-2 respectively, clinical outcomes between two groups were compared in terms of length of ICU stay, need for inotropic support, need for mechanical ventilation and 28 days ICU mortality. Statistical Analysis: Mean and standard deviation were calculated. Test of analysis between two groups was done by t-test and then P value was calculated. Results: No significant difference was found between two groups whether vitamin D supplementation done once or twice weekly (P = 0.24) in terms of length of ICU stay. Patients of group-2 required significantly less inotropic support as compared to group-1 (P = 0.037). There was no significant difference found in duration of mechanical ventilation (P = 0.138) and 28 days ICU mortality (P = 0.284). Conclusion: From the above results we concluded that vitamin D supplementation in high dosages may be started in all critically ill patients, who are deficient in serum vitamin D level to get better clinical outcomes.
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Comparison of analgesic efficacy of ultrasound-guided transversus abdominus plane block and caudal block for inguinal hernia repair in pediatric population: A single-blinded, randomized controlled study p. 478
V Rajesh Kumar Kodali, Anushri Kandimalla, Mahesh Vakamudi
DOI:10.4103/aer.AER_77_20  
Background: Caudal analgesia was a widely practiced regional anesthesia technique in pediatric population. Transversus abdominus plane block (TAP) block has recently emerged as a promising analgesic method in pediatric lower abdominal surgeries. Aim: This study aimed to compare the analgesic efficacy of ultrasound-guided TAP block and caudal block. Setting: This study was conducted in the department of anesthesiology of a tertiary care teaching hospital. Design: This was a prospective, single-blinded, randomized controlled study. Materials and Methods: Sixty-two children of American Society of Anesthesiologists Class I and II undergoing inguinal hernia repair received TAP block at a dose of 0.5 ml.kg− 1 of 0.25% bupivacaine (Group A) or caudal block at a dose of 1 ml.kg− 1 of 0.25% bupivacaine (Group B) after randomization. The children were analyzed by comparing the post operative pain scores and duration of analgesia. Statistical analysis was done with IBM SPSS software 23 version. Unpaired sample t-test and Mann–Whitney U-test were used to compare the means of continuous variables. Fisher's exact test/Chi-square test was used to find the association between categorical variables. Results: Both groups were comparable in terms of age, gender, weight, and surgery duration. Duration of analgesia was longer in TAP block group compared to that of caudal analgesia (12.93 ± 2.91 h vs. 6.52 ± 1.67 P < 0.001). The postoperative pain scores were comparable up to 6 h and at 24 h. Pain scores at 12 h and 18 h were significantly higher in caudal analgesia group compared to that of TAP block group. Conclusion: Children who received TAP block had prolonged duration of analgesia and lower pain scores compared to those who received caudal analgesia.
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Comparison of videolaryngoscope and intubating laryngeal mask airway for tracheal intubation with manual-in-line stabilization in patients undergoing cervical spine surgery p. 485
Reena Jakhar, Deepti Saigal, Suniti Kale, Shipra Aggarwal
DOI:10.4103/aer.AER_90_20  
Background: This prospective, randomized study compared CMAC® videolaryngoscope with intubating laryngeal mask airway (ILMA) for intubation under manual-in-line-stabilization (MILS) in patients undergoing cervical spine surgery. Settings and Design: Sixty-five ASA Physical Status Classes I and II patients aged 18–65 years undergoing elective cervical spine surgery were randomly allocated into two groups: group CM-intubation with CMAC® videolaryngoscope (n = 33) and Group IL-intubation using ILMA (n = 32). Materials and Methods: Intubation was performed in all patients after the application of MILS. The primary outcomes included first attempt and overall intubation success rate, intubation time, and apnea time. The secondary objectives were degree of head movement, hemodynamic response, incidence of desaturation, sore throat, and tissue injury. Statistical Analysis: Normality of data was tested by the Kolmogorov–Smirnov test. Quantitative variables were compared using the unpaired t-test or Wilcoxon Mann–Whitney test and qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: CM group had a higher first attempt (96.97%, P = 0.054) and overall (100%, P = 0.053) intubation success rate than IL group (81.25% and 87.5%, respectively). Group CM had a significantly shorter (P < 0.0001) intubation time (33.13 ± 11.82 s) than IL group (55.71 ± 19.28 s), but group CM had significantly longer (P < 0.0001) apnea time (33.13 ± 11.82 s) than IL group (22.03 ± 7.14 s). The incidence of head movement was significantly lower in IL group (P = 0.011). Hypoxemia did not occur. Postintubation hemodynamic changes and tissue injury were significantly higher in ILMA group. Conclusion: CMAC group had higher intubation success rate and significantly shorter intubation time. However, ILMA group had a significantly shorter apnea time and significantly lower incidence of head movements.
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Comparison of different doses of clonidine as an additive to intrathecal isobaric levobupivacaine in patients undergoing infraumbilical surgeries p. 492
K Krishna, KS Muralidhara, M. C. B. Santhosh, G Shivakumar
DOI:10.4103/aer.AER_57_20  
Background: Spinal anesthesia is a safe, reliable, and inexpensive technique with the advantage of providing surgical anesthesia and prolonged postoperative pain relief, and it also blunts autonomic, somatic, and endocrine responses to surgical stimulus. Aim: The aim of this study was to assess the efficacy 15 μg and 30 μg of intrathecal clonidine along with 3 mL of 0.5% isobaric levobupivacaine in comparison with plain 0.5% isobaric levobupivacaine. Setting and Design: The prospective, interventional, randomized, comparative, double-blinded study was conducted after obtaining approval from the institutional ethical committee. Materials and Methods: Seventy-five patients posted for elective lower-limb orthopedic surgeries were randomly divided into three groups with 25 patients in each group as L (levobupivacaine 0.5%), LC-15 (levobupivacaine 0.5% + clonidine 15 μg), and LC-30 (levobupivacaine 0.5% + clonidine 30 μg). All the patients were given spinal anesthesia using the study drugs, and various parameters were monitored. Statistical Analysis: The three groups were compared statistically using analysis of variance and Student's t-test (independent samples t-test). P < 0.05 was considered statistically significant. Results: There was a statistically significant difference among the three groups with respect to the onset of time for maximum sensory blockade and duration of analgesia. A statistically significant difference was noted among the three groups with respect to the onset of time for maximum motor blockade. Conclusion: Both doses of clonidine produced prolonged sensory block compared to the control. It has been found that 30 μg of clonidine as an adjuvant has produced faster onset and prolonged duration sensory block compared to 15 μg of clonidine.
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The effect of midazolam and dexmedetomidine sedation on block characteristic following spinal bupivacaine: A randomized comparative study p. 497
Sanjay Kumar, Mumtaz Hussain, Nidhi Arun, Arvind Kumar, Mukesh Kumar
DOI:10.4103/aer.AER_85_20  
Background: Dexmedetomidine is widely used as an adjunct to general as well as regional anesthesia. Aims: This study was conducted to compare and evaluate the synergistic effect of single intravenous (i.v.) bolus dose of dexmedetomidine with midazolam on spinal block duration, analgesia, and sedation in patients undergoing infra-umbilical surgeries. Settings and Design: Prospective, randomized, comparative, and double-blinded study. Materials and Methods: One hundred patients between 18 and 60 years of age of American Society of Anesthesiologists physical status I and II posted for elective infra-umbilical surgery under subarachnoid block were randomly divided into two groups (Group D and Group M). Patients of Group D received i.v. dexmedetomidine 0.5 μg.kg−1 and of Group M received i.v. midazolam 0.05 mg.kg−1 as premedication 5 min before spinal anesthesia over 10 min. Vital parameters, Ramsay sedation score, level of sensory and motor block, recovery time for sensory blockade, postoperative numerical rating scale, time of requirement of the first dose of postoperative rescue analgesic, and duration of analgesia were recorded and analyzed. Statistical Analysis: Chi-square test, t-test, and analysis of variance test were applied to analyze data using SPSS package for Windows. Results and Conclusion: Premedication with single i.v. dexmedetomidine prolonged the duration and increased the maximum upper level of only sensory component of spinal anesthesia (6.42 ± 3.21 vs. 4.8 ± 1.21 thoracic segments higher than with midazolam sedation). This property can be beneficial in preventing undesirable prolongation of motor block and facilitating early ambulation in shorter duration of infra-umbilical surgeries. In addition, dexmedetomidine slowed the regression of sensory block and increased the time of the first request of analgesic.
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Bi-spectral index-guided comparison of propofol versus etomidate for induction in electroconvulsive therapy p. 504
Vikas Rajpurohit, Kriti Chaudhary, Rama Kishan, Kamlesh Kumari, Priyanka Sethi, Ankur Sharma
DOI:10.4103/aer.AER_92_20  
Background: Previous studies have compared varying doses of propofol and etomidate for electroconvulsive therapy (ECT) without monitoring the depth of anesthesia. Seizure duration may vary with the depth of anesthesia. Aim: This study aimed to compare the effects of bi-spectral index (BIS)-guided induction with propofol and etomidate on various parameters of ECT. Settings and Design: This was a prospective, randomized, double-blind study. Materials and Methods: Sixty patients undergoing ECT were randomly allocated to two groups. Group P received intravenous propofol 1–2 mg.kg−1 and Group E received etomidate 0.1–0.3 mg.kg−1 to attain a BIS of 40–60. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and BIS were recorded at various time points intraoperatively till 30 min following ECT. Seizure duration, recovery time, and adverse effects were also recorded. Statistical Analysis: Quantitative data were compared using unpaired t-test. Chi-square test or Fisher's exact test was used to compare categorical data. P < 0.05 was considered statistically significant. Results: The mean induction time and seizure duration were shorter (P < 0.001), and recovery time to obey commands was longer in Group P as compared to that of Group E (P = 0.031). HR, SBP, and DBP for 10 min after ECT had elevated more in Group E than that in Group P (P < 0.05). The incidence of myoclonus was higher in Group P compared to that of Group E (P = 0.012). Conclusion: During ECT, BIS-guided induction with propofol provides more stable hemodynamics than etomidate, but reduces induction time, seizure duration, and recovery time more as compared to that of etomidate.
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Randomized double-blinded comparative study of intravenous nalbuphine and tramadol for the treatment of postspinal anesthesia shivering p. 510
Deepak Kumar Nirala, Jay Prakash, Barun Ram, Vishwanath Kumar, Pradip Kumar Bhattacharya, Shio Priye
DOI:10.4103/aer.AER_95_20  
Context: Shivering is one of the most commonly recognized complications of the central neuraxial blockade. For optimal perioperative care, control of postspinal anesthesia shivering is essential. Aims: The present study designed to compare the clinical efficacy, hemodynamic parameters, and side effects of nalbuphine and tramadol for control of postspinal anesthesia shivering. Settings and Design: This was a prospective, randomized, double-blind study. Materials and Methods: This study was conducted on 90 American Society of Anesthesiologists Physical Status I and II patients of either gender, aged between 18 and 60 years, who subsequently developed shivering grade 3 or 4, scheduled for different surgical procedures under spinal anesthesia. The patients were randomized into two groups of 45 patients each to receive either nalbuphine 0.06 mg.kg−1 (Group N) or tramadol 1 mg.kg−1 (Group T). Grade of shivering, onset of shivering, time interval for cessation of shivering, response rate at 5 and 30 min, rescue dose, hemodynamic parameters, and side effects were observed at scheduled intervals. Statistical Analysis Used: Independent t-test and Chi-square/Fisher's exact test were used to analyze the data. Results: The time taken for cessation of shivering was significantly less with nalbuphine in comparison with tramadol (P < 0.05). It was observed that the response time at 5 and 30 min and rescue dose requirement for control of shivering were not much difference (P > 0.05). Conclusions: Both nalbuphine and tramadol are effective; however, the time taken for cessation of shivering is significantly less with nalbuphine when compared to tramadol. Furthermore, tramadol causes significantly more nausea and vomiting; however, nalbuphine causes significantly more sedation.
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Comparison of analgesic efficacy of dexamethasone versus tramadol in combination with ropivacaine in caudal anesthesia for children undergoing lower abdominal surgeries p. 515
Loveleen Kour, Anjali Mehta, Supriya Gandotra, Zahida Aziz
DOI:10.4103/aer.AER_110_20  
Background: Caudal anesthesia has emerged as a reliable and effective anesthetic technique in the pediatric age group. However, the limited duration of action of the local anesthetic drugs proves to one of the major hindrances in the complete utilization of caudal block as an effective analgesic technique. To overcome this shortcoming, adjuvant drugs were introduced into clinical practice. Aim: Our aim was to determine which of the two drugs – dexamethasone and tramadol – serves as a better adjuvant for caudal analgesia in pediatric patients. Settings and Design: This was a prospective, randomized, double-blind study that comprised 90 American Society of Anesthesiologist (ASA) physical status I and II pediatric patients posted for lower abdominal surgeries. Materials and Methods: Ninety ASA physical status I and II children aged 5–12 years posted for lower abdominal surgeries were chosen. They were randomly divided into three groups – Group R received 0.5 ml.kg−1 of 0.2% ropivacaine plus 0.9% normal saline; Group T received 0.5 ml.kg−1 of 0.2% ropivacaine plus 2 mg.kg−1 tramadol; and Group D received 0.5 ml.kg−1 of 0.2% ropivacaine plus 0.1 mg.kg−1 dexamethasone. Postoperative pain was assessed using a modified objective pain score and time to first rescue analgesia (duration of sensory block) was recorded. Postoperative sedation and any other postoperative adverse effects were noted. Statistical Analysis: Student's independent t-test was employed for comparing continuous variables and Chi-square test for categorical variables. Kruskal–Wallis test was used for postoperative pain and sedation score data. Results: The duration of sensory block was significantly longer with dexamethasone than tramadol. No significant postoperative sedation or any other adverse effect was noted in any patient. Conclusion: Dexamethasone is superior to tramadol as an adjuvant to ropivacaine for pediatric lower abdominal surgeries.
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Is spinal dexmedetomidine aggravating hypotension after tourniquet deflation? p. 521
Mohamed Maher El Baz, Ahmed Mohamed Farid
DOI:10.4103/aer.AER_7_21  
Background and Aims: The addition of dexmedetomidine to spinal anesthesia decreases the incidence of tourniquet pain but may aggravate hypotension after tourniquet deflation. Methods: Fifty patients were included in this prospective, double-blinded, randomized study, randomly divided into two equal groups of 25 patients each. Spinal anesthesia was performed using 2.5 mL of 0.5% hyperbaric bupivacaine plus 0.5 mL of normal saline in control group (Group C) or 2.5 mL of 0.5% hyperbaric bupivacaine plus 0.5 mL (5 μg) of dexmedetomidine in (Group D). Tourniquet pain was treated by 50 mg of meperidine and repeated in a dose of 20 mg, and the total meperidine consumption was calculated. After tourniquet deflation, heart rate and mean blood pressure were measured for 15 min in the operating room and at these times: before induction of anesthesia (baseline), after inflating tourniquet (inflation), 1 min before deflating tourniquet (predeflation), after tourniquet deflation (10 min postdeflation), and maximum blood pressure and heart rate changes. Duration of time that started before the minimum blood pressure and maximum heart rate was changed until recovery was recorded. Results: Pain after torniquet inflation was significantly higher in the Group C compared to the Group D. The maximal change of blood pressure was lower in the dexmedetomidine than in the control group. The mean time between the maximal change in blood pressure reached and started to recover was 135 ± 14 s in the dexmedetomidine group and 80 ± 31 s in the control group (P < 0.01) and maximal heart rate change was lower in dexmedetomidine group than the control group. The time between the maximal heart rate changes until recovery was 113.2 ± 19 s in the dexmedetomidine group and 53.2 ± 11 s in the control group P < 0.01. Conclusion: Adding dexmedetomidine to spinal anesthesia decreases the incidence of tourniquet pain but aggravates the hemodynamic effect of tourniquet deflation.
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Ultrasound-guided suprainguinal fascia iliaca compartment block for postoperative analgesia in patients undergoing hip and femur surgeries: A retrospective analysis p. 525
Rafat Shamim, Ganpat Prasad, Prateek Singh Bais, Vansh Priya, Tapas Kumar Singh, Suruchi Ambasta, Abhishek K Philips
DOI:10.4103/aer.AER_9_21  
Context: Fractures of femur and hip surgeries pose a challenge because of excruciating pain. Fascia iliaca compartment block is an effective and easily learned procedure to decrease postoperative pain score and dosage of opioid. Many adjuvants are combined with local anesthetics to prolong the postoperative analgesia. Aims: The aim was to study duration of postoperative analgesia in terms of Numeric Rating Scale (NRS), number of times rescue analgesic used, any adverse effect, and patient satisfaction score. Settings and Design: Operation theatre of Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. Materials and Methods: The present study was retrospective study with 203 patients evaluated. Based on the combination of the anesthesia and drugs, study patients were divided into six groups. Pain scores were assessed at 6 hourly intervals for 24 h. Statistical Analysis Used: Kruskal–Wallis H-test used to compare NRS as well as age and duration of anesthesia. Chi-square test/Fisher's exact test used to compare the proportions. Results: Postoperative analgesia was comparable and insignificant (P > 0.05) at 0, 6, 12 h in all six groups. Better postoperative analgesia was observed with dexmedetomidine and dexamethasone as adjuvant at 18 h, dexmedetomidine as adjuvant in comparison to dexamethasone as adjuvant at 24 h. Rescue analgesia in postoperative period was required maximum in plain bupivacaine. Satisfaction levels were good and excellent in dexmedetomidine and dexamethasone as adjuvant. Conclusions: Addition of dexmedetomidine to bupivacaine provides longer duration, good quality postoperative analgesia, reduced requirement for rescue analgesic, lesser postoperative nausea and vomiting, and better satisfaction levels.
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Brain-relaxing effect of different diuretic regimens in supratentorial tumor surgery: A comparative study guided by optic nerve sheath diameter p. 531
Mohamed Adel Aboelela, Alrefaey Kandeel Alrefaey
DOI:10.4103/aer.AER_15_21  
Background: Hyperosmolar therapy is a well-established method to approach brain relaxation during craniotomy. Mannitol is used with a wide range of dosing regimens, combination with loop diuretics exerts a synergistic effect resulting in both reduction of the dose and its complications. Ultrasound measurement of optic nerve sheath diameter (ONSD) gives reliable information about intracranial pressure (ICP) and avoids overdosing and complications of osmotherapy. Aims and Objectives: In this study, we compare the ordinary dose of mannitol with the low dose combined with furosemide and detect the effect on ICP by ONSD. Setting and Design: This is a prospective, randomized, double-blind study involving 60 patients undergoing supratentorial brain tumor surgery. Materials and Methods: Sixty patients were enrolled in this study, divided into two equal groups: Group M received mannitol 1 g.kg−1: while Group F received mannitol 0.25 g.kg−1 and furosemide 0.5 mg.kg−1. Reduction in ONSD measurement was the primary objective, while brain-relaxation score (BRS), hemodynamic changes, urine output, serum lactate, and changes in serum electrolyte were the secondary objectives. Statistical Analysis: Data collected were analyzed using SPSS software, IBM, USA, version 22. P value was considered significant if <0.05. Results: ONSD and BRS showed no statistically significant difference between the studied groups. After diuresis, Group M showed significant reduction in heart rate and mean arterial blood pressure, serum sodium, potassium, and lactate (P = 0.02, P = 0.02, P = 0.001, P = 0.001, P = 0.001, P = 0.001 respectively), with increased urine output (UOP) and fluids replacement (P = 0.00, P = 0.01, respectively). Conclusion: Compared to high dose, adding loop diuretics to low-dose mannitol during supratentorial brain tumor surgeries resulted in comparable BRSs with a lower incidence of hemodynamic and metabolic disturbances.
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Novel position for laryngeal mask airway insertion in patients with postburn contracture over neck: A case series p. 536
Prashant Shivaraj Sajjan, Vandana Sharashchandra Kulkarni
DOI:10.4103/aer.AER_76_20  
Difficult intubation in cases of post burn contracture over neck is a known problem. We report five cases of postburn contracture over neck, posted for scar excision and split skin grafting. Detailed preanesthetic examination and airway evaluation was done. Anticipating difficulty in conventional laryngoscopy and endotracheal intubation in these patients due restricted neck movements we planned to manage these cases under general anesthesia using classic laryngeal mask airway (LMA). Standard method of LMA insertion was unsuccessful. The patients were repositioned using shoulder elevation and jaw thrust after which LMA could be successfully inserted in these patients. The cases were subsequently managed uneventfully. Classic LMA can be used as a useful alternative in the management of difficult airway for the administration of general anesthesia. In cases where standard method is unsuccessful elevation of shoulders can help in insertion of LMA.
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CASE REPORT Top

Regional anesthesia facilitating surgical and medical management of a patient with necrotizing fasciitis and diabetic ketoacidosis p. 539
Sandeep Tony Dhanjal, Trevor Edgington, Christopher Varghese Maani
DOI:10.4103/aer.AER_98_20  
Emergent surgery in the setting of a concomitant medical (nonsurgical) emergency challenges the anesthesiology team with multiple and often conflicting concerns. During these rare situations, general anesthesia is often employed. This case report demonstrates a safe and effective regional anesthetic technique utilized as the primary anesthetic during emergent surgery in the setting of a medical emergency. In this particular case, the medical emergency was profound diabetic ketoacidosis and the surgical emergency was life-threatening necrotizing fasciitis of the left upper extremity. An ever-increasing body of literature supports that anesthetic technique has an impact on morbidity and mortality outcomes in specific patient populations. The aim of this case report is to describe the successful use of regional anesthesia to facilitate emergent surgery in a patient who also has a concurrent emergent medical condition. In addition, we review the literature describing the utility of regional anesthesia in such patients.
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ERRATUM Top

Erratum: Randomized controlled study using ropivacaine with intravenous adjuvants in spinal anaesthesia in lower limb surgeries p. 543

DOI:10.4103/0259-1162.311731  
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NOTICE OF RETRACTION Top

Retraction: Evaluation of Ultrasound-guided Erector Spinae Plane Block and Oblique Subcostal Transversus Abdominis Plane Block in Laparoscopic Cholecystectomy: Randomized, Controlled, Prospective Study p. 544

DOI:10.4103/0259-1162.308938  
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