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April-June 2021
Volume 37 | Issue 2
Page Nos. 145-314

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EDITORIAL  

Moving ahead with JOACP Highly accessed article p. 145
Pradeep Bhatia
DOI:10.4103/joacp.joacp_314_21  
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REVIEW ARTICLES Top

Anesthetic considerations in patients with cystic pulmonary adenomatoid malformations p. 146
Bhavna Gupta, Kapil Chaudhary, Nitin Hayaran, Sujoy Neogi
DOI:10.4103/joacp.JOACP_406_20  
Congenital pulmonary adenomatoid malformation (CPAM) is a rare entity. The authors searched the US National Library of Medicine Database, EMBASE, Google Scholar, PubMed Central for anesthetic management in CPAM. The search was performed using the terms: congenital cystic adenomatoid malformation, congenital pulmonary adenomatoid malformation, CCAM, CPAM, anesthetic management. The prognosis of CPAM depends on timely diagnosis, presence of hydrops, degree of hypoplasia of remaining lung, and the size of the lesion. Symptomatic patients must be treated surgically and lobectomy is considered the gold standard. Anesthetic management of such cases is challenging as it involves thoracotomy or thoracoscopic lobectomy or cystectomy and can lead to sudden hemodynamic Collapse. Early extubation should be considered to avoid iatrogenic ventilator-induced bronchial stump dehiscence resulting from positive pressure ventilation.
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Sugammadex and anaphylaxis: An analysis of 33 published cases p. 153
Baris Arslan, Tuna Sahin, Hatice Ozdogan
DOI:10.4103/joacp.JOACP_383_19  
In this study, the published sugammadex-induced anaphylaxis reports were reviewed to determine similarities in their presentation during anesthesia. PubMed was searched for sugammadex-induced anaphylaxis without time limitation. Reports were evaluated if they were in English and met the criteria of anaphylaxis determined by the World Allergy Organization. Two independent reviewers extracted and assessed the data using predesigned data collection forms. In total, 23 suitable articles were found and 33 sugammadex-induced anaphylaxis cases were included in the study. The mean age was 43.09 years (from 3–89 years) and 17 (51.5%) of the patients were female. Considering all reported cases, the average onset time of anaphylaxis was 3.08 min, with a median of 3 min (range 1–8 min). The most common signs and symptoms were hypotension, tachycardia, erythema, and desaturation. Of the 20 patients who underwent confirmatory skin testing, 15 had a positive skin reaction for sugammadex. Epinephrine was not given when indicated in about 25% of cases. Sugammadex-induced anaphylaxis onset time was less than 5 min in 92.3% of all the reported cases. Rapid diagnosis and early recognition of signs and symptoms of anaphylaxis are essential for a favorable prognosis. Treatment needs to be started as soon as possible to ensure the best outcome for the patient.
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Common anti-COVID-19 drugs and their anticipated interaction with anesthetic agents p. 160
Shagun B Shah, Uma Hariharan, Rajiv Chawla
DOI:10.4103/joacp.JOACP_461_20  
The corona virus disease 2019 (COVID-19) pandemic has till date (26/7/20) affected 1crore 62 lac 73 thousand 638 people globally with almost 6.5 lakh mortalities. COVID-19 has invaded the operation theatre and intensive care unit (ICU) in a short span of 6 months. It appears inevitable that all of us, as anesthesiologists, have to treat COVID-positive patients, either in the ICU or the operation theatre. Many asymptomatic, presumably noninfected people including frontline health care workers are also consuming potential anticorona viral drugs (such as hydroxychloroquine) prophylactically and may present for surgery. Detailed knowledge of which anesthetic and perioperative care drugs can interact with anti-COVID drugs would be very valuable for pre, intra-, and postoperative management of such patients and COVID-19 positive patients requiring intubation, mechanical ventilation, and ICU-sedation. Powered with this knowledge, anesthesiologists and intensivists can minimize the adverse effects of drug interactions. An extensive literature search using different search engines including Cochrane, Embase, Google Scholar, Scopus, and PubMed for all indexed review articles, original articles, case reports, and referenced webpages was performed to extract the most current and relevant literature on drug-drug interactions for clinicians.
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The barrier techniques for airway management in covid-19 patients - review of literature p. 171
Pratishtha Yadav, Rakesh Garg
DOI:10.4103/joacp.JOACP_411_20  
The coronavirus disease 2019 (COVID-19) has emerged as a pandemic and shall prevail for some time around the globe. The disease can manifest from asymptomatic to severe respiratory compromise requiring airway intervention. Transmission of COVID-19 has been reported to be by droplets, fomites, and aerosols, and airway management is an aerosol-generating procedure. The high viral load in the patient's airway puts the clinician performing intubation at a very high risk of viral load exposure. So, the need for barrier devices was considered and led to reporting of various such devices. All these devices have been reported individually and have not been compared. We present a review of all the information on these devices based on the reported literature.
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COVID-19 ARDS: A Multispecialty Assessment of Challenges in Care, Review of Research, and Recommendations p. 179
Shibu Sasidharan, Vijay Singh, Jaskanwar Singh, Gurdarshdeep Singh Madan, Harpreet Singh Dhillon, Prasanta K Dash, Babitha Shibu, Gurpreet Kaur Dhillon
DOI:10.4103/joacp.JOACP_14_21  
Physicians and care providers are familiar with the management of ARDS, however, when it occurs as a sequalae of COVID-19, it has different features and there remains uncertainty on the consensus of management. To answer this question on how it compares and contrasts with ARDS from other causes, the authors reviewed the published literature and management guidelines as well as their own clinical experience while managing patients with COVID-19 ARDS. For research, a PubMed search was conducted on 01.04.2021 using the systematic review filter to identify articles that were published using MeSH terms COVID-19 and ARDS. Systematic reviews or meta-analyses were selected from a systematic search for literature containing diagnostic, prognostic and management strategies in MEDLINE/PubMed. Those were compared and reviewed to the existing practices by the various treating specialists and recommendations were made. Specifically, the COVID-19 ARDS, its risk factors and pathophysiology, lab diagnosis, radiological findings, rational of recommendation of drugs proposed so far, oxygenation and ventilation strategies and the psychological ramifications of the disease were. discussed. Because of the high mortality in mechanically ventilated patients, the above recommendations and findings direct the potential for improvement in the management of patients with COVID-19 ARDS.
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ORIGINAL ARTICLE Top

Competency-based undergraduate curriculum implementation in anesthesiology–A survey-based comparison of two models of training p. 196
Rangraj Setlur, Nikahat Jahan, Nipun Gupta, Kiran Sheshadri
DOI:10.4103/joacp.JOACP_147_20  
Background and Aim: Imparting the knowledge and skills of Anesthesiology to undergraduates can be challenging. Competency Based Undergraduate (CBUG) Curriculum for the Undergraduate medical students introduced by the Medical Council of India (MCI) aims to improve the quality of the Indian Medical Graduate (IMG). The Department of Anesthesiology and Critical Care of our college redrafted the training program and brought it in-line with the CBUG Curriculum beginning February 2019. A questionnaire based survey was conducted to assess the efficacy, satisfaction levels and the perception of the students towards the new competency based curriculum. The aim was to assess the students perception of the competency based curriculum and to evaluate two slightly different approaches to the implementation of the curriculum. Material and Methods: Two groups of undergraduate medical students belonging to the 6th and 8th term, underwent two different models of teaching. The 8th term students had already completed their theory classes based on the older curriculum a year ago when they were in 6th term. However, their clinics and tutorials were modelled as per the new CBUG Curriculum. The current 6th term students had their first exposure to Anesthesiology and their theory, tutorials and clinics were scheduled in the same term, simulation based training was added, the operation theatre rotation was held in the mornings at 0730hrs and the intensive care unit rounds were held in the evenings. There was no difference in the theory classes taken for the two batches, however the clinics were different. After both the batches finished their rotation, they were given the survey questionnaire to assess their perception of the model of CBUG Curriculum that they were exposed to. Results: The results of the survey revealed that about 80% of the students in both groups preferred that theory classes and practical training should be conducted in parallel in 6th term. About 60% students in both groups felt that early morning clinics 0800hrs were better than mid-morning clinics at 1100hrs as they get to see and do more procedures. 66%-82% students in both groups felt that the practical training in the OT, ICU and skills lab were very helpful or extremely helpful. The most important aspect of Anesthesiology rotation was "learning basic life saving skills and simulation based learning" according to 85% students in both groups. Nearly 80% students in both groups felt that the training in Anesthesiology should be allotted more time and more weightage in undergraduate training. 72% students in 6th term and 63% students in 8th term felt more confident of handling emergencies after their Anesthesiology rotation. Conclusion: The new curriculum was extremely well received by the students of both groups. The model used for 6th term students comprising of teaching theory and practical in the same term and having early morning clinics, was found to be superior as compared to the model used to teach 8th term students where there was a gap of one year between theory and practical teaching and the clinics were held midmorning.
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COMMENTARY Top

Competency based anesthesia education: A welcome step p. 203
Mukul Chandra Kapoor
DOI:10.4103/joacp.JOACP_466_20  
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ORIGINAL ARTICLES Top

Comparison of the time taken for subarachnoid block using ultrasound-guided method versus landmark technique for cesarean section – A randomized controlled study p. 205
B Gayathri, CK Swetha Ramani, Karthika Urkavalan, A Pushparani, A Rajendran
DOI:10.4103/joacp.JOACP_35_20  
Background and Aims: Spinal anesthesia is the regional technique preferred for cesarean section and is usually administered using the traditional landmark technique. Ultrasonography of the spine appears to be helpful in locating the puncture site and increasing the success rate. The primary objective of this study was to assess the use of ultrasonogram in locating the lumbar interspinous space for spinal anesthesia in laboring parturients brought for elective cesarean section. Material and Methods: Sixty parturients scheduled to undergo elective cesarean section under spinal anesthesia were included in this prospective randomized controlled trial, after obtaining the institutional ethical clearance. In Group I, 30 patients received spinal anesthesia by landmark technique and in Group II, 30 patients underwent ultrasound-guided spinal anesthesia. The statistical analysis was done using SPSS software version 17 (SPSS Inc., Chicago, Illinois, USA) for Microsoft windows. Results: The time taken for spinal in Group I was longer than in Group II (62 ± 18s; 41 ± 11s; P = 0.0001). The number of attempts of needle insertion was significantly less in Group II (group I 1.86 ± 1.04: group II 1.06 ± 0.25). However, the total preparation time (28 8.30 ± 92 vs 804.73 ± 77; P = 0.0001) was more in the ultrasound-guided than in the landmark group. The patients had better satisfaction in group II. Conclusion: Preprocedural ultrasound is a useful tool for successful lumbar puncture in parturients as it minimizes the number of attempts of needle insertion and provides better patient satisfaction.
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Failure rate of labor epidural: An observational study among different levels of trainee anesthesiologists in a university hospital of a developing country p. 210
Samina Ismail, Amir Raza, Kahif Munshi, Rabia Tabassum
DOI:10.4103/joacp.JOACP_39_19  
Context: Frequent use of labor epidural has also led to a corresponding increase in failed epidural analgesia (FEA). Aims: This study aims to identify the overall rate of FEA and evaluate its association with trainee anesthesiologist at different years/levels of anesthesia residency training. Settings and Design: Prospective observational study was conducted for one year in the labor room suit of a university hospital. Methods and Material: After university ethics committee approval, full-term parturient receiving labor epidurals and consenting for the study were included. FEA was identified by the presence of one or more set criteria of failure including; pain of numeric rating scale of >4 at 45 minutes after epidural placement, accidental dural puncture, need to re-site the epidural, abandoning the procedure, and maternal dissatisfaction with labor pain relief. Statistical Analysis Used: A binary logistic regression was used to assess the association between failure rate of labor epidural and grades of anesthesiologists. Odds ratio (OR) and 95% confidence interval (CI) were reported. P value ≤0.05 was considered significant. Results: Out of 500 women included, 76 (15.2%) had FEA, which was significantly hiagh in 2nd and 3rd year residents compared to 5th year and above level anesthesiologists [OR = 2.08; 95% CI: 1.17 to 3.67; P = 0.012]. Failure rate was also high but insignificant in 4th year residents compared to senior level anesthesiologists [OR = 1.78; 95%CI: 0.89 to 3.53; P = 0.098]. Conclusions: The incidence of FEA is comparable to those quoted in literature from developed countries and shows association to experience and year of training of anesthesia residents.
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Ease of lumbar epidural catheter insertion with prepuncture ultrasound as guidance compared with conventional palpatory technique when performed by anesthesiology residents: A randomized controlled trial p. 216
Anguraj Jagadish, Srinivasan Swaminathan, Prasanna U Bidkar, Suman L Gupta, Sethuramachandran Adinarayanan
DOI:10.4103/joacp.JOACP_394_19  
Background and Aims: Lumbar epidural catheter insertion is conventionally performed by anesthesia residents by palpation of anatomical landmarks with relatively blind localization of epidural space which may lead to an increase in failure rate. We aim to compare the ease of lumbar epidural catheterization using prepuncture ultrasound as guidance with that of conventional palpatory technique. Comparisons were made with reference to number of insertion attempts, total time taken for the procedure, frequency of dural puncture, and overall satisfaction score as assessed by Likert's scale. Material and Methods: Eighty, ASA 1-3, patients undergoing elective surgeries requiring lumbar epidural catheterization were recruited for the study. Study participants were randomized into two groups. In group P, epidural catheterization was performed using the conventional palpatory method and in group U, it was performed with the help of ultrasound determined parameters. Number of insertion attempts, total time taken for successful insertion of epidural catheter, frequency of dural puncture, and overall satisfaction of ease of insertion as determined by Likert's scale were compared between both the groups. Data were analyzed using SPSS statistical software version 17 and P value <0.05 was considered statistically significant. Results: The number of insertion attempts was significantly lesser in Group U (P = 0.019). The total procedure time was significantly higher in group U (P < .001). There was no significant difference in ease of insertion score, as measured by Likert's scale between both the groups (P = 0.45). < Conclusion: Prepuncture ultrasound guidance improves the first attempt success rate of lumbar epidural catheterization with reduced incidence of dural puncture with similar overall satisfaction score but increases the total time taken for the procedure when compared to conventional palpatory technique.
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Laryngeal mask airway protector generates higher oropharyngeal leak pressures compared to the laryngeal mask airway supreme: A randomized clinical trial in the ambulatory surgery unit p. 221
Emilie Acx, Els Van Caelenberg, Luc De Baerdemaeker, Marc Coppens
DOI:10.4103/joacp.JOACP_416_19  
Background and Aims: The Laryngeal Mask Airway (LMA) Protector™ is one of the latest introduced supraglottic airway devices. It provides access and functional separation of the respiratory and digestive tracts. Compared to the LMA Supreme™, it has two digestive ports, one to provide suction in the pharyngeal region and one for gastric tube insertion. High oropharyngeal leak pressure is a marker for safe ventilation when using LMA devices. We hypothesized that oropharyngeal leak pressure of the LMA Protector™ is 5 cm H2O higher than the oropharyngeal leak pressure of the LMA Supreme™ at various cuff volumes. Secondary outcome measures were ease of insertion of both masks, fiberoptic confirmation of correct positioning, failures of insertion, presence of blood staining, sore throat, presence of air leak and insertion time. < Material and Methods: American Society of Anesthesiologists (ASA) I-III patients aged >18 years, scheduled for elective minor ambulatory surgery under general anesthesia with a LMA were included. Patients were randomized in the LMA Protector™ or LMA Supreme™ group based on a computer-generated random sequence table. After general anesthesia induction, oropharyngeal leak pressures were measured. < Results: Oropharyngeal leak pressures were significantly higher (P < 0.0001) for LMA Protector™ compared to LMA Supreme™ at different cuff volumes and a cuff pressure of 65 cm H2O. Insertion time was significantly higher for the LMA Protector™ (29 sec) [interquartile range (IQR) 23, 35] compared to the LMA Supreme™ (19 sec) (IQR 16, 22) (P < 0.0001). There were no statistically significant differences in ease of insertion (number of attempts for succesful positioning), failures of insertion, presence of blood staining, sore throat or presence of air leak. Conclusion: Oropharyngeal leak pressures were consistently higher (>5 cm H2O) for LMA Protector™ compared to LMA Supreme™. LMA Protector™, therefore, allows effective ventilation at higher airway pressures than LMA Supreme™. Trial Registration: http://clinicaltrials.gov.NCT03462550.
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Effect of airway device and depth of anesthesia on intra-ocular pressure measurement during general anesthesia in children: A randomized controlled trial p. 226
Vanlal Darlong, Ramkumar Kalaiyarasan, Dalim K Baidya, Ravindra Pandey, Renu Sinha, Jyotsna Punj, Tanuj Dada
DOI:10.4103/joacp.JOACP_55_19  
Background and Aims: Accurate measurement of intraocular pressure (IOP) under anaesthesia is essential for diagnosis and further management of pediatric glaucoma patients. However, depth of anaesthesia and use of airway device like laryngeal mask airway (LMA) or endotracheal tube can influence IOP values measured. We planned this study to compare change of IOP with facemask or LMA. Change of IOP at varying depth of anaesthesia was also assessed. Material and Methods: After Institutional ethical clearance and informed parental consent, 89 children of glaucoma aged 0-12 years were included in this prospective randomized controlled trial. The children were randomized to facemask (Group M) and LMA (Group L). Sevoflurane was the sole general anaesthetic used in both the groups and IOP were recorded after induction, at BIS 40-60, after LMA insertion (Group L), at BIS 60-80 and BIS more than 80. Results: The IOP values did not differ significantly between the groups at BIS 40-60 and at BIS 60-80. Moreover, pre and post LMA insertion IOP values were also comparable in Gr L (p = 0.11). However, significant increase in IOP values were observed with increasing BIS values within each group. The mean IOP in Group M at BIS 40-60 was 13.41 ± 4.04 as compared to 14.18 ± 3.64 at BIS 60-80 (p = 0.003). There was a similar pattern observed in Group L, where mean IOP at BIS 40-60 & BIS 60-80 was 14.13 ± 4.90 and 15.52 ± 4.57 respectively (p < 0.001). Conclusion: Either facemask or classic LMA can be safely used as per anaesthesiologist's preference without any significant effect on IOP. BIS monitoring may be used during IOP measurement in paediatric glaucoma suspects for accurate assessment of IOP.
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A randomized comparison of epidural, dural puncture epidural, and combined spinal-epidural without intrathecal opioids for labor analgesia p. 231
Wahba Z Bakhet
DOI:10.4103/joacp.JOACP_347_19  
Background and Aims: Dural puncture epidural (DPE) has been shown to improve labor analgesia over epidural (EPL), with fewer side effects than a combined spinal-epidural (CSE). However, there is some debate regarding the superiority of DPE over EPL and CSE. Therefore, we aimed to compare the effects of EPL, DPE, and CSE without intrathecal opioids on the epidural local anesthetic (LA) consumption and occurrence of side effects in early labor. Material and Methods: We randomly assigned parturient to one of the 3 groups; EPL, DPE, or CSE. EPL and DPE groups received a 10 mL loading dose of 0.1% bupivacaine with fentanyl 2 μg/mL. CSE group received intrathecal 2.5 mg bupivacaine (without opioids). Labor analgesia was maintained in all patients via patient-controlled epidural analgesia (PCEA). The primary outcome was the mean hourly consumption of epidural LA. Results: The mean hourly consumption of epidural LA anesthetic was significantly lower in CSE (9.55 mL), compared with the EPL (11 mL), and DPE (10.5 mL), P < 0.01; but no significant difference was seen between EPL and DPE. Compared with EPL and DPE, CSE achieved faster time to complete analgesia defined as a numeric rating pain scale (NRPS) ≤1 and sensory block, lower NRPS in the first hour and higher frequencies of complete analgesia. There were no differences between groups in terms of physician top-up boluses, the occurrence of side-effects, mode of delivery, Apgar scores, and maternal satisfaction. Conclusion: Compared with EPL and DPE, CSE without intrathecal opioids, had a less epidural LA consumption, faster onset of analgesia, with no difference in the incidence of side effects. Trial Registration: This study was registered at www.clinicaltrials.gov (NCT03980951).
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Vitamin D levels of anesthesiologists working in tertiary care hospital of South Asian country: An observational study p. 237
Sonika Bishnoi, Satinder Gombar, Vanita Ahuja, Neerja Bhardwaj, Jasbinder Kaur
DOI:10.4103/joacp.JOACP_310_19  
Background and Aims: Vitamin D deficiency is now emerging as a major global health problem. Doctors spend most of their time indoors and hence, have very low sun exposure. With limited studies on vitamin D levels of anesthesiologists and no published study from South Asian countries, we planned to determine vitamin D levels in anesthesiologists. Material and Methods: One hundred twenty anesthesiologists, working in two tertiary care hospitals, were enrolled in this study. The participants were asked to complete the questionnaire and blood samples were drawn at the same sitting for measuring serum 25(OH) D and serum calcium levels. A subgroup analysis of anesthesiologists was done based on vitamin D status levels defined as per Endocrine society clinical practice guidelines 2011 on vitamin D deficiency. Vitamin D deficiency: 25(OH) D <20 ng/ml (<50 nmol/l), Vitamin D insufficiency: 25(OH) D of 21–29 ng/ml (52.5–72.5 nmol/l), Vitamin D sufficiency: 25(OH) D of ≥30 ng/ml (≥75 nmol/l). Results: The mean working hours in a day [mean ± standard deviation (SD)] were 10.70 ± 1.56 hours with a range of 8–15 hours. The mean ± SD level of vitamin D in anesthesiologists was 14.56 ± 9.39 ng/ml with a range of 5.30–58.00 ng/ml. Out of 120 anesthesiologists, 101 (84.2%) anesthesiologists had deficient levels of vitamin D, 10 (8.3%) had insufficient levels, and 9 (7.5%) anesthesiologists had sufficient levels of vitamin D. Majority of the anesthesiologists had normal serum calcium levels. A total of 91.5% of doctors had vitamin D deficiency who were not taking vitamin D supplement groups as compared to 28.6% in doctors who had taken vitamin D supplements in the past. Conclusion: Prevalence of vitamin D deficiency/insufficiency was high among anesthesiologists. However, levels were optimal in professionals taking vitamin D supplements.
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Preparation, validation, and evaluation of an information leaflet for patients undergoing day-care surgeries under general anesthesia at a busy tertiary care hospital p. 243
Amit Raja Panigrahi, Sumitra G Bakshi
DOI:10.4103/joacp.JOACP_264_19  
Background and Aims: It is essential that patients posted for day-care surgeries are adequately prepared preoperatively. Verbal information alone may not be always effective. This study aimed to prepare, validate, and evaluate the efficacy of a patient information leaflet (PIL) for patients undergoing day-care surgeries under general anesthesia (GA). Material and Methods: After approval from the hospital ethics committee a PIL was prepared in English. Readability and design of the leaflet were checked using standard tests: Flesch readability ease test (FRE), Flesch Kincaid grade level (FKGL), and Baker Able leaflet design (BALD). It was translated into three regional languages. The PIL was tested among patients using a questionnaire. Seventy-nine adult patients posted for elective day-care procedures were included while emergency surgeries were excluded. Patient knowledge pre and post-PIL was compared using paired 't' test. The influence of age, gender, and education level on the usefulness of PIL were analyzed using the Chi-square test and knowledge was compared using ANOVA. Results: The English leaflet had an FRE Score of 63.9 and FKGL of 6.4, which is "standard". The BALD score for all leaflets was 25 ("above standard"). The overall knowledge scores significantly improved from 52.6% (preintervention) to 70.7% (postintervention), P < 0.001. Knowledge improvement was seen with the use of PIL in all four languages. Sixty eight percent of patients strongly recommended the PIL while 31% were willing to recommend it to others. Conclusion: The PILs developed in this study have standard readability, good design and validated for efficacy.
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A randomized double-blinded controlled trial comparing ultrasound-guided versus conventional injection for caudal block in children undergoing infra-umbilical surgeries p. 249
Navya Kollipara, V Rajesh Kumar Kodali, Aruna Parameswari
DOI:10.4103/joacp.JOACP_361_19  
Background and Aims: Caudal epidural block is widely used in pediatric surgeries to provide intraoperative and postoperative analgesia in infra-umbilical surgeries. The conventional technique involves the risk of multiple punctures and other complications such as dural puncture, vascular puncture, and intraosseous injection. Material and Methods: Around 106 children aged between 6 months to 10 years belonging to ASA class I-II scheduled for elective infra-umbilical surgeries were included after obtaining written informed consent from parents/guardians. All children were randomized into two groups: ultrasound-guided (Group U) or conventional caudal group (Group C). All were premedicated with oral midazolam and inhalational induction was done with oxygen and 6–8% sevoflurane. Caudal block of 1 mL/kg of 0.125% bupivacaine was administered in both groups. The primary outcome assessed was 1st puncture success rate and the secondary outcomes assessed were number of skin punctures, block performing time, and block success rate. Results: Group U had a higher first puncture success rate (P = 0.001) than Group C (90.6% v/s 64.2%) and was statistically significant. The number of punctures were significantly less (P = 0.01) in Group U (1.09 ± 0.295) than Group C (1.45 ± 0.667). Block performing time was significantly higher (P = 0.0005) in Group U (53.19 ± 10.97 s) than Group C (30.34 ± 7.34 s). There was no difference in the overall block success rate between the groups (98.1% v/s 100%). Conclusion: Ultrasound-guided caudal injection increases the first puncture success rate and decreases the number of punctures required compared to conventional caudal block in pediatric infra-umbilical surgeries.
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Comparative evaluation of dexmedetomidine and fentanyl in total intravenous anesthesia for laparoscopic cholecystectomy: A randomised controlled study p. 255
Tabish Husnain Siddiqui, Nitin Choudhary, Abhijit Kumar, Amit Kohli, Sonia Wadhawan, Poonam Bhadoria
DOI:10.4103/joacp.JOACP_253_18  
Background and Aims: Laparoscopic cholecystectomy is one of the commonly performed ambulatory surgeries. The selection of anesthetic agents for ambulatory surgeries should be done bearing in mind the need for early discharge. Opioids form an integral component of total intravenous anesthesia (TIVA) but their associated side effects may result in an increased hospital stay. Hence, we planned a study to compare the opioid (fentanyl) and non-opioid (dexmedetomidine) based technique of TIVA for laparoscopic surgery. Material and Methods: Ninety ASA I and II patients between 18-60 years of either sex posted for laparoscopic cholecystectomy were randomly allocated into two groups namely group D (Dexmedetomidine) and group F (Fentanyl). Patients received propofol infusion along with group specific drug infusion, after which an appropriate size proseal laryngeal mask airway was placed. The patients were assessed for discharge time from post-anesthesia care unit (PACU), on table recovery time, time to first rescue analgesia, hemodynamic parameters, incidence of postoperative nausea and vomiting (PONV) and any other complication. Results: Demographic profile of both the groups was comparable. Group D had longer on table recovery time (13.00 ± 2.34 min vs 6.29 ± 2.46 min; P < 0.001) and time to discharge from PACU (6.80 ± 3.96 min vs 2.36 ± 1.67 min; P < 0.001) compared to group F. Group F had better hemodynamic stability compared to group D. In group D, 77% patients required rescue analgesia in first one hour post surgery, unlike 22% in group F. No patient in group D had PONV. Conclusion: Opioid based technique (Fentanyl) of TIVA is superior over non-opioid based (dexmedetomidine) technique with faster recovery, early discharge, decreased postoperative pain scores and better hemodynamic stability. PONV is observed with opioids which can be treated successfully with antiemetics.
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Desmopressin nasal spray reduces blood loss and improves the quality of the surgical field during functional endoscopic sinus surgery p. 261
Reza Safaeian, Valiollah Hassani, Arman Ghandi, Masood Mohseni
DOI:10.4103/joacp.JOACP_227_19  
Background and Aims: Making a dry surgical field during functional endoscopic sinus surgery (FESS) is a challenge for anesthetists. This study was conducted to evaluate the pre-emptive hemostatic effects of a single dose of an intranasal spray of desmopressin (DDAVP) in sinus surgery. Material and Methods: Sixty consecutive patient's as first-time candidates for FESS due to chronic sinusitis were enrolled. They were randomly allocated to receive either a nasal spray of DDAVP 20 μg or sterile water before induction of anesthesia. Management of anesthesia was achieved with propofol and remifentanil infusions. Blood loss, quality of the surgical field, and surgeon's satisfaction were compared between the two groups. Results: Blood loss in the DDAVP group was 147 ± 43 mL and in the placebo group 212 ± 64 mL (mean ± SD, P < 0.01). The quality of the surgical field in the DDAVP group was better than the placebo group. (median score, 1 (1–2) vs. 2 (1–3), P = 0.017). Surgeons were more satisfied with the surgical field in the DDAVP group than in the control group (median score, 4 (2.8–5) vs. 3 (2-3), P = 0.04). Conclusion: Premedication with nasal spray DDAVP 20 μg effectively reduces bleeding and improves the surgical field during FESS.
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A randomized control led study comparing CMAC video laryngoscope and Macintosh laryngoscope for insertion of double lumen tube in patients undergoing elective thoracotomy p. 266
Amit Mathew, Jacob Chandy, Joseph Punnoose, Birla Roy Gnanamuthu, L Jeyseelan, Raj Sahajanandan
DOI:10.4103/joacp.JOACP_79_20  
Background and Aims: Double lumen tube (DLT) insertion for isolation of lung during thoracic surgery is challenging and is associated with considerable airway trauma. The advent of video laryngoscopy has revolutionized the management of difficult airway. Use of video laryngoscopy may reduce the time to intubate for DLTs even in patients with normal airway. Material and Methods: A total of 87 ASA 1–3 adults, scheduled to undergo elective thoracotomy, requiring a DLT were randomly allocated to videolaryngoscope (CMAC) arm or Macintosh laryngoscope arm. It was on open label study, and only the patient was blinded. The primary objective of this study was to compare the mean time taken for DLT intubation with CMAC (Mac 3) and Macintosh laryngoscope blade and the secondary objectives included the hemodynamic response to intubation, the level of difficulty using the intubation difficulty scale (IDS), and complications associated with intubation. Data was analysed using the statistical software SPSS (version 18.0). Results: The time taken for intubation was not significantly different (42.8 ± 14.8 s for CMAC and 42.5 ± 11.5 s for Macintosh laryngoscope P -0.908). The CMAC video laryngoscope was associated with an improved laryngoscopy grade (Grade I in 81.8% with CMAC and in 46.5% with Macintosh), less pressure applied on the tongue, and less external laryngeal pressure required. Hemodynamic responses to intubation were similar in both groups. Conclusion: Macintosh blade is as good as CMAC (mac 3) blade to facilitate DLT intubation in adult patients with no anticipated airway difficulty, however CMAC was superior as it offers better laryngoscopic view, needed less force, and fewer external laryngeal manipulations.
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Comparative evaluation of analgesic efficacy of buprenorphine transdermal patch and fentanyl patch in management of postoperative pain after arthroscopic lower limb surgery: A randomized controlled trial p. 272
Hariom Khandelwal, Anoop Negi, Nishith Govil, Ashutosh Singh, Kumar Parag, Bharat Bhushan Bhardwaj
DOI:10.4103/joacp.JOACP_405_20  
Background and Aims: Transdermal opioids are newer modality in use for the control of postoperative pain, because of its noninvasiveness, longer duration of action, sustained blood levels, and with minimal side effects. The study was aimed to evaluate the efficacy of analgesia of buprenorphine patch 10, 20 μg·h-1 and fentanyl patch 25 μg·h-1 for relief of pain in the postoperative period in patients undergoing arthroscopic lower limb surgeries. Materials and Methods: It was a randomized, double-blinded, prospective study in which adult patients undergoing lower limb arthroscopic surgery were randomly segregated into three groups. In Group 1 (fentanyl patch 25 μg·h-1), Group 2 (buprenorphine patch 10 μg·h-1), and Group 3 (buprenorphine patch 20 μg·h-1), transdermal patches were applied 12 h prior to surgery. Mean NRS score, total rescue analgesic requirement, drug-related adverse effects, and hemodynamic status were evaluated till 72 h in the postoperative period. Results: Out of 175 screened patients, 150 patients were finally analyzed. Baseline characteristics were the same among all the three groups. Median NRS score was lowest in Group 3 [P value < 0.05 at 2, 4, 8, 12, and 24 h after surgery (Kruskal Wallis test). The total consumption of postoperative rescue analgesic diclofenac was the lowest in Group 3 as compared to other groups without any significant increase in adverse events. Conclusions: In arthroscopic lower limb surgery, buprenorphine patch (20 μg·h-1) applied 12 h prior to surgery is an effective postoperative analgesic and it is not associated with any significant adverse effects.
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FORUM Top

Containment of varicella outbreak in intensive care unit of a tertiary level hospital p. 279
Raman Sharma, Kapil Goyal, Nidhi Bhatia, Vikas Rana, Mini P Singh, Ashish Bhalla, Gurpreet Singh, Ashok Kumar, Kajal Jain
DOI:10.4103/joacp.JOACP_542_20  
Background: Varicella–Zoster virus (VZV) infection in healthcare organizations, especially in intensive care units (ICU), having admitted immunocompromised patients, is of serious concern as well as poses threat to healthcare workers working in such critical areas. The present report defines the transmission and infection control measures initiated to curtail VZV infection spread in the trauma ICU of a tertiary care hospital of North India. Outbreak Report: At the infection outset, there were 12 patients admitted in ICU and 54 healthcare workers were posted to manage these critical patients. After confirmation of VZV infection, all susceptible patients as well as healthcare workers were quarantined and fresh intake of patients was restricted. Out of the total healthcare workers, 14 (25.92%) were found susceptible (as per protective VZV IgG titers) and were vaccinated. Of the 12 patients admitted in the ICU, six patients were discharged and sent home directly, four patients expired due to their critical disease state, one patient left against medical advice, and one patient remained admitted in ICU till the incubation period was over. Epidemiologically, line listing for index case reporting was done. The efficacy of control measures was re-evaluated to strengthen existing infection control practices and general measures viz. strict hand washing, adherence to aseptic protocols and intensification of environmental cleaning. Conclusions: Established varicella surveillance measures ensure VZV outbreaks are identified in a timely manner and control measures implemented to prevent further transmission. Also, vaccination policy among HCWs is the utmost requirement despite having huge financial implications.
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COVID-19 pandemic and preparedness of anesthesia team in a stand-alone cancer centre in Eastern India p. 284
Jyotsna Goswami, Anshuman Sarkar, Sudipta Mukherjee, Pralay S Ghosh, Angshuman R Pal, Suparna M Barman, Sumantra S Banerjee, Rudranil Nandi, Sanjay Bhattacharyya
DOI:10.4103/joacp.JOACP_454_20  
India came under the grip of the coronavirus disease-2019 (COVID-19) pandemic and is now seeing rising graph. Cancer patients are specially in the high-risk group because of their immunocompromised status on one hand and progressive disease on the other hand. Hence, cancer care facility needs to prepare a clear strategy to manage their space, staff and supplies so that optimum patient care can be continued in the face of COVID-19 pandemic. In addition, infection prevention measures need to be robust to reduce in-hospital transmission. The working area of anesthesia and Critical Care is spread over the whole hospital such as operating room, ICU, isolation area, out-patient dept (OPD) area, various diagnostic areas and in-patient dept (IPD) to attend code blue calls. In this article, we describe the preparedness and initial response measures of the anesthesia and Critical Care department of a stand-alone tertiary level cancer care centre in eastern part of India. These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow, introduction and adequate supply of personal protective equipment for staff and formulation of clinical guidelines for anesthetic management. These containment measures are necessary to continue care of cancer patients, optimize the quality of care provided to COVID-19 positive cancer patients and to reduce the risk of viral transmission to other patients or healthcare providers.
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CASE REPORTS Top

Novel management of critically induced polyneuropathy in intensive care patients: A case report of two patients p. 290
Vanita Ahuja, Selwin Rajan Selvam, Anjuman Chander, Nishit Sawal
DOI:10.4103/joacp.JOACP_427_19  
There has been tremendous growth in patients requiring critical care with severe infections. During a prolonged stay in the intensive care unit (ICU), patients develop critical illness polyneuropathy (CIP). The early identification of neurological involvement requires special attention during ICU care. We describe two cases who developed complete motor weakness after a prolonged stay in ICU. Patients were successfully managed with pyridostigmine and testosterone hormonal therapy initially and later with pyridostigmine only. The present case series highlights the need for early recognition, assessment, and novel management of CIP in ICU patients. However, the role of nutrition, physiotherapy, and supportive care is equally essential for the successful outcome in these patients.
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Imipenem-induced paroxysmal supraventricular tachycardia in a sepsis patient p. 293
Vanita Ahuja, Harjit Sharma, Vaishali Singla
DOI:10.4103/joacp.JOACP_409_19  
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LETTERS TO EDITOR Top

Pericapsular nerve group (PENG) block for hip fractures: Another weapon in the armamentarium of anesthesiologists p. 295
Rajendra Kumar Sahoo, Ashok Jadon, Santosh Kumar Sharma, Abhijit S Nair
DOI:10.4103/joacp.JOACP_295_20  
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Learning as we grow, growing as we learn p. 297
Gauri Raman Gangakhedkar
DOI:10.4103/joacp.JOACP_378_19  
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Airway management of a patient with laryngotracheal disruption following blunt neck trauma p. 298
Swetha N Sivachalam, Sunil Rajan, Jerry Paul, Lakshmi Kumar
DOI:10.4103/joacp.JOACP_368_18  
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Pre-anesthesia ward for optimization of co-morbid illnesses of high-risk surgical patients: The time is now p. 299
Om P Sanjeev, Prakash K Dubey, Manoj Tripathi
DOI:10.4103/joacp.JOACP_352_17  
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A rare cause of intraoral endotracheal tube kinking in obstructive hydrocephalus p. 301
Gaurav Jain, Amiya K Barik, Sagarika Panda
DOI:10.4103/joacp.JOACP_239_19  
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Amiodarone in junctional ectopic tachycardia: A word of caution! Highly accessed article p. 302
Pooja Ahuja, Ashish Walian, Rohan Magoon, Ramesh Kashav
DOI:10.4103/joacp.JOACP_403_19  
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A curious case of hiccups during laparoscopic surgery p. 304
Chengyuan Zhang, Neil Shaw
DOI:10.4103/joacp.JOACP_184_19  
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Edentulous patient and intraoperative endotracheal tube migration p. 305
Priya Rudingwa, C Madhanmohan
DOI:10.4103/joacp.JOACP_280_18  
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Postoperative Acute Superficial Thrombophlebitis, an interesting case p. 307
Soumya Sarkar, Aswini Kuberan, Lakshmi N Yaddanapudi
DOI:10.4103/joacp.JOACP_331_18  
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Effect of sodium bicarbonate infusion in off-pump coronary artery bypass grafting in patients with renal dysfunction: Cautious interpretation is required p. 309
Habib M. R. Karim
DOI:10.4103/joacp.JOACP_320_18  
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Diagnosis and practical implications of ECG lead reversal: Anesthesiologist perspective p. 311
Ramya Ravi, Chandrasekaran Aravind, Vishnudharen Sundararajan, Lenin B Elakkumanan
DOI:10.4103/joacp.JOACP_363_18  
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Personal protective equipment for Health care workers donning for COVID-19 areas: Walking a tight rope between safety and comfort! p. 312
Anju Gupta, Nishkarsh Gupta
DOI:10.4103/joacp.JOACP_427_20  
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ACKNOWLEDGMENT TO EDITORS AND REVIEWERS Top

Acknowledgment to Editors and Reviewers p. 314
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