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   Table of Contents - Current issue
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April-June 2020
Volume 14 | Issue 2
Page Nos. 177-355

Online since Monday, October 12, 2020

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ORIGINAL ARTICLES  

Survey of workplace perceptions of female anesthesiologists Highly accessed article p. 177
Brigid Flynn, Katherine Stiles, Abbey Fritzel, Paul Weyker, Natalia Ivascu, Niaman Nazir, Jeanette Lozenski
DOI:10.4103/aer.AER_17_20  
Background: Disparities encountered by men and women physicians are well documented. However, evidence is lacking concerning the effects of gender on daily practice in the specialty of anesthesiology. Aims: To evaluate gender disparities perceived by female anesthesiologists. Setting and Design: Anonymous, voluntary 30-question, electronic secure REDcap survey. Materials and Methods: Survey link was sent via email, Twitter and the Facebook page, Physician Mom's Group. Instructions dictated that only female attending anesthesiologists participate and to partake in the survey one time. Statistical Analysis: Categorical variables were summarized using frequencies and percentages. Associations between categorical variables were tested using Chi-square test. Likert scale items were treated as continuous variables. T-tests were utilized to examine differences between those who reported burnout and those who did not. Results: 502 survey responses were received and analyzed. Female leadership was valued by 78%, yet only 47% had leadership roles. Being female was identified by 51% as negatively affecting career advancement and 90% perceived that women in medicine need to work harder than men to achieve the same career goals. Sexual harassment was experienced by 55%. Nearly 35% of institutions did not offer paid maternity leave. Burnout was identified in 43% of respondents and was significantly associated with work-life balance not being ideal (P < 0.0001), gender negatively affecting career advancement (P < 0.0001), experiencing sexual harassment at work (P = 0.002), feeling the need to work harder than men (P = 0.0033), being responsible for majority of household duties (P = 0.0074), lack of weekly exercise (P = 0.0135) and lack of lactation needs at work (P = 0.0007). Conclusions: Understanding perceptions of female anesthesiologists may lead to actionable plans aimed at improving workplace equity or conditions.
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A comparative study of dexamethasone versus midazolam as adjuvant to 0.5% bupivacaine in ultrasound-guided supraclavicular brachial plexus block for upper-limb surgeries Highly accessed article p. 183
HE Kantharaja, Bindu Nagaraj, HJ Thejesh
DOI:10.4103/aer.AER_35_20  
Background: Ultrasound has been effective in using low volume of local anesthetics for supraclavicular block. Steroids have been shown to increase the duration of local anesthetics. Aims and Objectives: In this study, we compare the efficacy of dexamethasone versus midazolam when added to bupivacaine in supraclavicular brachial plexus block for upper-limb surgeries with regard to the time of onset and duration of sensory and motor blockades, duration of analgesia, sedation, and hemodynamic parameters. 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 1 and 2, undergoing upper-limb surgeries under ultrasound-guided supraclavicular brachial plexus block. Materials and Methods: Sixty patients were divided into two groups of 30 each. Group dexamethasone (Group D) received bupivacaine 0.5% 18 mL + dexamethasone 4 mg + 1 mL normal saline. Group midazolam (Group M) received bupivacaine 0.5% 18 mL + 2 mg midazolam. We compared the onset and duration of sensory and motor blocks, hemodynamic variables, pain and sedation scores, and duration of analgesia. Statistical Analysis: The statistical software, namely SPSS 18.0 and R environment ver. 3.2.2, were used for the analysis of the data. P < 0.05 was considered statistically significant. Results: The onset of sensory and motor blocks was significantly faster in Group D compared to Group M. The duration of sensory and motor blockades and duration of analgesia showed a significant increase in Group D in comparison with Group M. Conclusion: Dexamethasone as an adjuvant hastens the onset and prolongs the duration of both sensory and motor blocks and reduces postoperative analgesic requirement when compared to midazolam.
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Effect of prophylaxis of amiodarone and magnesium to prevent atrial fibrillation in patients with rheumatic valve disease undergoing mitral valve replacement surgery Highly accessed article p. 189
Shruti Sharma, Rajesh Angral, Heena Saini
DOI:10.4103/aer.AER_63_20  
Context: Maintenance of sinus rhythm is superior to the incidence of atrial fibrillation (AF) in patients with rheumatic valve disease undergoing mitral valve replacement (MVR) surgery. Aim: To evaluate the effect of prophylactic combination of intravenous (i.v.) amiodarone and magnesium sulfate (MgSO4) in patients undergoing MVR surgery. Materials and Methods: One hundred and twenty patients with valvular heart disease with or without AF were randomly divided into two groups. Group I (n = 60) received amiodarone (3 mg.kg−1 in 20 mL saline) + MgSO4 (30 mg.kg− 1 in 20 mL saline), and Group II (n = 60) received 40 mL of normal saline. The standardized protocol for cardiopulmonary bypass was maintained for all the patients. Statistical Analysis: Continuous variables were expressed as mean ± standard deviation and categorical variables were summarized as frequencies and percentages. Student's independent t-test was employed for comparing continuous variables. Chi-square test was applied for comparing categorical variables. Results: Before surgery, AF was observed in 58.3% of patients in Group I and in 53.3% of patients in Group II (P = 0.581). Postoperatively, in the intensive care unit, 26.7% of the patients in Group I and 71.7% in Group II had AF (P < 0.001). At the time of discharge, 30% of patients in Group I and 73.3% of patients in Group II had AF (P < 0.001). Conclusion: A single combined prophylactic intraoperative dose of i.v. amiodarone and MgSO4 decreased postbypass arrhythmia in comparison to the placebo group in patients of MVR surgery.
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Comparision of dexmedetomidine and propofol in patients undergoing laparoscopic cholecystectomy under spinal anesthesia p. 194
Heena Saini, Rajesh Angral, Shruti Sharma, Raj Rishi Sharma, Ravinder Kumar
DOI:10.4103/aer.AER_64_20  
Background: Spinal anesthesia (SA) with sedation is considered to be an alternative to general anesthesia for laparoscopic cholecystectomy (LC) in high-risk patients. Ketamine in analgesic dose with propofol or dexmedetomidine infusion provides titratable sedation, hemodynamic stability, and minimum respiratory depression without psychomimetic effects. Aim: To compare the efficacy of ketamine–dexmedetomidine and ketamine-propofol combination in relation to sedation, analgesia, hemodynamic effects, and perioperative side effects. Settings and Design: This was a prospective, randomized single-blind comparative study comprising 100 American Society of Anesthesiologists I, II, and III patients posted for LC. Materials and Methods: Patients were randomized into two groups of 50 patients each. Group KP (ketamine + propofol) received intravenous (i.v.) bolus of injection ketamine 0.5 mg.kg−1 and propofol infusion at 3 mg.kg−1.h−1. Group KD (ketamine + dexmedetomidine) received i.v. bolus of injection ketamine 0.5 mg.kg−1 and dexmedetomidine infusion at 0.4 μg.kg−1.h−1. Parameters observed were vitals, perioperative side effects, time to first rescue analgesia, and return of consciousness. Statistical Analysis: Student's independent t-test was employed for comparing continuous variables. Chi-square test or Fisher's exact test, whichever appropriate, was applied for comparing categorical variables. Results: Duration of analgesia was longer in KD Group (191.2 vs. 173.5 min), and time to regain consciousness was faster in KP Group (14.9 vs. 20.4 min). Conclusion: Both the techniques of sedation are feasible, safe, and comparable, except the duration of analgesia and time to regain consciousness which was longer in KD Group.
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Ultrasound measurement of inferior vena cava collapsibility as a tool to predict propofol-induced hypotension Highly accessed article p. 199
Shyam Sundar Purushothaman, Ani Alex, Rajesh Kesavan, Sindhu Balakrishnan, Sunil Rajan, Lakshmi Kumar
DOI:10.4103/aer.AER_75_20  
Background: Hypotension is common under anesthesia and can cause organ underperfusion and ischemia, especially during induction. This could be because of the cardiovascular depressant and vasodilatory effects of anesthetic agents, as well as lack of surgical stimulation. Aim of Study: The aim was to evaluate the utility of preinduction inferior vena cava (IVC) measurement to predict significant hypotension after induction of anesthesia with propofol. Settings and Design: This was a prospective, open-label study conducted in a tertiary care institute. Subjects and Methods: This study was conducted on 50 patients undergoing general anesthesia. Ultrasound machine (Mindray® M7) was used to visualize IVC. The measurements taken were maximum diameter of IVC (IVCmax) and minimum diameter of IVC (IVCmin). IVC collapsibility index (IVC-CI) was calculated as (IVCmax − IVCmin)/IVCmax and was expressed as a ratio. Statistical Tests Used: Receiver operating characteristic (ROC) curve analysis and Chi-square test were used for statistical tests. Results: The relation between significant hypotension and IVC-CI was evaluated using ROC curve analysis. We found the area under curve to be 0.959 and a cutoff of 0.43 (43% collapsibility). The association of significant hypotension with IVC-CI of >43% was calculated and found to be statistically significant (P < 0.001). The sensitivity of IVC CI of >43% in predicting development of significant hypotension was 86.67% and the specificity was 94.29%. It had very high negative and positive predictive values (94.29% and 86.67%, respectively) with an accuracy of 92%. Conclusion: Patients with an IVC collapsibility of more than 43%, as assessed by ultrasonography, are more likely to develop significant hypotension after induction with propofol.
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Acceptability and feasibility of an innovative anesthesia technique in a low-resource setting at a rural community ophthalmic center: A prospective journey p. 203
Shilpi Sethi, Ketaki Subhedar, Sandeep Sharma, Manish Sethi
DOI:10.4103/aer.AER_46_20  
Background: Ocular blindness and ocular morbidities are very much prevalent in pediatric age group in India. Mostly, these are all surgically amenable, provided they have access to safe anesthesia. Suboptimal facilities for conventional general anesthesia (GA) led to a different thought process. The combination of anesthetic and analgesic property of ketamine was utilized in a low-resource setting at a tertiary ophthalmic center for pediatric ophthalmic surgeries. Aims: The aim of this study was to decipher whether this technique is acceptable and feasible. Settings and Design: It was a prospective consecutive series at a rural eye center done over a period of 5 years. Materials and Methods: Inclusion criterion was children undergoing eye surgeries between the ages of 7 and 18 years, who could be adequately counseled about the concept of painless intravenous cannulation and subsequent painless block. Intravenous anesthesia comprised of ketamine, in conjunction with peribulbar block. Complications of the technique, time to discharge, mean pain score, and patient and surgeon satisfaction score were documented. Statistical Analysis Used: Data were analyzed on Microsoft Excel. Results: A total of 905 cases were conducted uneventfully without conversion to GA. No emergency resuscitation was required. The surgeon and the patient had a satisfying experience, with the technique being totally acceptable to them. Conclusions: Intravenous ketamine is an inexpensive and safe anesthetic technique when used in conjunction with regional block and is certainly a boon for minimal resource ophthalmic setup in rural India.
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Randomized controlled study using ropivacaine with intravenous adjuvants in spinal anaesthesia in lower limb surgeries p. 208
MS Abhishek, TR Nagraj
DOI:10.4103/aer.AER_70_20  
Background: In recent years, several adjuvants have been used to prolong the duration of the subarachnoid block. These adjuvants have either been used via intrathecal route or intravenous (i.v.) route. Dexmedetomidine and clonidine have been used as adjuvants to local anesthetic drugs by intrathecal, epidural, caudal, and i.v. routes and for peripheral nerve blocks. In this study, we endeavored at finding the efficacy of dexmedetomidine and clonidine in improving the analgesia quality and duration of the subarachnoid block. Setting and Design: A prospective, double-blind, randomized control trial comprising 70 subjects posted for elective lower limb surgeries. Materials and Methods: Seventy patients were selected at random and were allocated to two groups (Group C and Group D) of 35 each. In Group C, the patients received isobaric ropivacaine with clonidine 1.0 μg.kg−1 intravenously. In Group D, the patients received isobaric ropivacaine with dexmedetomidine 0.5 μg.kg−1 intravenously. Perioperatively, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation were recorded and documented every 5 min till the end of surgery. Time of onset, level of sensory blockade, and duration of sensory blockade were recorded. Motor block was assessed using modified Bromage scale. Data validation and analysis were carried out by SPSS version 16. A P < 0.05 was considered statistically significant. Results: Time of onset of sensory block in Dexmedetomidine group and Clonidine group was 2.70 ± 1.25 minutes and 3.50 ± 1.23 minutes respectively (P = 0.021). Time of onset of motor block in Dexmedetomidine group and Clonidine group was 3.55 ± 1.60 minutes and 4.30 ± 1.45 minutes respectively (P = 0.034). Time for 2 segment regressions of sensory block in Dexmedetomidine group and Clonidine group was 140.30 ± 12.32 minutes and 125.65±14.33minutes respectively (P = 0.047). Time of regressions of motor blockade to Bromage Scale 1 in Dexmedetomidine group and Clonidine group was 148.65 ± 15.23 minutes and 129.70 ± 19.35 minutes respectively (P = 0.032). Conclusion: The use of i.v. dexmedetomidine perioperatively prolongs the duration of sensory and motor block significantly when compared to i.v. clonidine.
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Comparative study of preoperative airway assessment by conventional clinical predictors and ultrasound-assisted predictors p. 213
Urvashi Yadav, Rakesh Bahadur Singh, Shweta Chaudhari, Swati Srivastava
DOI:10.4103/aer.AER_52_20  
Aims: The aim of this study is to evaluate the effectiveness of airway sonographic parameters as the predictors of difficult laryngoscopy and to evaluate the validity of combined sonographic and clinical tests. Materials and Methods: This prospective and observational study analyzed a sample of 200 patients who were categorized as having easy (Grades 1 and 2) or difficult (Grades 3 and 4) laryngoscopy based on the laryngoscopic criteria of Cormack-Lahane (CL). Sonographic parameters, including the anterior neck soft-tissue thickness at the level of vocal cord (ANS-VC), ANS tissue thickness at the level of hyoid, and ratio of depth of pre-epiglottic space to distance from epiglottis to midpoint of the distance between vocal cords and clinical parameters, including modified Mallampati class, thyromental distance, and hyomental distance ratio (HMDR), were analyzed. Univariate and multivariate regression analysis was used for the statistical analysis. Results: Twenty patients (10%) were categorized as having difficult laryngoscopy. Statistically significant differences between patients with difficult and easy laryngoscopy were noted for 5 of 6 parameters. The diagnostic validity profiles showed variable sensitivity (26.5%–87.5%) and good specificity (58.9%–94.2%) and negative predictive value (88.8%–97.03%). ANS-VC has the highest sensitivity (87.50%) and area under curve value (0.887), whereas HMDR showed highest specificity (94.2%) and highest accuracy (89.60%) which means it has low false-positive prediction rate. The combination of tests improved the diagnostic validity profile (highest area under the curve, 0.897). Conclusion: Sonographic predictors can help in identifying difficult laryngoscopy. Combined clinical and ultrasonographic parameters showed better validity profiles in comparison to the individual tests.
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Comparison of intravenous nalbuphine and paracetamol on maternal hemodynamic status, neonatal APGAR score, and postoperative pain given before induction of general anesthesia for elective cesarean section p. 219
Prashant Kumar Mishra, Jay Brijesh Singh Yadav, Arun Kumar Singh, Rakesh Bahadur Singh
DOI:10.4103/aer.AER_69_20  
Background: Stress response to endotracheal intubation and surgery is associated with exaggerated hemodynamic response and an increase in catecholamine levels which is deleterious to both the mother and fetus. We aimed to compare the effects of intravenous nalbuphine and paracetamol on maternal hemodynamic status, neonatal APGAR score, and postoperative pain using the visual analog scale for elective cesarean section under general anesthesia. Study Design: This was a prospective, randomized, double-blinded clinical study. Materials and Methods: Sixty full-term pregnant patients, belonging to the American Society of Anaesthesiologist physical status Classes I and II, scheduled for elective cesarean section under general anesthesia were enrolled for the study. The patients were randomly allocated into two groups of 30 patients each to receive paracetamol (15 mg.kg− 1) in Group P and nalbuphine (0.2 mg.kg−1) in Group N before induction of general anesthesia. Maternal heart rate, blood pressure, and oxygen saturation were recorded before infusion of study drugs, after induction, after intubation, and during surgery across all periods. APGAR score of neonates was recorded by a pediatrician. Time to reach visual analogue score-1 was recorded. Results: Significant attenuation of maternal hemodynamic response was observed with nalbuphine compared to the paracetamol group (P < 0.05). The time to achieve visual analogue score-1 in the postoperative period was higher in the nalbuphine group. APGAR score at 1 min was significant between the groups and at 5 min, nonsignificant difference was observed (P > 0.05). Conclusion: Nalbuphine and paracetamol are effective in perioperative hemodynamic stability of mother and APGAR score of neonates. However, nalbuphine had better hemodynamic stability as compared to paracetamol with a comparable APGAR score at 5 min.
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Ultrasound-guided bilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A randomized controlled trial p. 226
Ruchi Verma, Divya Srivastava, Ruchi Saxena, Tapas K Singh, Devendra Gupta, Anil Agarwal, Prabhakar Mishra
DOI:10.4103/aer.AER_41_20  
Background: Laparoscopic cholecystectomy (LC) is associated with moderate-to-severe pain in immediate postoperative period. Some patients even suffer from prolonged pain long after surgery. Aims: The aim of present study is to determine the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) in patients undergoing LC, time to ambulation after surgery, and incidence of prolonged pain up to 6 months later. Settings and Design: This was a double-blinded prospective randomized controlled trial. Materials and Methods: Eighty-five adults posted for elective LC were randomized to receive bilateral ESPB at T7 level with either 20 mL of 0.375% ropivacaine or 20 mL normal saline. Postoperative static and dynamic pain score as per the visual analog scale (VAS), intraoperative requirement of fentanyl, postoperative use of diclofenac, time to ambulation after surgery, and presence of any pain after surgery were noted. Statistical Analysis: Independent t-test and Mann–Whitney U-test were used for quantitative data, while Chi-square test was used for comparing qualitative data. Results: Static and dynamic VAS scores were significantly lower in ESPB group (P < 0.05). Intraoperative fentanyl requirement (165 ± 30.72 – ESPB, 180.95 ± 29.12 – controls, P = 0.020) and number of patients requiring diclofenac (28/42 – ESPB, 37/42 – controls, P = 0.019) were lower, while number of patients ambulating by 4 hours (20/42 – ESPB, 9/42 – control, P = 0.012) were higher in ESPB group. Patients suffering from pain at 1 week (22/42 – ESPB and 34/42 – control, P = 0.005) and 1 month (9/42 – ESPB and 13/42 – control, P = 0.207) were lower in ESPB group. Conclusion: ESPB provides effective analgesia and early ambulation after LC. The benefit extends to 1 week thereafter.
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Ultrasound-guided anterior quadratus lumborum block for postoperative pain after laparoscopic pyeloplasty: A randomized controlled trial p. 233
Divya Srivastava, Ruchi Verma, Tapas K Singh, Alka Verma, Abhilash Chandra, Sandeep Sahu, Prabhakar Mishra
DOI:10.4103/aer.AER_45_20  
Background: Quadratus lumborum block (QLB) has provided adequate analgesia and lowered postoperative opioid requirement in comparison to controls for some urological surgeries. Aims: The aim of this study was to assess the efficacy of postprocedure ultrasound-guided QLB in comparison to port-site infiltrations with local anesthetics (as control) in lowering postoperative pain after laparoscopic pyeloplasty. Settings and Design: This was a prospective, single-blinded, randomized controlled trial. Materials and Methods: Fifty-three adults undergoing laparoscopic pyeloplasty were randomly allocated to either anterior QLB group (n = 27) or port-site infiltration Group P (n = 26) with 20 mL of 0.5% ropivacaine. The primary outcomes were static and dynamic pain on the Visual Analog Scale (VAS) of 0–100 at the 30th min, 2nd, 6th, 12th, and 24th hour after surgery. The secondary outcomes were number of patients requiring rescue analgesics and having postoperative nausea or vomiting (PONV) in 24 hours after surgery. Statistical Analysis: Intergroup comparison of VAS was done with Student's t-test. Categorical data were analyzed using the Chi-square test. Results: The static VAS scores were found to be significantly lower in QLB group at the 2nd, 6th, and 12th hour, and the dynamic VAS was lower at all time points after the 30th min in the QLB group. The number of patients requiring rescue analgesics were significantly lower in the QLB group (13 as compared to 21 in Group P; P = 0.015). The incidence of PONV was comparable. No other side effects were seen. Conclusion: Ultrasound-guided anterior QLB is more effective in comparison to traditional technique of port-site local anesthetic infiltration for providing analgesia after laparoscopic pyeloplasty.
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Ultrasound-guided caudal epidural anesthesia in adults for anorectal procedures Highly accessed article p. 239
Prasanna Vadhanan, Iniya Rajendran, Preethipriyadharshini Rajasekar
DOI:10.4103/aer.AER_60_20  
Introduction: Caudal epidural is a commonly performed regional anesthetic technique in children. In adults, the high-failure rates associated with landmark-based techniques deter its widespread use. Fluoroscopy-guided caudal epidural steroid injections are widely used as a treatment modality in chronic back pain. Ultrasound (US) guidance has been shown to be equally effective as fluoroscopic-guided caudal injections. We aimed to assess the feasibility of US guided caudal epidurals as a sole anesthesia technique in adult patients undergoing minor anorectal procedures. Subjects and Methods: Fifty consecutive adult patients undergoing elective minor anorectal procedures were recruited for this study. Eligible patients received US-guided caudal epidural and success rates, surgical patient and surgeon's comfort were assessed using validated tools. Any adverse events were also observed. Results: The block was successful in all patients. One patient had pain in the perianal region requiring skin infiltration. All patients were either highly satisfied or satisfied of the procedure. Surgeons rated the surgical conditions as highly satisfied (90%), satisfied (8%), or unsatisfied (2%). Two patients rated the caudal injections were of moderate pain, rest all rated it as mildly painful. One patient experienced a single episode of urinary incontinence. Conclusion: US-guided caudal epidural can be considered as an option for anorectal procedures of short duration with acceptable success rates, surgical conditions, and patient comfort.
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Comparison of ultrasoundguided ilioinguinal iliohypogastric nerve block with wound infiltration during pediatric herniotomy surgeries p. 243
Wahaja A Karim, Sapna Bathla, Shraddha Malik, Deep Arora
DOI:10.4103/aer.AER_22_20  
Background and Aims: The purpose of this study was to compare the analgesic efficacy of the ilioinguinal-iliohypogastric nerve block (II/IH) with local wound infiltration in children undergoing herniotomy surgeries. Methods: After ethics committee approval and informed consent, 100 children aged 6 months–7 years posted for herniotomy surgeries were randomly divided into Group B and Group W. Local wound infiltration was performed in Group W by the surgeon at the time of port placement and the end of the surgery with 0.2 mL.kg−1 of 0.25% bupivacaine. Ipsilateral II/IH was performed in Group B at the end of the surgery, under ultrasonographic guidance with a Sonosite portable ultrasound unit and a linear 5–10 MHz probe with a 22G hypodermic needle, and 0.2 mL.kg−1 of 0.25% bupivacaine was used on each side. The parameters recorded were postoperative hemodynamics, paracetamol and opioid requirements, postoperative pain scores, postoperative nausea vomiting, and the need for rescue analgesia in the first 6 h postoperatively. Results: The median pain scores were significantly lower in the II/IH group than the local wound infiltration group at 10 min (2 [0–2.5] compared to 2 [3–4]; P& #61; 0.011), 30 min (1.5 [0–3] compared to 3 [2–5]; P < 0.001), 1 h (1.5 [0–2] compared to 2 [2–3]; P < 0.001) and 2 h (2 [0–2] compared to 2 [1.5–2.5]; P = 0.010) postoperatively. The need for postoperative opioids and rescue analgesia was also significantly lower in the II/IH group (P < 0.001). Conclusion: II/IH is superior to local wound infiltration for postoperative analgesia in pediatric herniotomy surgeries.
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Articaine and dexmedetomidine – Supplemented articaine for arteriovenous fistula creation under ultrasound-guided supraclavicular block p. 248
Simon Halim Armanious, Gamal A Abdelhameed
DOI:10.4103/aer.AER_147_19  
Background: Articaine has emerged as a local anesthetic (LA) that produces sensory and motor blockade shorter than bupivacaine and lower in neurotoxicity than lidocaine. Studies have shown that adding dexmedetomidine to LA produces prolongation of sensory and motor bock duration. Early regain of motor power with adequate analgesia is needed in hemodialysis fistula creation surgery, for early start of physiotherapy. We designed this study to test efficacy of adding dexmedetomidine to articaine on the duration of sensory and motor block. Methods: After university review board approval, written informed consent to participate in the study was obtained. Patients with chronic renal failure undergoing radiocephalic hemodialysis fistula creation were eligible for enrollment in this double-blind, randomized trial. Patients receive either 40 ml of 2% articaine hydrochloride or 40 ml of articaine 2% mixed with dexmedetomidine (1 μg.kg− 1). Sensory block duration in minutes is assessed by pinprick test and motor block duration in minutes is tested by Bromage scale; both are recorded as a primary outcome. Secondary outcomes, including onset of sensory and motor block, time for rescue analgesia, hemodynamic changes, oversedation, and possible side effect, were recorded. Results: Fifty patients were enrolled in the study (25 in the articaine Group A and 25 in the articaine and dexmedetomidine group [AD]). Longer sensory block duration was in Group AD (230–260 min) than in Group A (172–185 min) with P < 0.001. In addition, motor block duration was significantly longer in Group AD than in Group A, (220 ± 110 min), (165 ± 45 min), respectively. The duration of effective analgesia was significantly longer in Group AD (363 ± 134 min) versus in Group A (244 ± 84 min). The onset of block was short and similar between groups. Conclusion: Addition of dexmedetomidine to articaine during arteriovenous fistula creation provide prolongation of sensory and motor block duration and augment analgesia. Trial registration: This trial was registered at Clinical trial.gov https://clinicaltrials.gov/ct2/show/NCT04171349 with the identification number NCT04171349.
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Dexmedetomidine and ketamine as an adjuvant to levobupivacaine for pediatric caudal analgesia: A randomized, controlled study p. 253
Ganesh K Ram, Prakash K Dubey, P Akhileshwar, Alok Ranjan
DOI:10.4103/aer.AER_42_20  
Background: Ketamine and dexmedetomidine as an adjuvant to caudal block are used in the pediatric population. Aims: We aimed to compare the analgesic and safety profile of dexmedetomidine with ketamine for single-shot caudal block. Settings and Design: This was a randomized controlled study conducted in a tertiary care university hospital. Materials and Methods: Ninety patients admitted for routine infraumbilical surgical procedures under general anesthesia were enrolled in this double-blind randomized study. Following caudal block under general anesthesia, patients were allocated to one of three groups; Group LS received 0.75 mL.kg− 1 levobupivacaine 0.25% diluted in saline 0.9%, Group LK received 0.75 mL.kg− 1 levobupivacaine 0.25% with ketamine 0.5 mg.kg− 1, and Group LD received 0.75 mL.kg− 1 levobupivacaine 0.25% with dexmedetomidine 1 μg.kg− 1. Postoperative pain was assessed by the Face, Legs, Activity, Cry, and Consolability (FLACC) score, and the duration of analgesia (time from caudal block to time at which FLACC score 4 or more) was recorded. Hemodynamic parameters and oxygen saturation were also monitored. Statistical Analysis Used: Categorical data were analyzed by Chi-squire test and numerical continuous data were analyzed by Student's t-test for comparison between two groups. Mann–Whitney test was used to compare score. One-way analysis of variance was used to compare the means between three groups. Results: The addition of dexmedetomidine and ketamine to levobupivacaine resulted in significant prolongation of postoperative analgesia duration (467 min and 385 min, respectively) compared with 0.25% levobupivacaine alone (276 min). No significant side effects requiring intervention were observed in any group. Conclusions: Dexmedetomidine as an adjuvant to levobupivacaine provides a longer duration of analgesia as compared to ketamine without any significant side effect.
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Comparison of blood-conserving and allogenic transfusion-sparing effects of antifibrinolytics in scoliosis correction surgery p. 259
Seshadri Ramkiran, Mritunjay Kumar, Lakshmi Krishnakumar, Suresh G Nair
DOI:10.4103/aer.AER_59_20  
Background: Intraoperative antifibrinolytic drug administration is a safe and effective method of reducing blood loss and allogenic transfusions in patients undergoing spine deformity correction. Aim: This study aimed to compare the effectiveness of two antifibrinolytic drugs tranexamic acid (TXA) and epsilon amino caproic acid (EACA) in reducing peri-operative blood loss and transfusion requirements against a placebo control in patients with idiopathic scoliosis undergoing correction surgery. Setting and Design: This is a prospective, randomized, double-blinded, controlled comparative study. Methodology: Patients in TXA group received 50 mg.kg−1 bolus and 10 mg.kg−1.h−1 infusion as against 100 mg.kg−1 and 10 mg.kg−1.h−1 infusion in EACA group. The placebo group had saline bolus and infusion. Parameters observed included baseline demographic and deformity data, duration of surgery, total peri-operative blood loss, and allogenic packed red cell transfusion requirements. Statistical Analysis: Mean and standard deviation were used to represent the quantitative continuous data, and percentage was used to represent categorical data. The Student's t-test and ANOVA were used to compare means between groups. Bonferroni's multiple comparison test was used to find out the association between categorical variables. Results: A total of 36 patients were enrolled with 12 patients in each group. Peri-operative blood loss was 50.1% lower in patients receiving TXA and 17.7% lower in patients receiving EACA compared with the placebo group. The volume of total packed red cell transfusion was 66.7% lower in patients receiving TXA and 45.6% lower in patients receiving EACA compared with placebo. Conclusion: TXA was more effective in reducing total peri-operative blood loss and allogenic transfusion requirement in idiopathic scoliosis correction surgery compared to EACA.
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A prospective open-label randomized controlled trial to compare intrathecal 1% 2-chloroprocaine versus 0.5% bupivacaine in ambulatory elective surgeries p. 266
Balwinderjit Singh, Asha Anand, Joginder Pal Attri
DOI:10.4103/aer.AER_43_20  
Background: For an outpatient surgery, an ideal anesthetic drug should have a faster onset and shorter duration of action and minimal side effects. Although Bupivacaine is a drug of choice in spinal anesthesia but is not suitable for ambulatory surgeries. We aimed to compare 1% 2-chloroprocaine (2-CP) which is considered to be a short-acting agent with 0.5% hyperbaric bupivacaine as a spinal anesthetic agent in ambulatory surgeries. Materials and Methods: The study includes a prospective analysis of 60 patients who underwent ambulatory surgeries of <60 min and were randomly divided into two groups of 30 each: Group I – intrathecal injection of preservative-free formulation of 1% 2-CP 40 mg (4 mL) given and Group II – intrathecal injection of 0.5% hyperbaric bupivacaine 10 mg (2.0 mL) given time to reach surgical anesthesia, time for resolution of motor block, time for end of anesthesia, time to requirement of first postoperative analgesic, time to unassisted ambulation, time for micturition, and time to reach discharge readiness criteria, which were recorded. Results: We observed that in the CP group, onset time is early and there was more fast regression of surgical anesthesia in the CP group resulting in less time required for unassisted ambulation and less time for discharge from the hospital. Conclusion: We concluded that 2-CP can be used for spinal anesthesia in shorter duration surgeries with early recovery from anesthesia and hence early discharge from the hospital.
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A randomized controlled study comparing dexmedetomidine-midazolam with fentanyl-midazolam for sedation during awake fiberoptic intubation in anticipated difficult airway p. 271
Urvashi Yadav, Jay Brijesh Singh Yadav, Dhiraj Srivastava, Swati Srivastava
DOI:10.4103/aer.AER_44_20  
Background: Awake fibreoptic nasotracheal intubation is an effective technique for the management of patients with difficult airways. Adequate sedation with effective topicalization of the airway is important to overcome discomfort and achieve intubation successfully. Aim and Objectives: Our aim was to compare the effectiveness of dexmedetomidine-midazolam with fentanyl-midazolam infusion for providing conscious sedation during fibreoptic intubation in patients with anticipated difficult airway under topical anaesthesia. Materials and Methods: Thirty adult patients of ASA physical status classification I and II with anticipated difficult airway and planned for elective awake nasal fibreoptic intubation under conscious sedation were randomly allocated into two groups. Dexmedetomidine 1 μg.kg-1 diluted in 50 ml saline was infused in Group DM over 10 min and Fentanyl 2 μg.kg-1 diluted in 50 ml saline was infused in Group FM over 10 min. Topicalization of the airway was done in all patients. All patients were assessed for sedation score, ease of endotracheal tube placement, patient comfort and cooperation, tolerance to endotracheal tube, any adverse events and recall of procedure. Results: The score of the modified OAA/S was comparable between the groups (P > 0.05). Quality of AFOI was comparable in both groups (P > 0.05). The intubation time and first EtCO2 were significantly lower in dexmedetomidine group (P <0.05). Group DM also showed better hemodynamics and less episodes of desaturation than Group FM. Conclusion: Fentanyl-midazolam and dexmedetomidine-midazolam are both effective for awake fiberoptic intubation under topical anesthesia. Dexmedetomidine allows better endurance and more stable hemodynamics.
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Use of peripheral nerve blocks in perioperative management of cases with hypertrophic cardiomyopathy undergoing lower limb orthopedic surgeries p. 277
Manasij Mitra, Maitraye Basu, Kumar Shailendra, Anil Chandra Jain
DOI:10.4103/aer.AER_48_20  
Hypertrophic obstructive cardiomyopathy is a type of hypertrophic cardiomyopathy (HCM) that involves the left ventricular outflow tract obstruction. Most important parameters are preload, afterload, and ventricular contractility that are prone to fluctuations in HOCM patients in the perioperative period due to the surgical procedure, anesthetic agents and changes in intravascular volume. These lead to increased chances of arrhythmias and myocardial ischemia and can pose significant morbidity and mortality in HCM patients perioperatively. Here, we report three challenging cases of HCM with comorbidities who underwent successful operative management of lower limb fractures using regional nerve blocks. Although general anaesthesia is usually preferred in cases of HCM, this was not the preferred choice in these cases due to the asthmatic status, extremes of age, and also associated comorbidities such as chronic kidney disease Stage IV on maintenance hemodialysis. We selected Ultrasonography and peripheral nerve stimulator (PNS) guided regional nerve blocks including lumbar plexus and parasacral approach of sciatic nerve block in the first two patients and fascia iliaca compartment block with parasacral sciatic nerve block in the third case to successfully manage the patients perioperatively. Postoperative pain management was satisfactory. All the patients were discharged in a hemodynamically stable condition with advice for follow-up.
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Comparison of nasal bi-level positive airway pressure versus high-flow nasal cannula as a means of noninvasive respiratory support in pediatric cardiac surgery p. 283
Jessin Puliparambil Jayashankar, Pinky Rajan, Brijesh Parayaru Kottayil, Aveek Jayant, Rakhi Balachandran
DOI:10.4103/aer.AER_39_20  
Background: Noninvasive respiratory support is often used in preventing postextubation respiratory failure in neonates and infants after cardiac surgery. Aim: We compared the efficacy of nasal Bilevel Positive Airway Pressure (N/BiPAP) with that of High- flow Nasal Cannula(HFNC)in prevention of post extubation respiratory failure and maintenance of gas exchange in neonates and infants undergoing cardiac surgery. The incidence of complications related to the use of these modes were also compared. Settings and Design: This is a retrospective review of medical records of patients in pediatric cardiac intensive unit of a high-volume center. Methods: A total of 100 patients who received noninvasive respiratory support postextubation were divided into N/BiPAP group and HFNC group. The two groups were compared for postextubation respiratory failure, gas exchange in arterial blood gas at 24 h of extubation, and incidence of complications, namely pneumothorax, abdominal distension, and device–interface-related pressure ulcers. Results: Fifty patients each received N/BiPAP and HFNC after extubation. Patients who received N/BiPAP were younger (2.68 ± 2.97 months vs. 6.94 ± 4.04 months, P = 0.001) and had longer duration of postoperative ventilation (106.98 ± 79.02 h vs. 62.72 ± 46.14 h, P = 0.001). The reintubation rates were similar (20% [n = 10] in N/BiPAP group vs. 8% [n = 4] in HFNC group, P = 0.074). The mean arterial PO2 values at 24 h of extubation was 119.17 ± 56.07 mmHg for N/BiPAP group versus 123.32 ± 64.33 mmHg for HFNC group (P = 0.732). Arterial PCO2 values at 24 h were similar (43.97 ± 43.64 mmHg in N/BiPAP vs. 37.67 ± 4.78 mmHg in HFNC, P = 0.318). N/BiPAP group had higher incidence of abdominal distension (16% [n = 8] vs. nil in HFNC group, P = 0.003) and interface-related pressure ulcers (86% [n = 43] vs. 14% [n = 7] P = 0.006). Conclusion: N/BiPAP and HFNC have comparable efficacy in preventing reintubation and maintaining gas exchange. HFNC has fewer complications compared to N/BiPAP.
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Efficacy of new long-acting bupivacaine HTX-011 in providing pain relief for patients undergoing elective surgery – A meta-analysis of prospective randomized controlled trials p. 288
Basavana Goudra, Navdeep Singh, Linag Xue, Amandeep Goyal, Divakara Gouda, Preet Mohinder Singh
DOI:10.4103/aer.AER_34_20  
Background: The aim of the present meta-analysis is to critically analyze the various prospective randomized controlled trials comparing the safety and efficacy of a new, yet unapproved long-acting local anesthetic HTX-011. This is a combination of bupivacaine and meloxicam, and like its predecessors' liposomal bupivacaine and SABER bupivacaine, the combination slowly releases bupivacaine and provides therapeutic analgesic concentrations at the site of infiltration. Methods: We performed a meta-analysis of 7 randomized clinical trials comparing the use of HTX-011 with placebo and/or bupivacaine in patients undergoing abdominoplasty, bunionectomy, and herniorrhaphy. Comparisons were made for the patients who were opioid free at 24 h, pain scores at 24 h, patients likely to be opioid free at 72 h, and reduction of morphine consumption at 72 h. Results: While comparing pain scores at 24 h, we found that the use of HTX-011 was associated with a significant decrease in pain score in relation to both bupivacaine and placebo. The overall comparison of 12 groups showed that with HTX-011, patients are 3.25 times more likely to be opioid free at 72 h than either placebo or control. More patients were free of opioid at 24 h in the HTX-011 group when compared to bupivacaine. Finally, the consumption of morphine was less by 10.61 (95% CI: 8.13–13.09) in 14 groups that reported such consumption. Conclusion: HTX-011 has a clear advantage in comparison to both placebo and bupivacaine and provides better pain relief and reduces opioid consumption.
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The efficacy of intensive versus conventional insulin therapy in reducing mortality and morbidity in medical and surgical critically ill patients: A randomized controlled study p. 295
Ritu Gupta, Sukhminder Jit Singh Bajwa, John Abraham, Madhuri Kurdi
DOI:10.4103/aer.AER_62_20  
Context: Stress hyperglycemia in critically ill patients has been a matter of debate for years without any conclusive answer till date regarding glucose management and treatment thresholds. Aims: We planned a study with an aim to compare the efficacy of intensive versus conventional insulin therapy in reducing the mortality and morbidity in critically ill patients. The primary objective was to compare mortality between the two groups. The secondary objective was to find out if intensive insulin therapy is better than conventional insulin therapy in terms of various outcomes such as infections and need for inotropes and transfusion requirements. Settings and Design: It was a prospective randomized controlled study. The study population included 100 patients who received mechanical ventilation and admitted to the intensive care department of a tertiary care institute. Subjects and Methods: Patients were randomly assigned to two groups: intensive insulin therapy (IIT) and conventional insulin therapy (CIT) to receive either intensive or conventional insulin therapy. Insulin infusion was started only when blood glucose levels exceeded 200 mg%. Blood glucose levels were maintained between 80 and 110 mg% in the IIG and between 180 and 200 mg% in the CIG. Statistical Analysis Used: The data collected were analyzed separately for both the groups using Student's t-test and Chi-square test. Results: The two groups were comparable in terms of baseline demographic data including age, sex, preadmission diabetic status, and HbA1c at the time of admission. The two groups were not comparable in terms of Acute Physiology and Chronic Health Evaluation-II scores, and the difference between them was statistically significant with higher scores in the conventional group. The primary outcome, that is, mortality, was higher in the CIG with 29 patients (58%) versus 3 (6%) in the IIG (P = 0.02). The secondary outcomes were the measures of morbidity including infections, need for inotropic support, and need for blood transfusions, and these were significantly higher in the conventional group (P < 0.05). Conclusions: We conclude that tight glycemic control significantly lowers mortality and morbidity in critically ill patients, both surgical and medical. These benefits appear with the maintenance of tight blood glucose control of 80–110 mg.dL− 1 and not due to administration of insulin.
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Ultrasound-guided modified parasternal intercostal nerve block: Role of preemptive analgesic adjunct for mitigating poststernotomy pain p. 300
Santhosh Vilvanathan, MS Saravanababu, Rupa Sreedhar, Shinivas Vitthal Gadhinglajkar, Prasanta Kumar Dash, Subin Sukesan
DOI:10.4103/aer.AER_32_20  
Background and Aim: To assess the quality and effectiveness of postoperative pain relief after fast-tracking tracheal extubation in cardiac surgery intensive care unit, effected by a single-shot modified parasternal intercostal nerve block compared with routine in-hospital analgesic protocol, when administered before sternotomy. Design: A prospective, randomized, double-blinded interventional study. Setting: Single-center tertiary teaching hospital. Participants: Ninety adult patients undergoing elective coronary artery bypass grafting surgery under cardiopulmonary bypass. Materials and Methods: Patients were randomized into two groups. Patients in the parasternal intercostal block group (PIB) (n = 45) received ultrasound-guided modified parasternal intercostal nerve block with 0.5% levobupivacaine after anesthesia induction at 2nd–6th intercostal space along postinduction using standardized anesthesia drugs with routine postoperative hospital analgesic protocol with intravenous morphine. Patients in the group following routine hospital analgesia protocol (HAP) (n = 45) served as controls, with standardized anesthesia drugs and routine hospital postoperative analgesic protocol with intravenous morphine. The primary study outcome aimed to evaluate pain at rest and when doing deep breathing exercises with spirometry, coughing expectorations using a 11-point numerical rating scale. Results: The postoperative pain score at rest and during breathing exercises was compared between the two groups at different time durations (15 min after extubation and every 4th hourly for 24 h). Patients in the PIB group had significantly lower pain scores and better quality of analgesia during the entire study period at rest and during breathing exercise (P < 0.0001). Furthermore, the side effect profile and need of rescue analgesics were better in the PIB group than the HAP group at different time intervals. Conclusion: PIB is safe for presternotomy administration and provided significant quality of pain relief postoperatively, as seen after tracheal extubation for a period of 24 h, on rest as well as with deep breathing, coughing, and chest physiotherapy exercises when compared to intravenous morphine alone after sternotomy. This study further emphasizes the role of preemptive analgesia in mitigating postoperative sternotomy pain and it's role as a plausible safe analgesic adjunct facilitating fast tracking with sternotomies on systemic heparinization.
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Effects of passive head-and-neck movements on the performance of i-gel® supraglottic airway device in anesthetized patients – A randomized crossover trial p. 305
Shreyasi Ray, Jyotirmay Kirtania
DOI:10.4103/aer.AER_73_20  
Background: Passive movements of head and neck are sometimes unavoidable during surgery under general anesthesia due to patient positioning according to the needs of the surgery or transmitted movements from surgical manipulations. Aims: This prospective crossover randomized study evaluates the effects of passive movements of the head and neck on the performance of i-gel® supraglottic airway device in spontaneously breathing patients under general anesthesia. Materials and Methods: Sixty spontaneously breathing patients on pressure support ventilation with positive end-expiratory pressure (PEEP) under general anesthesia were randomized to seven sequences of passive head-and-neck movements with i-gel® in situ. After steady state of general anesthesia was achieved and maintenance with sevoflurane in N2O and O2 was reached, the passive head-and-neck movements were done. Peak airway pressure, exhaled minute volume, end-tidal carbon dioxide (ETCO2), oxygen saturation, audible leak of airway gases, and visible outward displacement of the i-gel® were recorded in the neutral position and with each passive head-and-neck movement. Paired continuous data were analyzed by Friedman rank sum test with paired Wilcoxon signed-rank test. Paired nominal data were analyzed by Cochran's Q test with pair-wise McNemar test. Results: Extension, right or left lateral flexion, and right or left rotation of the head and neck resulted in significant reduction in the exhaled minute ventilation, rise in ETCO2, and leak of airway gases compared to the neutral position (P < 0.05). Flexion movement did not cause significant changes in the exhaled minute ventilation, rise in ETCO2, and audible leak of airway gases as compared to the neutral position. Conclusions: Ventilatory performance of the i-gel® deteriorates upon extension, right or left lateral flexion, and right or left rotation of the head and neck in spontaneously breathing patients under general anesthesia on pressure support ventilation with PEEP.
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Cardiac preconditioning effect of ketamine–dexmedetomidine versus fentanyl–propofol during arrested heart revascularization p. 312
Mohammed Adel Hegazy, Refaat Abdelfattah Hegazi, Shimaa Rabea Hendawy, Mohamed Salah Hussein, Amr Abdellateef, Geha Awad, Ola Taha Abdeldayem
DOI:10.4103/aer.AER_55_20  
Background: Myocardial damage due to ischemia and reperfusion is still unavoidable during coronary surgery. Anesthetic agents have myocardial preconditioning effect. Ketamine has sympathomimetic effect, while dexmedetomidine has a sympatholytic effect in addition to anesthetic, analgesic, and anti-inflammatory properties of both the drugs. This study was carried out to compare ketamine–dexmedetomidine (KD) combination with fentanyl–propofol (FP) combination on the release of cardiac troponin T (cTnT) and outcome after coronary artery bypass graft. Patients and Methods: Ninety adult patients who underwent coronary artery bypass grafting (CABG) were assigned to receive either KD base anesthesia (KD group) or FP anesthesia (FP group). Trends of high-sensitive cTnT, CK-MB, and serum cortisol were followed in the first postoperative 24 h. Other outcomes were vital signs, weaning from cardiopulmonary bypass, tracheal extubation time, and echocardiographic findings. Results: There was a significant lower release of cTnT in KD group than FP group during its peak values at 6 h after aortic unclamping (92.01 ± 7.332 in KD versus 96.73 ± 12.532 ng.L−1 P = 0.032). significant lower levels of serum cortisol levels were noted KD group than in FP group at 6 and 12 h after aortic unclamping P < 0.001. As regard tracheal extubation time, patients assigned to KD group extubated earlier than whom in FP group 202.22 ± 28.674 versus 304.67 ± 40.598 min respectively P < 0.001. Conclusion: The use of KD during on-pump CABG confers better myocardial protective and anti-inflammatory effect than fentanyl propofol.
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Comparison of intra-articular analgesia and femoral nerve block for postoperative pain relief in unilateral total knee arthroplasty: A randomized clinical study p. 321
Jony Garg, Suneet Kathuria, Parshotam Lal Gautam, Neeru Luthra, Shikha Gupta
DOI:10.4103/aer.AER_56_20  
Background and Aims: Femoral nerve block (FNB) and intra-articular analgesia (IAA) are used for postoperative analgesia after total knee arthroplasty (TKA). Aims and Objectives: We aimed to determine the better technique among the two, with regard to duration and quality of postoperative analgesia along with 24-h rescue analgesic consumption. The functional recovery in the early postoperative period was also assessed. Settings and Design: This was a prospective double-blind study comprising 40 American Society of Anesthesiologists I–III patients undergoing elective TKA who were randomly assigned to two groups (n = 20). Methodology: In Group A, 20 mL ropivacaine 0.5%, containing dexmedetomidine (1 μg.kg− 1), was given by FNB, and in Group B, intra-articular administration of the same drug was done. Analgesic effect was evaluated by measuring the Visual Analog Scale (VAS) and duration of analgesia. Quadriceps muscle strength was noted. Statistical Analysis: Observation data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann–Whitney rank test. Results: The mean VAS on passive movement at the 2nd, 6th, and 16th h postoperatively was 1.75 ± 0.44, 2.90 ± 0.72, and 2.75 ± 0.44 in Group A as compared to 2.25 ± 0.72, 4.30 ± 2.05, and 2.20 ± 0.77 in Group B (P = 0.026, 0.043, and 0.014, respectively). In Group A, the first request for analgesic (rescue analgesic) was at 637 ± 119 min and the total consumption of tramadol was 50.00 mg. In Group B, the first request for analgesic was at 404.44 ± 136 min, with a total dose of 63.89 mg. The P value for the time of rescue analgesic was <0.001, while for total drug consumption, it was 0.018. Conclusion: We concluded that the duration and quality of analgesia (VAS) were significantly superior and rescue analgesic requirement less in patients who received FNB as compared to IAA.
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Evaluating analgesic efficacy of single femoral nerve block versus combined femoral-sciatic nerve block post total knee arthroplasty p. 326
Achirabha Sinha, Divya Arora, Shailendra Singh, Tanmoy Das, Mohua Biswas
DOI:10.4103/aer.AER_78_20  
Background: With increasing knee replacement surgeries, there has been a constant search for effective pain control modality. Aims: We compared the analgesic effect of femoral nerve block (FNB) alone with combined femoral and sciatic nerve block (SNB) for postoperative pain management after total knee arthroplasty (TKA). Setting and Design: This was a prospective observational study. Methods: A total of 150 adult patients of American Society of Anesthesiologists physical status class I and II scheduled for elective TKA under spinal anesthesia with 3.4-mL bupivacaine 0.5% and 20-μg fentanyl were randomly allocated to two groups. Group F patients received a single shot FNB with 20 ml 0.375% ropivacaine and Group FS patients received combined FNB with 20 mL of 0.375% ropivacaine and SNB with 40 ml of 0.375% ropivacaine at the end of surgery. The primary outcome was the change in Numeric Rating Scale (NRS) scores between Groups F and FS at 6, 12, 18, 24, and 48 h later. The secondary outcome was total doses of opioid required in both groups. Results: The demographic data were comparable in both groups. The NRS scores were higher and statistically significant in Group F than that in Group FS at all five measured time points (P < 0.00001), and the total pain score with a mean of 15.43 in Group F and a mean of 9.61 in Group FS was statistically significant. Significantly more opioid consumption was seen postoperatively in Group F as compared to Group FS at 12, 18, 24, and 48 h as depicted by P < 0.00001. Conclusions: We conclude that the FNB, when combined with SNB, shows superior results than femoral block alone. SNB reduced pain scores and opiate consumption postoperatively up to 48 h.
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Comparison of hemodynamic changes to nasal application of lignocaine jelly versus lubricant gel and responses to Ryle's tube insertion following their use in patients under general anesthesia p. 331
Rajesh Kesavan, Shyam Sundar Purushothaman, Pulak Tosh, Sindhu Balakrishnan, Rekha Varghese, Sunil Rajan
DOI:10.4103/aer.AER_74_20  
Background: Awake patients complain of burning sensation following nasal application of lignocaine jelly. Aim of the Study: The aim of the study was to assess hemodynamic changes, ease of insertion, number of attempts taken, and time required for insertion of Ryle's tube following nasal application of 2% lignocaine jelly versus lubricant gel in patients undergoing surgeries under general anesthesia. Settings and Design: This was a prospective, randomized, open-label study conducted in a tertiary care institute. Subjects and Methods: Eighty patients undergoing surgeries under general anesthesia who required insertion of a Ryle's tube were included. In Group A, 2% lignocaine jelly was used, whereas in Group B, lubricant gel was used prior to Ryle's tube insertion, after induction of anesthesia. Hypertension and/or tachycardia were managed by increasing sevoflurane by 0.5%–1%, followed by propofol bolus of 0.5 mg.kg−1. Statistical Tests Used: Chi-square test and Independent samples t test. Results: Both heart rate and mean arterial pressure were significantly higher at 1 min after nasal application of lignocaine jelly and 1 and 5 min after Ryle's tube insertion in Group A compared to Group B. Ease of insertion of Ryle's tube, number of attempts, and time taken for insertion were comparable in both groups. Significantly higher number of patients in Group A required sevoflurane to be increased and needed propofol boluses. Conclusion: Use of lubricant gel for aiding insertion of Ryle's tube in patients under general anesthesia was associated with attenuated heart rate and blood pressure responses without affecting the ease, number of attempts, or time taken for successful insertion of the Ryle's tube.
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Evaluation of the efficacy of hyperbaric oxygen therapy in the management of diabetic ulcer using Bates-Jensen wound assessment tool p. 335
Usha Shukla, Atit Kumar, S Anushapreethi, Shailenera Pal Singh
DOI:10.4103/aer.AER_68_20  
Background and Aims: Hyperbaric oxygen therapy (HBOT) has been used as a treatment modality for diabetic wound ulcers recently. The aim of the present study was to evaluate the efficacy of HBOT in the management of diabetic ulcer using Bates-Jensen Wound Assessment Tool. Materials and Methods: A total of 50 patients with diabetic ulcer were included in this prospective, randomized, controlled study. Patients were randomly divided into two equal-sized (n = 25) study groups. Patients in Group CT received only conventional therapy and in Group HT received HBOT along with conventional therapy. Wound ulcers were analyzed on 0, 10th, 20th, and 30th sessions using Bates-Jensen Wound Assessment Tool. Statistical analysis was performed using Microsoft (MS) Office Excel Software with the Chi-square test (level of significance, P = 0.05). Results: The healing recovery rate as changes in the Bates-Jensen Wound Assessment Tool from the 0th to 10th session in Group CT 0.88 ± 1.09 as compared to Group HT 9.96 ± 2.73 improved significantly with P = 0.0001. The grading score recorded from the 10th to 20th session in Group CT 3.73 ± 2.55 as compared to Group HT 10.40 ± 2.47 improved statistically significant, P = 0.0001. The grading score recorded from 20th to 30th session in Group CT 6.16 ± 2.01 as compared to Group HT 6.46 ± 2.19, P = 0.646 was not significant. Conclusion: HBOT has a definitive adjunctive treatment option in healing diabetic ulcers and improving quality of life.
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Effect of fentanyl on block characteristics as adjuvant to intrathecal bupivacaine for lower limb surgeries p. 343
Pooja Abbi, Anita Kumari, Ruchi Gupta, Nikhil Monga, Harmandeep Kaur, Keerat Kaur Kullar
DOI:10.4103/aer.AER_58_20  
Background: Regional anesthesia is the preferred technique for most of lower abdominal and lower limb surgeries as it allows the patient to remain awake and minimize the problems associated with airway management. Hyperbaric bupivacaine 0.5%, although extensively used for spinal anesthesia, has a limitation of short duration. The addition of fentanyl, a synthetic lipophilic opioid, is known to prolong postoperative analgesia. Aims: We aimed to study the effect of the addition of different doses of fentanyl to hyperbaric bupivacaine about hemodynamic changes, the extent of sensory and motor block, duration of analgesia, and complications that occur during the procedure. Settings and Design: This study was a prospective, comparative, randomized, and double-blind study. Materials and Methods: Patients were randomly allocated to three groups of 30 each. Group I (n [number of patients] = 30) received bupivacaine 0.5% heavy 2.0 mL diluted up to 2.5 mL with normal saline. Group II (n = 30) received bupivacaine 0.5% heavy 2.0 mL and fentanyl 20 μg diluted up to 2.5 mL with normal saline, and Group III (n = 30) received bupivacaine 0.5% heavy 2.0 mL and fentanyl 50 μg diluted up to 2.5 mL with normal saline. Statistical Analysis: The data were analyzed using Chi-square and Student's t-test. Results and Conclusions: The onset of sensory and motor block was early in Group III in comparison to Group I and Group II (P < 0.05). The duration of analgesia was significantly longer in Group III, followed by Group II, and least in Group I. None of the patients in Groups I and II had any complications such as hypotension, nausea, vomiting, bradycardia, and pruritus. However, the incidence of hypotension, nausea, and pruritus was more in Group III. 2 mg intrathecal bupivacaine with 20 μg fentanyl provides reliable and satisfactory sensory and motor block without increasing the incidence of side effects.
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CASE REPORTS Top

Uncorrected tetralogy of Fallot's: Anesthetic challenges p. 349
Priyanka Dwivedi, Satish Kumar, Shahbaz Ahmad, Santosh Sharma
DOI:10.4103/aer.AER_65_20  
Tetrology of Fallot's (TOF) is the most common cause of cyanotic congenital heart disease, and accounts for 10% of all congenital heart diseases. Right to left shunting and hyperviscosity of blood predisposes these patients to brain abscess. Perioperative management of these patients with uncorrected TOF for noncardiac surgery is a challenge for the anesthesiologists owing to the long-term effects of hypoxia and decreased pulmonary blood flow, resulting in considerable modification of the physiology and neurological complications. We are hereby reporting the anaesthetic management of an 8 year old child with uncorrected TOF presenting with multiple brain abscesses who underwent craniotomy with uneventful recovery.
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Acute transient sialadenitis – “anesthesia mumps:” Case report and review of literature p. 352
Ravees Jan, Khalid Mohammed Alshuaibi, Insha Ur Rehman, Parmod Kumar Bithal
DOI:10.4103/aer.AER_80_20  
Acute postoperative sialadenitis, called “anesthesia mumps,” has been reported in different surgical procedures. It is usually benign in nature, and the swelling resolves spontaneously without any treatment in the majority of cases. The attending physician should be aware of this transient condition. Very rarely, serious complications can occur such as respiratory distress warranting urgent intervention. We report a case of acute transient sialadenitis in a 6-year-old child who underwent general anesthesia for upper gastrointestinal endoscopy, which resolved spontaneously without any treatment.
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NOTICE OF RETRACTION Top

Retraction: Does the preoperative administration of tranexamic acid reduce perioperative blood loss and transfusion requirements after head neck cancer surgery? A randomized, controlled trial p. 355

DOI:10.4103/0259-1162.297841  
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