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   Table of Contents - Current issue
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January-March 2021
Volume 37 | Issue 1
Page Nos. 1-142

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EDITORIAL  

An Odyssey of an Editor: Adieu & Best Wishes JOACP! Highly accessed article p. 1
Anju Grewal
DOI:10.4103/0970-9185.313431  
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REVIEW ARTICLES Top

Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group p. 3
Ajay Gandhi, Klaus Görlinger, Sukesh C Nair, Poonam M Kapoor, Anjan Trikha, Yatin Mehta, Anil Handoo, Anil Karlekar, Jyoti Kotwal, Joseph John, Shashikant Apte, Vijay Vohra, Gajendra Gupta, Aseem K Tiwari, Anjali Rani, Shweta A Singh
DOI:10.4103/joacp.JOACP_410_20  
In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.
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Evolution of videolaryngoscopy in pediatric population p. 14
Anju Gupta, Ridhima Sharma, Nishkarsh Gupta
DOI:10.4103/joacp.JOACP_7_19  
Direct laryngoscopy has remained the sole method for securing airway ever since the inception of endotracheal intubation. The recent introduction of video-laryngoscopes has brought a paradigm shift in the pratice of airway management. It is claimed that they improve the glottic view and first pass success rates in adult population. The airway management in children is more challenging than adults. The role of videolaryngoscopy for routine intubation in children is not clearly proven. This review attempts to discuss various videolaryngosocpes available for use in pediatric patients.
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Artificial Intelligence and technology in COVID Era: A narrative review p. 28
Vanita Ahuja, Lekshmi V Nair
DOI:10.4103/joacp.JOACP_558_20  
Application of artificial intelligence (AI) in the medical field during the coronavirus disease 2019 (COVID-19) era is being explored further due to its beneficial aspects such as self-reported data analysis, X-ray interpretation, computed tomography (CT) image recognition, and patient management. This narrative review article included published articles from MEDLINE/PubMed, Google Scholar and National Informatics Center egov mobile apps. The database was searched for “Artificial intelligence” and “COVID-19” and “respiratory care unit” written in the English language during a period of one year 2019-2020. The relevance of AI for patients is in hands of people with digital health tools, Aarogya setu app and Smartphone technology. AI shows about 95% accuracy in detecting COVID-19-specific chest findings. Robots with AI are being used for patient assessment and drug delivery to patients to avoid the spread of infection. The pandemic outbreak has replaced the classroom method of teaching with the online execution of teaching practices and simulators. AI algorithms have been used to develop major organ tissue characterization and intelligent pain management techniques for patients. The Blue-dot AI-based algorithm helps in providing early warning signs. The AI model automatically identifies a patient in respiratory distress based on face detection, face recognition, facial action unit detection, expression recognition, posture, extremity movement analysis, visitation frequency detection sound pressure, and light level detection. There is now no looking back as AI and machine learning are to stay in the field of training, teaching, patient care, and research in the future.
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COMMENTARY Top

Emerging role of artificial intelligence in medical sciences—Are we ready! p. 35
Rakesh Garg, Anuradha Patel, Wasimul Hoda
DOI:10.4103/joacp.JOACP_634_20  
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REVIEW ARTICLE Top

Ketamine-induced neurotoxicity in neurodevelopment: A synopsis of main pathways based on recent in vivo experimental findings Highly accessed article p. 37
Konstantina Kalopita, Athanasios Armakolas, Anastassios Philippou, Apostolos Zarros, Panagoula Angelogianni
DOI:10.4103/joacp.JOACP_415_19  
Ketamine, a phencyclidine derivative and N-methyl-D-aspartate (NMDA) receptor antagonist, is widely used as an anesthetic, analgesic, and sedative agent in daily pediatric practice. Experimental studies have suggested that early prenatal or postnatal exposure to ketamine can induce neuroapoptosis, and establish neurobehavioral deficits that are evident in adulthood. However, most of the currently available clinical evidence is derived from retrospective and observational clinical studies. We, herein, attempt a brief review of the cellular and molecular mechanisms suggested to mediate ketamine-induced developmental neurotoxicity, utilizing a selected number of recent in vivo experimental evidence.
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ORIGINAL ARTICLES Top

Effect of large volume paracentesis performed just prior to transjugular intrahepatic portosystemic shunt on the anesthetic management during the procedure p. 43
Hanzhou Li, Zhuo Sun, Nadine Odo, Jayanth H Keshavamurthy, Shvetank Agarwal
DOI:10.4103/joacp.JOACP_265_19  
Background and Aims: Patients often undergo paracentesis prior to a transjugular intrahepatic portosystemic shunt (TIPS) procedure to improve respiratory mechanics. However, the effect of large volume paracentesis (LVP) on intraoperative hemodynamics and anesthetic management when it is performed immediately before the TIPS procedure is not well documented. Material and Methods: This is a retrospective study in patients undergoing the TIPS procedure between 2004 and 2017. Patients were divided into two groups based on the volume of preoperative paracentesis, namely, small volume paracentesis (SVP), defined as paracentesis volume less than 5 L and LVP, defined as paracentesis volume of at least 5 L. Patients' demographics and perioperative information were collected through chart review. The Wilcoxon signed-rank test, student's t-test, and Fisher's exact test were used when appropriate. Uni- and multivariate linear regression analyses were used to determine the predictive value of paracentesis volume in relation to intraoperative hemodynamics and management of hypotension. Results: Of 49 patients, 19 (39%) received LVP and the remainder received SVP. Baseline demographics were comparable between groups as were intraoperative hypotension and volume of infused crystalloid and colloid. However, vasopressor use (P = 0.02) and packed red blood cell transfusion (P = 0.01) were significantly higher in the large volume group. Paracentesis volume was an independent predictor of the phenylephrine dose (P = 0.0004), and of crystalloid (P = 0.05) and colloid (P = 0.009) volume administered after adjusting for age, sex, body mass index, alcohol use, hemoglobin, and model for end-stage liver disease score. Conclusion: The anesthetic management of patients who undergo LVP just prior to a TIPS procedure may require larger doses of vasopressors and colloids to prevent intraoperative hemodynamic instability during the TIPS placement but may be as well tolerated as SVP.
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A survey of cardiopulmonary resuscitation in COVID-19 patients p. 47
Mukul C Kapoor, S SC Chakra Rao, Rasesh Dewan, Bernd W Böttiger
DOI:10.4103/joacp.JOACP_36_21  
Background and Aims: The novel coronavirus 2 (SARS-CoV-2) pandemic has placed severe resource constraints on hospitals. High mortality rates of the COVID-19 have overwhelmed the resuscitation services. The constant fear of virus infection during cardiopulmonary resuscitation (CPR) has placed severe restrictions on the resuscitation services. Reports of poor outcomes after CPR further dampened the spirits of CPR providers. Hence we surveyed CPR practices for COVID -19 patients across hospitals in India by health care providers. Material and Methods: An online survey using Google Forms was initiated to collect data on performance of CPR in diagnosed cases of COVID-19 after in-hospital cardiac arrest. The survey's web-link was publicized using social media, and participation sought of all personnel involved in CPR delivery in COVID-19 patients. The responses received were analyzed. The main outcome measured were determination of the percentage of COVID-19 patients discharged home who were administered CPR. Results: There were 248 responses from different parts of India. At the time of cardiac arrest, 194 victims had diffuse lung infiltrates, 22 had mild lung disease, while 32 had no documented lung lesion. Twenty-five victims had evidence of pulmonary embolism, 39 had cardiac involvement, and 3 had brain involvement. Return of spontaneous circulation (ROSC) was achieved in 59.27% of cases but ROSC sustained in only 22.59%. 7.25% of patients, who received CPR, could be discharged home. Conclusion: The survey has shown reasonable survival rates after CPR administration in COVID-19 patients suffering from IHCA. We should not ignore the need to maximize live outcomes after CPR, even in COVID-19 patients.
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The incidence of anosmia in patients with laboratory-confirmed COVID 19 infection in India: An observational study p. 51
Vinod Kumar, Sapna Singla, Nishkarsh Gupta, Sachidanand Jee Bharati, Rakesh Garg, Anuja Pandit, Saurabh Vig, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/joacp.JOACP_653_20  
Background and Aims: Acute loss of smell or anosmia is a common and sometimes the only symptom observed in patients with coronavirus disease-2019 (COVID-19). The objective of the study was to determine the prevalence, time of onset, and duration of anosmia in patients with COVID-19 infection and the association of anosmia with other symptoms and eosinophil count. Material and Methods: Two hundred patients with laboratory-confirmed COVID-19 infection, who were asymptomatic or mildly symptomatic were assessed for olfaction with a nonirritant odor. The presence of anosmia was recorded, and a questionnaire integrating the anosmia reporting tool was filled. Patients with anosmia/hyposmia were followed telephonically at 7 and 14 days for resolution of anosmia and other symptoms. The presence of anosmia was correlated with eosinophil count. Results: Of the 200 COVID-19 patients, 87% were symptomatic. More than half of the patients had fever (56%). Anosmia was observed in 30% of the patients and hyposmia in 4% of patients. In 41% of the patients, olfactory loss was reported before diagnosis. The mean duration of anosmia was 7.8 (± 5) days; 97% of patients recovered with a resolution of symptoms within 2 weeks. Ageusia was the most commonly and significantly associated symptom with anosmia (66%, n = 45) followed by sore throat (41%), and rhinorrhea (28%). The symptoms in both the sexes were comparable. Absolute eosinophil count of <40/μL was observed in 59 patients (29.5%) and an absolute eosinophil count of 0 in 17 patients (8.5%). Among the 68 anosmic patients, 36 (47%) patients had eosinopenia, which was statistically significant. Conclusion: Anosmia is an early and sometimes the only symptom in approximately one-third of the patients with COVID-19 infection. Eosinophil count should be checked in anosomic patient with suspicion of COVID-19 infection. Objective tools for olfactory and gustatory assessment should be brought into practice for early and prompt diagnosis to control the spread of the disease.
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COVID-19 pandemic and its impact on peer review speed of anesthesiology journals: An observational study p. 57
Bikram Kishore Behera, Rakesh Vadakkethil Radhakrishnan, Chitta Ranjan Mohanty, Snigdha Bellapukonda
DOI:10.4103/joacp.JOACP_652_20  
Background and Aims: Publication of a scientific article in a reputed journal is an uphill task that demands a significant amount of time and effort from the author and editorial team. It is a matter of great enthusiasm for all prospective researchers to know whether this daily evolving publication load of articles during this pandemic had changed the journal's inherent peer review or publication process. We aimed to compare the peer review speed of anesthesiology journal articles published during pandemic (2020) to the previous year and to analyze various factors affecting peer review speed. Material and Methods: Overall, 16 anesthesiology journals indexed in MEDLINE database were retrospectively analyzed. A set of 24 articles published in 2019 of the included journals were selected from each journal for control and a set of 12 articles published between January to September 2020 was selected for comparison. Time taken for acceptance and publication from the time of submission was noted. Peer review timing was calculated and its relationship with h-index, continent of journal origin and article processing charges were evaluated. Results: The median peer review time in 2019 and 2020 were 116 (108-125) days and 79 (65-105.5) days, respectively. There was a 31.8% decrease (P = 0.0021) in peer review time of all articles in 2020 compared to 2019. The median peer review timings of COVID-19 articles were 35 (22-42.5) days. A 55.6% decrease was noted in peer review time of COVID-19 articles compared to non-COVID-19 articles in 2020. There was a significant correlation between peer review time and h-index (r = 0.558, P = 0.024). There was no significant difference in peer review timing of journals with or without article processing charge (P = 0.75) and between journals from different continents (P = 0.56). Conclusion: Anesthesiology journals managed to curtail their turnaround time for peer review during the pandemic compared to previous year. Journal with higher h-index had longer peer review time. The option for articles processing charge and continent of publishing journal had no impact on peer review speed.
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Efficacy of ondansetron and palonosetron in prevention of shivering under spinal anesthesia: A prospective randomized double-blind study in patients undergoing elective LSCS p. 63
Manoj K Sharma, Deepak Mishra, Nitin Goel
DOI:10.4103/joacp.JOACP_215_18  
Background and Aims: Postanesthesia shivering (PAS) is a common, distressing experience. Ondansetron, the classical 5HT3 antagonist has been in use for its prevention since long. Palonosetron, a newly introduced potent antiemetic drug with better pharmacodynamics is currently in use by clinicians. Hence, a study was conducted to compare the efficacy of ondansetron and palonosetron in preventing PAS in patients undergoing elective lower segment caesarean section (LSCS) under spinal anaesthesia. Material and Methods: A total of 84 patients scheduled for elective LSCS under spinal anesthesia were randomly allocated to one of the two study groups (Group O & P). Accordingly, 8 mg of ondansetron or 0.075 mg palonosetron was administered in the same volume intravenously 30 min preoperatively. Sublingual temperature was recorded regularly. All patients were observed for 90 min postspinal for PAS. Observations were analyzed statiscally. Results: No statistically significant intergroup difference was observed in the duration of surgery, and sublingual temperature. However, statistically significant difference was recorded for PAS (23.8% in ondansetron group, 9.5% in palonosetron group). Conclusion: Prophylactic administration of palonosetron significantly reduced incidence of PAS compared to ondansetron. However, further studies with larger sample size and more heterogeneous groups are suggested.
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Effect of oral gabapentin premedication on hemodynamic parameters and postoperative pain in patients of laparoscopic cholecystectomy: A randomized double-blind controlled study p. 67
Richa Jain, Mahendra Kumar, Tanveer Singh, RS Rautela, S Kumar
DOI:10.4103/joacp.JOACP_439_19  
Background and Aims: Carbon dioxide (CO2) pneumoperitoneum created during laparoscopic cholecystectomy causes adverse hemodynamic changes such as rise in arterial pressure. The aim of this study was to assess the effect of oral gabapentin premedication on hemodynamic parameters in addition to postoperative nausea and vomiting (PONV) and pain in patients of laparoscopic cholecystectomy conducted under general anesthesia. Material and Methods: Randomly selected 60 American Society of Anesthesiologists (ASA) class I patients scheduled for laparoscopic cholecystectomy were premedicated with either gabapentin 1200 mg (Group GB) or placebo (Group PL) 2 h prior to induction of anesthesia. Anesthesia was induced with fentanyl, propofol, and vecuronium; and maintained with oxygen (33%), nitrous oxide (66%), and isoflurane (1%) with controlled ventilation. Hemodynamic parameters were recorded at various time intervals intraoperatively and during pneumoperitoneum every 10 min till 50 min. Postoperatively visual analog score (VAS) for pain, incidence of PONV, and sedation score were recorded for 6 h. The collected data were analyzed statistically by using repeated measures analysis of variance (ANOVA), Student's t test, Chi-square test, and Mann–Whitney U test. Results: Changes in mean BP, systolic BP, and diastolic BP from prepneumoperitoneum values were significantly less in group GB during pneumoperitoneum (P < 0.05) with no significant change in HR in both groups (>0.05). VAS score was significantly lower in group GB. The duration of analgesia and PONV free period were significantly higher in group GB (P < 0.01). Conclusion: Oral gabapentin premedication may be used to control hemodynamic parameters during pneumoperitoneum in patients undergoing laparoscopic cholecystectomy.
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High-volume, multilevel local anesthetics–Epinephrine infiltration in kyphoscoliosis surgery: Intra and postoperative analgesia p. 73
Alaa Mazy, Mohamed Serry, Mohamed Kassem
DOI:10.4103/joacp.JOACP_338_17  
Background and Aims: Local anesthetic (LA) infiltration is one of the analgesic techniques employed during scoliosis correction surgery. However, its efficacy is controversial. In the present study for optimizing analgesia using the infiltration technique, we proposed two modifications; first is the preemptive use of high volume infiltration, second is applying three anatomical multilevel infiltrations involving the sensory, motor, and sympathetic innervations consecutively. Material and Methods: This prospective study involved 48 patients randomized into two groups. After general anesthesia (GA), the infiltration group (I) received bupivacaine 0.5% 2 mg/kg, lidocaine 5 mg/kg, and epinephrine 5 mcg/mL of the total volume (100 mL per 10 cm of the wound length) as a preemptive infiltration at three levels; subcutaneous, intramuscular, and the deep neural paravertebral levels, timed before skin incision, muscular dissection, and instrumentation consecutively. The control group (C) received normal saline in the same manner. Data were compared by Mann-Whitney, Chi-square, and t-test as suitable. Results: Intraoperatively, the LA infiltration reduced fentanyl, atracurium, isoflurane, nitroglycerine, and propofol consumption. Postoperatively, there was a 41% reduction in morphine consumption, longer time to the first analgesic request, lower VAS, early ambulation, and hospital discharge with high-patient satisfaction. Conclusion: The preemptive, high-volume, multilevel infiltration provided a significant intra and postoperative analgesia in scoliosis surgery.
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Comparison of analgesic requirements in robot-assisted versus conventional laparoscopic abdominal surgeries p. 79
Athira Suresh Mangalath, Lakshmi Kumar, Ambreen Basheer Sawant, Rajesh Kesavan, Greeshma Ravindran, Rajan Sunil
DOI:10.4103/joacp.JOACP_354_18  
Background and Aims: Robot-assisted surgery is advantageous in the precision of tissue handling and shorter postoperative recovery. We compared postoperative analgesic requirements in laparoscopic versus robot-assisted surgery in the first 24 h as our primary objective. The secondary outcomes were extubation on table, time to ambulation, and length of ICU stay. Material and Methods: After approval from the ethics committee 48 patients undergoing either laparoscopic (group L [n = 24]) or robotic abdominal surgery (group R [n = 24]) were evaluated for analgesic requirements postoperative targeting a numerical rating scale ≤3 in a prospective comparative study. Postoperative patients were allotted to a three-tier pain management, level 1 comprising paracetamol 1 g intravenously every 8 h, level 2, 1.5 mg/kg tramadol every 8 h, and level 3 fentanyl 0.5 μg/kg. The total analgesic consumption in the first 24 h was calculated for each group. Statistical analysis was performed using the Chi-square test and Mann-Whitney U test. Results: Age, weight, and types of surgery were comparable between the groups. The intraoperative opioid use was comparable between both groups but the duration of surgery was longer in group R. Postoperative analgesic requirements were significantly less in group R (P = 0.024) and the length of ICU stay was shorter (P < 0.05). The time to ambulation was significantly shorter in group R patients (P < 0.001). Conclusion: Analgesic requirements were significantly less in robot-assisted laparoscopic surgery in the first 24 h. The time to ambulation and length of ICU stay were shorter in the robot-assisted group in comparison to the laparoscopic group.
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Effect of transcutaneous electrical nerve stimulation on quality of recovery and pain after abdominal hysterectomy p. 85
Serkan Karaman, Tuğba Karaman, Hulya Deveci, Asker Z Ozsoy, Ilhan B Delibas
DOI:10.4103/joacp.JOACP_207_19  
Background and Aims: Transcutaneous electrical nerve stimulation (TENS) is a noninvasive complementary therapy for postoperative pain management. The effect of TENS on quality of recovery (QoR) and pain treatment in the early postoperative period is not well documented. The aim of this study was to evaluate the effect of TENS on postoperative QoR and pain in patients who had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO). Material and Methods: Fifty-two patients were randomized into two groups: control (sham TENS treatment) and TENS (TENS treatment). QoR, dynamic pain, and static pain were evaluated after surgery. Results: The QoR score was significantly higher in the TENS group as compared with that in the control group (P = 0.029). Pain scores during coughing (dynamic pain) were significantly less in TENS group compared to control group (P <0.001). However, there was no between-group difference in pain scores at rest (static pain) or total analgesic consumption (P = 0.63 or P = 0.83, respectively). Conclusion: TENS may be a valuable tool to improve patients' QoR and dynamic pain scores after TAH + BSO.
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Comparative evaluation of transsacrococcygeal and transcoccygeal approach of ganglion impar block for management of coccygodynia Highly accessed article p. 90
Naveen Malhotra, Sudeep Goyal, Amit Kumar, Kanika , Vishal Singla, Zile Singh Kundu
DOI:10.4103/joacp.JOACP_588_20  
Background and Aims: Coccygodynia or Coccydynia is pain in the area of coccyx and ganglion impar block is commonly used technique for treatment of coccygodynia. Material and Methods: Forty patients of either sex in the age group of 20-70 years suffering from coccygodynia, who failed to respond to six weeks of conservative treatment were enrolled in the study. All patients were subjected to detailed clinical history, examination in the Pain Management Centre (Pain Clinic) of our Institute and imaging studies were reviewed. The patients were randomly divided into two groups of 20 each by a computer generated randomization number table: Group-TS (n = 20): Patients were administered ganglion Impar block by trans-sacrococcygeal approach Group-TC (n = 20): Patients were administered ganglion Impar block by trans-coccygeal approach with 8 ml of 0.5% bupivacaine plus 2 ml of 40mg/ml methylprednisolone acetate under fluoroscopic guidance. Results: Both the techniques of ganglion Impar block were effective and provided good pain relief to the patients with coccygodynia. There was a statistically and clinically significant improvement in pain score after ganglion Impar block in both the groups at all time intervals during the study period. (p < 0.05). The mean pain score after ganglion Impar block was <2 at all time intervals throughout the three month study period in all patients in the two groups. All patients in both the groups had excellent satisfaction immediately after ganglion Impar block. Five patients each in both groups required second ganglion Impar block during the three months study period. Conclusion: Both trans-sacrococcygeal and trans-coccygeal approaches of ganglion Impar block with a combination of local anaesthetic and steroid are safe and effective for management of coccygodynia. Trans-coccygeal ganglion Impar block through the first intra-coccygeal joint is better in terms of improvement in pain score, functional disability, patient satisfaction and ease of administration.
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Evaluation of the accuracy of vibration sense with VibraTipTM as a tool to determine the level of anesthesia following subarachnoid block and its correlation with the pinprick sensation p. 97
Sangineni Kalyani Surya Dhana Lakshmi, C Kasavanesi Ramakrishna, Dasari SatyaSree, P Vangala Prakash
DOI:10.4103/joacp.JOACP_258_18  
Background and Aims: Assessment of level of anesthesia after subarachnoid block (SAB) is essential. We aimed to evaluate the efficacy of vibration sense as a criteria to determine the level of surgical anesthesia. Method and Materials: The study included patients, scheduled for various surgeries under SAB. The baseline values of vibration sense perception using VibraTipTM, motor power using the modified Bromage scale, and sensory block by pinprick method were recorded preoperatively and at 5 and 7 min after administration of SAB. The correlation between vibration sense, loss of pinprick sensation, and level of anesthesia were assessed. Results: The concordance correlation coefficient between the pinprick and vibration sense at 5 min and 7 min showed poor strength of agreement with Pearson ρ (precision) being 0.4192 at 5 min and 0.4701 at 7 min. Conclusion: Vibration sense serves as a reliable indicator to assess the level of surgical anesthesia following SAB. Vibration sense testing with VibraTipTM along with motor power assessment can be used as a tool for assessment of level of block. There is a poor correlation between level of vibration sense and pinprick.
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Comparison of morphine, dexmedetomidine and dexamethasone as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus block for postoperative analgesia—a randomized controlled trial p. 102
Rajagopalan Venkatraman, Anand Pushparani, Krishnamoorthy Karthik, Prabuvel Nandhini
DOI:10.4103/joacp.JOACP_70_19  
Background and Aims: An ideal adjuvant to local anesthetic in a nerve block should prolong the duration of analgesia, and hasten the onset of sensory and motor blockade without significant adverse effects. The aim of this study was to compare morphine, dexmedetomidine, and dexamethasone as an additive to ropivacaine in ultrasound-guided supraclavicular brachial plexus block (SBPB) for postoperative analgesia. Material and Methods: In this randomized, double-blinded study, 150 patients undergoing upper extremity surgery were randomly divided into three groups: group A (morphine 5 mg), group B (dexmedetomidine 50 μg), and group C (dexamethasone 8 mg). The additives were added to 30 ml of 0.5% ropivacaine solution and administered in SBPB. The duration of postoperative analgesia, onset of sensory and motor blockade, sedation, and adverse effects were observed. The pain was assessed by visual analog scale (VAS) and sedation by Ramsay sedation score. The duration of postoperative analgesia was taken as time consumed from block completion to administration of rescue analgesia (VAS >3). Results: The demographic profile was similar in both groups. The duration of analgesia was significantly longer in dexamethasone (867.2 ± 217.6 min) than morphine (739. 2 ± 162.5 min) and dexmedetomidine (654.2 ± 179.9 min) (P < 0.001). The onset of sensory and motor blockade was quicker with dexmedetomidine than dexamethasone and morphine. Three cases of block failure were reported with morphine. No major adverse effects were reported. Conclusion: Dexamethasone is an ideal adjuvant to ropivacaine in brachial plexus block to prolong postoperative analgesia and devoid of adverse effects. Dexmedetomidine has a quicker onset of sensory and motor blockade.
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Airway management using LMA-evaluation of three insertional techniques-a prospective randomised study p. 108
T Shyam, Venkatesh Selvaraj
DOI:10.4103/joacp.JOACP_60_19  
Background and Aims: Laryngeal Mask Airway [LMA] insertion has become as a basic procedural skill needed for all health care providers. Search for the most successful insertion technique continues. We evaluated the success rate of the three LMA insertion techniques- standard, 90 degree rotational and 180 degree rotational technique. Material and Methods: A total of 180 patients of ASA I-II aged 18-65 years undergoing open superficial surgical procedures with (LMA® Unique™ Airway, Teleflex®, Teleflex Medical Europe Ltd, Ireland) as an airway management device and with neuromuscular blocking agents, were randomly allocated to three groups, in this prospective randomized study. In the standard technique group (n = 60), the LMA was inserted by standard digital intraoral method. In the 90 degree rotational technique group (n = 60), the LMA was rotated counter-clockwise through 90 degree in the mouth and advanced until the resistance of the hypopharynx was felt, and then straightened out in the hypopharynx. In 180 degree rotational technique, LMA was inserted back-to-front, like a Guedel airway. The parameters studied were: the LMA placement success at first attempt, insertion time, need for more than one attempt at insertion, need for external airway manipulations, postoperative sore throat, blood staining and other post-operative (airway related) complications. Results: The first attempt success rate in the standard technique was 83.9%, in 90 degree rotational technique was 75% and 180 degree rotational was 93.5%. The first attempt success rate was higher in 180 degree rotational group compared to 90 degree rotational group (P < 0.05), but there was no statistically significant difference (P > 0.05) between 90 degree rotational group and the standard technique group. There was no statistically significant difference among the two groups in terms of the secondary outcomes. Conclusion: We conclude that 180 degree rotational technique of LMA insertion is more successful than 90 degree rotational technique in adult patients under general anaesthesia.
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Effect of intracuff dexamethasone on incidence and severity of post operative sore -Prospective randomized study p. 114
Sunil Rajan, Naina Narayani, Jerry Paul, Lakshmi Kumar
DOI:10.4103/joacp.JOACP_28_19  
Background and Aims: Postoperative sore throat (POST) continues to be a common concern following endotracheal intubation. Objectives of the present study were to compare the effects of intracuff dexamethasone on the incidence and severity of POST, postoperative hoarseness of voice (POHV) and cough (POC). Material and Methods: This prospective, randomized, double blinded study was conducted in 60 patients undergoing short laparoscopic surgery lasting <2 h. Patients were randomly allocated into Group A and B. After intubation, endotracheal tube (ETT) cuffs were filled with saline in group A and with 0.1 mg/kg dexamethasone in group B. All patients received general anesthesia as per a standardized protocol. Incidence and severity of POST, POC, and POHV were assessed. Results: As compared to group A, the number of patients who had sore throat was significantly low in group B at 2, 6, 12, and 24 h (P < 0.001). Though more number of patients in group A had postop cough at all time points and postop hoarseness of voice at 2,6, and 12 h, the difference was statistically significant only at 2 h and 6 h for both. Severity as well as the incidence of POST, POC, and POHV showed a downward trend in both groups with time. In group B, no patient had POST after 12 h, POC after 6 h, and none complained of POHV in the postoperative period. Conclusion: Intracuff dexamethasone 0.1 mg/kg significantly reduces incidence and severity of POST, POC, and POHV which occur following general anesthesia with endotracheal intubation in patients undergoing short pelvic laparoscopic procedures lasting <2 h.
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Anesthetic management and outcomes of patients with Steven-Johnson Syndrome—A retrospective review study p. 119
Manjula V Ramsali, Koshy G Puduchira, Sitaram P Maganti, Sarada Devi Vankaylapatti, Surender Pasupuleti, Dilipkumar Kulkarni
DOI:10.4103/joacp.JOACP_46_19  
Background and Aims: Steven-Johnson Syndrome (SJS) is a rare and severe form of erythema exudative multiforme. Multisystem involvement in SJS and the suspicion of precipitation of the disease with exposure to anesthetic drugs makes anesthesia a challenging task. The concerns during anesthesia are the mucosal lesions and special care that is required to prevent injury to the oropharynx and larynx during airway management and also the drugs used for anesthesia. In the literature, very few isolated case reports or case series are available. Here, we have analyzed the cases of SJS coming for ophthalmic anesthesia, taking into consideration factors like mode of presentation, precipitating factors, associated diseases, types of anesthesia, anesthetic modifications, and various drugs used during anesthesia. Material and Methods: The electronic medical records of 497 cases of SJS who required interventions like ophthalmic examination or surgery (either under local or general anesthesia) over a period of 18 months were analyzed retrospectively. The records were reviewed to obtain the concerned details like anesthesia-inducing agents, muscle relaxants, inhalational agents, and analgesics. The problems concerned with monitoring and intubation were also noted. The data were analyzed and presented as frequency and percentage. Results: Patient age ranged between 9 months and 72 years. Many surgeries were conducted under general anesthesia (441) although a few required local (peribulbar block) anesthesia (56). The drugs administered for general anesthesia were sevoflurane, isoflurane, propofol, thiopentone, vecuronium, and atracurium and those administered for pain management were fentanyl, tramadol, butorphanol, and paracetamol. The patients who were sensitive to nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol were not administered the same. None of the patients reacted adversely to the different drugs used for anesthesia. Conclusion: Identifying the precipitating factors, understanding the pathophysiology and its implications for anesthesia will help in successfully managing anesthesia in the rare cases of SJS.
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Pulsed radiofrequency for chronic post-herniorrhaphy inguinal pain: A road less traveled p. 124
Sukanya Mitra, Jasveer Singh, Kompal Jain, Swati Jindal
DOI:10.4103/joacp.JOACP_90_20  
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Ultrasound guided erector spinae plane block –An effective rescue analgesia for pediatric open upper abdominal surgery p. 126
Aswini Kuberan, Nagalakshmi Swaminathan, Adinarayanan Sethuramachandran, Mukilan Balasubramanian
DOI:10.4103/joacp.JOACP_69_20  
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A rare case of tracheoesophageal fistula and pneumothorax occurring simultaneously in a patient following percutaneous dilatational tracheostomy p. 127
Karan Singla, Kamal Kajal, Neha Chauhan, Sunita Kajal, Vikas Saini
DOI:10.4103/joacp.JOACP_98_19  
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In reply to the article “A simple solution to fogging inside goggles used as a part of personal protective equipment” p. 129
Sandip Kumar Sahu, Rakesh Vadakkethil Radhakrishnan, Chitta Ranjan Mohanty, Bikram Kishore Behera, Bishnu Prasad Patro
DOI:10.4103/joacp.JOACP_627_20  
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Anesthetic considerations of CHILD syndrome p. 130
Ameya Pappu, Manpreet Kaur, Joel J Gnanadhas, Rakesh Dawar, Ajay Singh
DOI:10.4103/joacp.JOACP_425_19  
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Anesthesia management of a case of hyperhomocysteinemia induced mesenteric venous thrombosis and short review of literature p. 132
Shalendra Singh, Pothireddy Sreenivasulu, Subhasish Patnaik, Deepak Dwivedi
DOI:10.4103/joacp.JOACP_440_20  
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Perioperative antibiotics administration: Who will take the onus? p. 134
Pranshuta Sabharwal, Gurukaran Kaur Sidhu, Summit Dev Bloria, Rajeev Chauhan
DOI:10.4103/joacp.JOACP_436_19  
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Failure of hinged tip laryngoscope due to design variation p. 135
Vibhavari Milind Naik, Basantha Kumar Rayani, Aanchal Bharuka
DOI:10.4103/joacp.JOACP_374_19  
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Anesthetic management of Ehlers-Danlos syndrome patient with Takayasu arteritis for capsulorrhaphy of the temporomandibular joint p. 136
Shalendra Singh, Nipun Gupta, Pothireddy Sreenivasulu, Munish Sood
DOI:10.4103/joacp.JOACP_301_19  
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Persistent low bispectral index values with propofol in a patient of cirrhosis p. 137
Ankur Khandelwal, Shruti Gupta, Gyaninder P Singh, Arvind Chaturvedi
DOI:10.4103/joacp.JOACP_277_18  
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Effect of anesthetic agent on brain volume: A transcranial sonographic assessment p. 139
Indu Kapoor, Charu Mahajan, Hemanshu Prabhakar
DOI:10.4103/joacp.JOACP_274_19  
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FDA approved ready to use phenylephrine p. 141
Pradeep Kumar Bhatia, Ankur Sharma
DOI:10.4103/joacp.JOACP_379_19  
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Magnesium: The neglected cation in COVID-19? Highly accessed article p. 141
Jes Jose, Rohan Magoon, Poonam M Kapoor
DOI:10.4103/joacp.JOACP_628_20  
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