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   Table of Contents - Current issue
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October-December 2020
Volume 36 | Issue 4
Page Nos. 433-574

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EDITORIAL  

Oxygen therapy in the critically ill: Less is the new more? p. 433
Rohan Magoon, Neeti Makhija, Jes Jose
DOI:10.4103/joacp.JOACP_142_20  
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REVIEW ARTICLES Top

Systemic manifestations of COVID-19 Highly accessed article p. 435
Rubina K Mahajan, Gunchan Paul, Ramit Mahajan, Parshotam L Gautam, Birinder Paul
DOI:10.4103/joacp.JOACP_359_20  
Coronavirus disease 2019 (COVID-19), caused due to a novel coronavirus SARS-CoV-2, has swept across the planet and has become a public health emergency of international concern. Like other coronaviruses, it predominantly involves the respiratory system. However, several atypical manifestations of the disease have been reported worldwide in a short span of time. Almost all organ systems (cardiovascular, gastrointestinal, renal, hepatic, endocrine, and nervous system) have been reported to be involved. This review concisely summarizes the systemic effects of COVID-19, thus emphasizing that the disease can present in various forms and the healthcare workers need to be extra vigilant, approaching all patients with a high index of suspicion.
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Perioperative concerns in Pott's spine: A review p. 443
Geetanjali Tolia Chilkoti, Nidhi Jain, Medha Mohta, Ashok K Saxena
DOI:10.4103/joacp.JOACP_167_19  
Pott's disease is the most common granulomatous spine infection caused by tubercle bacilli and is a common site of osseous tuberculosis, accounting for 50–60% of cases. The delay in establishing diagnosis and management results in complications such as spinal cord compression and spinal deformity. The aim of this narrative review is to discuss the perioperative concerns in patients for spine surgery. The literature source for this review was obtained via PubMed, Medline, Google Scholar, Cochrane database of systematic reviews, and textbooks until December 2019. On the literature search, we could not retrieve any review article specifically discussing the perioperative concerns of spinal tuberculosis. Therefore, the aim of the present narrative review is to discuss the perioperative concerns of patients for spine surgery along with the specific concerns related to spinal tuberculosis.
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Chronic hip pain in adults: Current knowledge and future prospective Highly accessed article p. 450
Vanita Ahuja, Deepak Thapa, Sofia Patial, Anjuman Chander, Anupam Ahuja
DOI:10.4103/joacp.JOACP_170_19  
Chronic hip pain is distressing to the patient as it not only impairs the daily activities of life but also affects the quality of life. Chronic hip pain is difficult to diagnose as patients often present with associated chronic lumbar spine and/or knee joint pain. Moreover, nonorthopaedic causes may also present as chronic hip pain. The accurate diagnosis of chronic hip pain starts with a detailed history of the patient and thorough knowledge of anatomy of the hip joint. Various physical tests are performed to look for the causes of hip pain and investigations to confirm the diagnosis. Management of chronic hip pain should be mechanistic-based multimodal therapy targeting the pain pathway. This narrative review will describe relevant anatomy, causes, assessment, investigation, and management of chronic hip pain. The focus will be on current evidence-based management of hip osteoarthritis, greater trochanteric pain syndrome, meralgia paresthetica, and piriformis syndrome. Recently, there is emphasis on the role of ultrasound in interventional pain procedures. The use of fluoroscopic-guided radiofrequency in periarticular branches of hip joint has reported to provide pain relief of up to 36 months. However, the current evidence for use of platelet-rich plasma in chronic hip osteoarthritis pain is inconclusive. Further research is required in the management of chronic hip pain regarding comparison of fluoroscopic- and ultrasound-guided procedures, role of platelet-rich plasma, and radiofrequency procedures with long-term follow-up of patients.
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Should serial monitoring of procalcitonin be done routinely in critically ill patients of ICU: A systematic review and meta-analysis p. 458
Rupali Patnaik, Afzal Azim, Prabhaker Mishra
DOI:10.4103/joacp.JOACP_388_19  
Sepsis is a life-threatening condition with dysregulated host response to infection. It is a major determinant of mortality in the intensive care unit (ICU). Procalcitonin (PCT) is widely investigated for prognosis in patients with sepsis. Most of the studies have cited that elevated PCT concentrations and PCT non-clearance are associated with poor outcomes in patients with sepsis and some studies have cited as having no additional benefit. Most of the studies have evaluated single PCT measurement and correlated with prognosis and outcome in septic patients. Limited literature is there about serial PCT levels and its impact on the outcome of patients with sepsis. We searched literature through PubMed, Embase, Web of Knowledge, and the Cochrane Library from 2007 to 2017 and present a systematic review and meta-analysis of studies evaluating the utility of serial measurement of PCT for prognosis in critically ill patients. Articles that assessed PCT non-clearance as a marker of mortality data were included. The primary objective of this meta-analysis was to pool the results of all the available studies on serial PCT non-clearance as a mortality predictor and formulate overall area under receiver operating curve (AUROC). To find out the overall proportion of mortality in PCT non-clearance was our secondary objective. To detect the mortality using PCT non-clearance, ROC curve analysis was done. Area under curve (AUC) of the studies was varying between 0.52 and 0.86. Overall AUC was observed 0.711 (95% confidence interval (CI): 0.662–0.760) under fixed effect model and 0.708 (95% CI: 0.648–0.769) under random effect model. There was moderate variation among the studies, i.e., I2 50.80% (95% CI: 0.00–80.42%). The overall proportion of mortality was 37.54% with much heterogeneity (I2 88.24%) among the studies. PCT non-clearance is a fair predictor of mortality. Further studies are needed to define optimal cut off point for PCT non-clearance in ICU patients with sepsis.
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ORIGINAL ARTICLES Top

Decrease in heart rate following the administration of sugammadex in adults p. 465
Trent Sims, Joshua Peterson, Mohammed Hakim, Catherine Roth, Dmitry Tumin, Joseph D Tobias, Jennifer K Hansen
DOI:10.4103/joacp.JOACP_346_19  
Background and Aims: Sugammadex is a novel agent for reversal of steroidal neuromuscular blocking agents (NMBAs) with potential advantages over acetylcholinesterase inhibitors. In preclinical trials, there have been rare instances of bradycardia with progression to cardiac arrest. To better define this issue, its incidence and mitigating factors, we prospectively evaluated the incidence of bradycardia after sugammadex administration in adults. Material and Methods: Patients ≥ 18 years of age who received sugammadex were included in this prospective, open label trial. After administration, heart rate (HR) was continuously monitored. HR was recorded every minute for 15 minutes and then every five minutes for the next 15 minutes or until patient was transferred out of the operating room. Bradycardia was defined as HR less than 60 beats/minute (bpm) or decrease in HR by ≥ 10 beats per minute (bpm) if the baseline HR was <70 bpm. Results: The study cohort included 200 patients. Bradycardia was observed in 13 cases (7%; 95% confidence interval: 4, 11), occurring a median of 4 minutes after sugammadex administration (IQR: 4, 9, range: 2-25). Among patients developing bradycardia, two (15%) had cardiac comorbid conditions. One patient received treatment for bradycardia with ephedrine. No clinically significant blood pressure changes were noted. On bivariate analysis, patients receiving a higher initial sugammadex dose were more likely to develop bradycardia. On multivariable logistic regression, initial sugammadex dose was not associated with the risk of bradycardia. Conclusion: The incidence of bradycardia after administration of sugammadex in our study was low and not associated with significant hemodynamic changes.
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COMMENTARY Top

Cardiovascular adverse effects of sugammadex Highly accessed article p. 469
Mukul Chandra Kapoor
DOI:10.4103/joacp.JOACP_132_20  
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ORIGINAL ARTICLES Top

The COVID-19 hydroxychloroquine prophylaxis perception of Indian anesthesiologists: A survey-based original article Highly accessed article p. 471
Shagun B Shah, Akhilesh Pahade, Rajiv Chawla
DOI:10.4103/joacp.JOACP_379_20  
Background and Aims: HCQ gained importance following the National Task Force advisory as an anti-SARS-Cov-2 (coronavirus disease-2019 [COVID-19]) drug for frontline healthcare workers (including anesthesiologists). Report of a young anesthesiologist in Assam developing cardiac arrest following HCQ intake for COVID-19 prophylaxis made us even more concerned. A conscious decision has been made by a large majority among us––to have or not to have HCQ. However, less severe complications such as gastrointestinal upset, skin-rash, visual-disturbance, headache, and dizziness even if experienced by HCQ users were likely to go unreported unless shared. The present survey was conducted to assess the prevailing perception among Indian anesthesiologists about HCQ's preventive effect against COVID-19. The information has been pooled together and discussed in this study. Material and Methods: A total of 247 respondents participated in this pan-India survey. The survey questionnaire was prepared using “Google Forms” and conducted via links delivered through WhatsApp and electronic-mail. Results: 55.9% (138/247) of the respondents had consumed HCQ, 38% (94/247) did not, and 6.1% (15/247) were undecided at the time of responding to the survey. In total, 47 respondents who ingested HCQ reported a side-effect, gastritis being the commonest (31). Conclusion: The evidence for the effectiveness of HCQ against COVID-19 in India is reportedly as strong and weak as other drugs that have been promoted. The survey highlights the reasons consumption of HCQ and represents the opinion of 247 practicing Indian anesthesiologists. It informs the benefits and side effects of HCQ, which can help others in reaching a balanced decision.
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A randomized controlled trial comparing McGRATH series 5 videolaryngoscope with the Macintosh laryngoscope for nasotracheal intubation p. 477
Reshma Ambulkar, Priya Ranganathan, Sukhada Savarkar, Jigeeshu V Divatia
DOI:10.4103/joacp.JOACP_1_20  
Background and Aims: The aim of this study was to compare the efficacy of McGRATH series 5 videolaryngoscope (VL) with Macintosh laryngoscope for nasotracheal intubation (NTI) in patients without anticipated difficult airways undergoing head and neck cancer surgeries. Material and Methods: We randomized 60 adult patients for NTI by experienced anesthetists with either Macintosh laryngoscope or McGRATH series 5 VL (VL group). The primary objective was to compare time taken for intubation (TTI). The secondary objectives included success rates, number of attempts, need for optimization maneuvers, Cormack and Lehane (CL) grade, and percentage of difficult intubations. Results: The mean TTI in the VL group was 43 (±10.6) versus 75 (±38.0) s in the Macintosh group (99% CI: 12.5; –51.6 s; P < 0.001). The overall intubation success rate was 100% in both groups. All 29 (100%) patients in the VL group were intubated in the first attempt versus 26 (86%) patients in the Macintosh group (99% CI –5; 33%; P = 0.11). In the Macintosh group, 20 (66%) patients needed optimization maneuver versus none in the VL group (99% CI 40; 91%; P < 0.001). In the VL group, 28 (96%) patients had a CL grade 1 view versus 9 (31%) in Macintosh group (99% CI 38; 92%; P < 0.001). There were no difficult intubations in the VL group versus 3 (10%) in the Macintosh group (99% CI: 7; 28%; P = 0.237). There was no trauma to oropharyngeal structures in either group. Conclusion: The McGRATH series 5 VL has faster TTI, better glottic visualization, and less need for optimization maneuvers than the Macintosh laryngoscope for NTI in patients with unanticipated difficult airways, when performed by experienced anesthetists.
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Comparison of conventional C-MAC video laryngoscope guided intubation by anesthesia trainees with and without Frova endotracheal introducer: A randomized clinical trial p. 483
Meenupriya Arasu, Priya Rudingwa, M V S Satyaprakash, Sakthirajan Panneerselvam, Aswini Kuberan
DOI:10.4103/joacp.JOACP_263_20  
Background and Aims: Successful intubation with video laryngoscopes necessitates good hand-eye coordination and the use of intubation adjuncts like bougie and stylet. We proposed this study to find whether using Frova introducer with C-MAC video laryngoscope will reduce the intubation time in trainee anesthesiologists. Material and Methods: We enrolled 140 adults without any difficult airway predictors. They were randomly assigned to undergo C-MAC video laryngoscope guided intubation by anesthesia residents using tracheal tube preloaded over Frova introducer (n = 70) or without Frova introducer (n = 70). Primary outcome was the intubation time. Secondary outcomes were the number of redirections of tracheal tube or Frova introducer toward glottis, need for external laryngeal maneuvers (ELMs), first attempt intubation success rate, and ease of intubation. Results: The median actual intubation time (IQR) in Frova and non-Frova group, respectively, were 25.46 (28.11–19.80) and 19.96 (26.59–15.52) s (P = 0.001). The number of redirections of TT or Frova introducer toward glottis, first attempt success rate, and ease of intubation were comparable. The need for ELMs [n (%)] was 15 (21.4) and 26 (37.1) in Frova and non-Frova group, respectively (P = 0.04). Conclusion: Frova introducer guided endotracheal intubation with C-MAC videolaryngoscope in patients with normal airways had a marginally prolonged intubation time with a significant reduction in the need of external laryngeal manoeuvres but with a comparable number of redirections and attempts. Further research is needed to generalize these findings to patients with difficult airways.
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EC50 of sevoflurane for classic laryngeal mask airway insertion in children at different time points: A randomized blind trial p. 489
Sameer Sethi, Nitika Goel, Babita Ghai, Mantoliya N Sharma, Jagat Ram
DOI:10.4103/joacp.JOACP_108_19  
Background and Aims: Literature documents EC50(End-tidal) of sevoflurane for CLMA (Classic Laryngeal Mask airway) insertion between 1.5 and 2% and most of these studies suggest maintaining the required end-tidal sevoflurane concentration for 10-25 minutes before LMA insertion. Waiting for this long interval for blood brain sevoflurane equilibration may not be feasible in children especially during failed ventilation. We aimed to estimate EC50 of sevoflurane for CLMA insertion at equilibration time points of 2.5 min and 5.0 min. Material and Methods: In this randomized trial, children aged 2_8 years of either sex having American Society of Anesthesiologists status I undergoing elective cataract surgery were included. After inhalational induction of general anesthesia with 8% sevoflurane and 100% oxygen, intravenous cannulation was secured. The sevoflurane vaporizer was finely adjusted to maintain an end-tidal sevoflurane concentration at 2% for 2.5 min for first child in group 2.5 and 5 min in group 5.0. This was followed by LMA insertion which was considered to be unsuccessful if there was “movement” and successful if “no movement” occurred. End-tidal concentration was increased/decreased (step-size 0.2%) using Dixon and Massey up and down method in the next patient depending upon the previous patient's response. Results: EC50 of sevoflurane for insertion of classic LMA in children aged 2-8 yrs in 100% oxygen was 1.1% (0.9-1.2) at 2.5 min and 1.6% (1.5-1.7) at 5.0 min. Derived EC95 (95% CI) at 2.5 min was 1.8% (1.5-9.2) and at 5.0 min was 1.8% (1.4-8.8) respectively. Conclusion: We suggest maintaining end-tidal sevoflurane of 1.6% for 2.5 min and 1.8% for 5 min for successful CLMA insertion.
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Comparison and evaluation of single-use LMA supreme versus the reusable proseal LMA in paralyzed patients undergoing surgery with controlled ventilation p. 494
Suvidha Sood, Shikha Chahar, Anil Thakur, Madhu Gupta, Anupriya Saxena, Shalini Subramanian
DOI:10.4103/joacp.JOACP_298_18  
Background and Aims: The objective of this prospective randomized blinded study was to assess the safety and efficacy of the laryngeal mask airway (LMA) Supreme as compared with the LMA Proseal. Material and Methods: A total of 60 patients were randomised into two groups to either receive a Proseal LMA (PLMA) or Supreme LMA (SLMA) for airway management. The primary outcome was to measure oropharyngeal leak pressure (OLP) in both groups. The secondary outcomes were the measurement of insertion time, insertion success rate, fibreoptic grading, intracuff pressure, ease of ventilation, and airway pressure on standard ventilatory settings and postoperative complications. Results: Intracuff pressure increase after 60 minutes of induction was significantly higher in the PLMA group (PLMA 97.43 ± 11.03 cm of H2O and SLMA 75.17 ± 8.95 cm of H2O). OLP was recorded after device insertion, after 30 min and after 60 min in each group and was found to be 28.71 ± 2.97, 30.93 ± 2.87, and 31.93 ± 2.72 cm of H2O in PLMA and 24.84 ± 2.08, 26.73 ± 2.26, and 27.95 ± 2.55 cm of H2O in SLMA group, respectively. The mean OLP with the SLMA was significantly (p=<.001) lower than PLMA. All the other parameters were comparable in both groups. Conclusion: PLMA is better than SLMA as airway device to ventilate at higher airway pressure in paralyzed adult patients. On the basis of our study, we recommend Proseal over Supreme LMA.
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Evaluating the effectiveness of TENS for maternal satisfaction in laboring parturients – Comparison with epidural analgesia p. 500
Ruchi Gupta, Gaganjot Kaur, Jasleen Kaur, Sunil Chawla, Shubhdeep Kaur, Keerat K Kullar, S Aujla
DOI:10.4103/joacp.JOACP_286_19  
Background and Aims: Labor pain is one of the most severe pain that a woman experiences in her lifetime. Various methods are being used to relieve this pain and to achieve higher maternal satisfaction. One such technique is transcutaneous electrical nerve stimulation (TENS) that uses low-frequency electrotherapy. The aim of our study was to evaluate TENS by comparing it to an established labor analgesia technique, i.e., epidural analgesia in terms of maternal satisfaction. Material and Methods: This prospective study was conducted on 60 parturients in active stage of labor. The choice of analgesia was made by the parturient after informed consent. In group A (n = 30) TENS was used, while in group B (n = 30) epidural ropivacaine 0.125% + 2 μg/ml fentanyl was given. Continuous monitoring of maternal vitals, visual analogue score, and fetal heart rate (FHR) was done. Maternal satisfaction was scored considering pain relief, ability to move and experience of labor at the end of delivery and outcome was labeled as favorable and unfavorable. Results: TENS was found to be favorable in 90% of parturients as compared to 96.6% in epidural (P 0.301). The number of highly satisfied parturients was 4 (13.3%) in TENS group and 17 (56.6%) in the epidural group (P= 0.000). Three patients in the epidural group had assisted delivery and two had cesarean section whereas all patients in TENS group delivered normally (P= 0.065). No significant difference was found in the fetal outcome. Conclusions: TENS is a good alternate choice for providing labor analgesia and may have a major role in future.
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Prophylactic low dose ketamine infusion for prevention of shivering during spinal anesthesia: A randomized double blind clinical trial p. 506
Ramyavel Thangavelu, Sagiev Koshy George, Ravichandran Kandasamy
DOI:10.4103/joacp.JOACP_201_19  
Background and Aims: Regional anesthesia is known to produce perioperative hypothermia and shivering. We aimed to evaluate if prophylactic low dose ketamine bolus followed by infusion would prevent intraoperative and postoperative shivering under spinal anesthesia. Material and Methods: Sixty patients belonging to American Society of Anaesthesiologists (ASA) 1 and 2 undergoing abdominal and lower limb surgery were randomized to receive either 0.2 mg/kg iv of ketamine bolus followed by infusion 0.1 mg/kg/hr (Group K) or5 ml of saline followed by 0.1 ml/kg/hr solution (Group S) as an infusion throughout the period of surgery. The incidence of shivering was the primary outcome of the study with degree of sedation and the hemodynamic profile between the two groups being the secondary outcomes. Hemodynamics (Heart rate, Mean Blood Pressure and temperature), Grade of shivering and grade of sedation were assessed intraoperatively and for grade of shivering and sedation two hours postoperatively. Repeated measures Analysis of Variance (ANOVA) was used to compare the hemodynamic variables and Chisquare test/Fisher's exact test to compare the grades of shivering and sedation between the two groups. Results: Intraoperative shivering was seen in eighteen patients in saline group (58.06%) and only with four patients (13.79%) with ketamine group (P < 0.001). Post operative shivering was also significantly less in ketamine group compared to saline (P = 0.01). Also, patients who received ketamine had significant sedation in the intraoperative period (P < 0.001). Conclusion: Prophylactic low dose ketamine administered as a small bolus followed by an infusion was effective in preventing both intraoperative and postoperative shivering.
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Comparative study of hemodynamic effects of intrathecal bupivacaine with butorphanol in cardiac and non-cardiac patients p. 511
Ruchi Gupta, Deepika Arora, Shubhdeep Kaur, Balpreet Kaur, Sukhvir Kaur
DOI:10.4103/joacp.JOACP_70_20  
Background and Aims: The synergism between intrathecal opioids and low dose local anesthetics makes it possible to achieve reliable spinal anesthesia (SA) with minimal hypotension. The study objective was to compare the hemodynamic effects of reduced dose of 0.5% intrathecal bupivacaine (2mL) with 25 μg butorphanol in cardiac vs non-cardiac patients. Material and Methods: We included sixty patients aged 30-80 years, undergoing infraumbilical surgeries in the study and compared thirty cardiac patients with mild to moderate reduction in left ventricular ejection fraction (LVEF) on 2D echocardiography (Group C) with 30 non-cardiac patients (Group NC) for similar types of surgery. Both the groups received 0.5% bupivacaine 2.0 ml with 25 μg butorphanol. Results: The spinal block characteristics were similar in both groups (P > 0.05). The blood pressure of the patients in the two groups was comparable till 80 min P > 0.05 after which Group NC had significant increase in blood pressure compared to Group C upto 95 min (P < 0.05). Similarly, heart rate was comparable until 90 min (P > 0.05) after which Group NC had significant increase in heart rate versus Group C upto 100 min (P < 0.05). Eight patients in group C and five patients in group NC showed hypotension. Bradycardia was seen in 4 patients in group C in comparison to only one patient in group NC.Conclusion: We can safely consider spinal anesthesia with 10 mg bupivacaine and 25μg butorphanol in cardiac patients with mild to moderately reduced ejection fraction presenting for infraumbilical non-cardiac surgeries with the advantage of intraoperative hemodynamic stability and adequate postoperative analgesia.
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Premedication with pregabalin 150mg versus 300mg for postoperative pain relief after laparoscopic cholecystectomy p. 518
Tanveer Singh, Suneet Kathuria, Richa Jain, Dinesh Sood, Shikha Gupta
DOI:10.4103/joacp.JOACP_440_19  
Background and Aims: Pregabalin has been used in various studies for postoperative pain relief in varying doses. However, there is no conclusive evidence to support a safe and effective dose of pregabalin. The present study was designed to compare the efficacy of two different preoperative doses of pregabalin (150 mg and 300mg) in patients undergoing laparoscopic cholecystectomy for postoperative pain relief. Material and Methods: Ninety adult patients of either sex with American Society of Anesthesiologist physical status I and II scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomized to receive pregabalin 150mg (group A), pregabalin 300mg (group B), or placebo (group C) orally 1 h before surgery. The pain was assessed using a visual analog scale (VAS) and a verbal rating scale (VRS) for the initial 24 h postoperatively. The primary outcome of our study was the comparative assessment of the severity of pain in the postoperative period in three groups. Postoperative analgesic consumption and incidence of side effects were assessed as secondary outcome measures. Results: VAS score was significantly more in group C than group A and B (P-value <0.05). The total amount of fentanyl required in 24 h was least in group B (228.33 ± 42.41μg) followed by group A (292.50 ± 46.49μg) and group C (322.50 ± 39.58μg) (P-value 0.0001). The incidence of sedation, dizziness, and visual disturbances was more in group B as compared to group A and was least in group C. Conclusions: Pregabalin 150 mg is effective in decreasing postoperative pain after laparoscopic cholecystectomy with fewer incidences of adverse effects such as sedation and visual disturbances as compared to pregabalin 300 mg.
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Effect of caudal bupivacaine alone and with adjuvant fentanyl and nalbuphine to minimize the catheter-related bladder discomfort after tubeless percutaneous nephrolithotomy: A prospective randomized study p. 524
Dinesh J Prajapati, Manoj Patel, Pankaj Patel, Mohankumar Vijayakumar, Arvind Ganpule, Deepak Mistry
DOI:10.4103/joacp.JOACP_285_18  
Background and Aims: Catheter-related bladder discomfort (CRBD) is a major cause of postoperative morbidity following urological procedures. The aim of this study was to compare the effect of caudal bupivacaine alone and with adjuvant fentanyl and nalbuphine to minimize the severity of CRBD after tubeless percutaneous nephrolithotomy (PCNL). Material and Methods: A randomized prospective study was conducted on one hundred thirty-two (American society of Anaesthesiologist physical status I to II) patients who presented for tubeless PCNL under general anesthesia. Patients were randomly divided into four groups control (C), bupivacaine (B), bupivacaine-fentanyl (BF), and bupivacaine-nalbuphine (BN) by using computer-generated codes. All patients received local infiltration at the procedure site while Groups B, BF, and BN received caudal epidural block (CEB) under ultrasound guidance after conclusion of the procedure. Groups B, BF, and BN received bupivacaine alone, bupivacaine-fentanyl, and bupivacaine-nalbuphine, respectively, for CEB. Patients were monitored 24 h for CRBD scale, visual analogue score (VAS), and duration of analgesia at 30 min, 1, 2, 4, 6, 12, 18, and 24 h intervals. The analgesics were supplemented if the CRBD score was >2 and VAS was ≥4. Student t-test, analysis of variance, and Chi-square test were applied for quantitative, within group occurrence, and qualitative analysis respectively. Results: The CRBD scores were considerably lower in the Groups BF and BN as compared to Groups C and B during the first four hours. The duration of analgesia was significantly prolonged in Group BN (475 ± 47 min) versus BF (320 ± 68 min) versus B (104 ± 40 min) versus C (26 ± 14 min). Conclusions: The severity of CRBD can be reduced with CEB. The effect of CEB can be prolonged with the addition of opioid.
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Correlation of the changing trends of red cell distribution width and serum lactate as a prognostic factor in sepsis and septic shock p. 531
Mukesh K Gupta, Ghanshyam Yadav, Yashpal Singh, Arvind Bhalekar
DOI:10.4103/joacp.JOACP_105_19  
Background and Aims: Various biomarkers are used for predicting outcome from sepsis and septic shock but single value doesn't give clear-cut picture. Changing trends of serum lactate and red cell distribution width (RDW) gives more accurate information of patient outcome. So, aim of this prospective observational study was to identify the correlation, for initial and changing trend of blood lactate level and RDW, with 28-day mortality in sepsis and septic shock. Material and Methods: Patient who fulfills the criteria of sepsis and septic shock, according to the consensus conference published in 2016, were included in this study. All patients were resuscitated and managed according to institutional protocol for sepsis and septic shock. Serum lactate and RDW was obtained from arterial blood gas and complete blood count, respectively. Serum lactate and RDW were recorded at 0 h, 6 h, 24 h, day 2, day 3, day 7, week 2, and week 3. Mean between two groups were compared with student t-test. Pearson and Spearman correlation coefficient was used for establishing correlation between two continuous data. P value < 0.05 indicates significant difference between two groups. Results: There is positive correlation between serum lactate and RDW at all-time point in non-survival group while negative correlation was found in survival group except on day1 and 2. Conclusion: Changing trends of serum lactate and RDW can be used as a prognostic marker in patient of sepsis and septic shock.
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Randomized double-blind trial comparing effects of low-flow vs high-flow anesthesia on postoperative lung functions using respirometer p. 535
T Krishna Prasad, N Gnanasekar, K Soundarya Priyadharsini, Robin Sajan Chacko
DOI:10.4103/joacp.JOACP_410_19  
Background and Aims: Modern anesthetic practice utilizes low-flow anesthesia with evolving evidence on its pulmonary effects. Studies comparing measurement of vital capacity and inspiratory reserve volume using respirometer in both low-flow and high-flow anesthesia are sparse. We evaluated the effects of low-flow and high-flow anesthesia on postoperative pulmonary functions using respirometer. Material and Methods: This was a prospective randomized double blind study wherein One hundred and ten patients undergoing peripheral surgeries under general anesthesia were allocated into two groups Group I- Low-flow anesthesia with O2 + N2O + Sevoflurane (0.5L + 0.5L + 3.5%) and Group II- High-flow anesthesia with O2 + N2O + Sevoflurane (2L + 2L + 2%). The difference in vital capacity (VC), inspiratory reserve volume (IRV), and peak expiratory flow rates (PEFR) from the preoperative period were compared in both the groups postoperatively. Results: The difference in VC, IRV, and PEFR measured in both the groups between the preoperative and postoperative period were found to be similar and statistically insignificant (P - 0.173, 1.00 and 0.213 respectively). The difference in single breath count (SBC), breath holding time (BHT), and respiratory rates (RR) were also similar in both the groups (P – 0.101, 0.698, and 0.467) respectively. Conclusions: The pulmonary effects of low-flow anesthesia are comparable with the high-flow ones in patients undergoing elective surgeries under general anesthesia.
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A comparative study of desflurane versus sevoflurane in obese patients: Effect on recovery profile p. 541
Tania Bansal, Kamakshi Garg, Sunil Katyal, Dinesh Sood, Anju Grewal, Arvind Kumar
DOI:10.4103/joacp.JOACP_307_19  
Background and Aims: Anesthesia in obese patients is difficult due to associated comorbidities and altered physiology. Desflurane and sevoflurane have a low fat-blood solubility coefficient and are better suited in these patients to achieve a rapid emergence. We studied BIS guided drug titration to compare the postoperative recovery characteristics and cognitive function of desflurane versus sevoflurane in obese patients undergoing laparoscopic abdominal surgeries. Material and Methods: After institutional ethics committee approval and written informed consent, sixty obese patients (BMI ≥30 kg/m2) were randomized to receive either BIS guided desflurane or sevoflurane. Recovery was assessed by time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person after discontinuation of volatile anesthetic agent. For cognitive function, time taken to complete Mini mental state examination (MMSE) score to baseline was compared in both study groups. Results: Difference of time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person was not significant between both anesthetic groups. Patients in sevoflurane group took significantly (P-value = 0.001) less time (40.07 ± 13 min) to achieve preoperative MMSE score than desflurane group (51.2 ± 11.7 min). Conclusion: Both desflurane and sevoflurane have similar recovery profile in obese patients when anesthetic concentration is carefully titrated. Reversal of cognitive function is significantly earlier in obese patients anesthetized with sevoflurane.
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Quantitative rise in intraocular pressure in patients undergoing robotic surgery in steep Trendelenburg position: A prospective observational study p. 546
Nitesh Goel, Itee Chowdhury, Jitendra Dubey, Amit Mittal, Soumi Pathak
DOI:10.4103/joacp.JOACP_96_20  
Background and Aims: Raised intraocular pressure (IOP) is one of the known causes of anterior ischemic optic neuropathy. In the case of robotic urological-gynecological surgeries, patient is kept in steep Trendelenburg supine-lithotomy position. Aim of this study was to observe the quantitative rise in IOP in steep Trendelenburg position (>45°) in robotic-assisted prostatectomy and hysterectomy. Material and Methods: After institutional ethical clearance and written informed consent, 100 patients undergoing robotic surgeries in steep Trendelenburg position were recruited for the study. IOP was measured at different time intervals in steep Trendelenburg position using Schiotz tonometer: Post intubation (T1), post pneumoperitoneum (T2), post steep Trendelenburg (T3), and rest readings were taken 30 min apart. T9 was taken 10 min after patient is made supine and parallel to the ground. Mean arterial pressure (MAP), positive inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2) values were recorded at different time points. Descriptive analysis, linear regression analysis, and Freidman's nonparametric tests were used to analyze the results. Results: Ninety-five patients were included for statistical analysis as five patients were excluded due to intraoperative interventions leading to alteration of results. Mean IOP at T1 was 19.181/18.462 mmHg in L/R eye. A gradual rise in IOP was observed with every time point while patient was in steep Trendelenburg position which reverts back to near normal values once the patient is changed to normal position 21.419/20.671: Left/right eye in mm of Hg. Uni and multiple regression analysis showed insignificant P value, thus no correlation between MAP, PIP, and EtCO2 with IOP. Conclusion: Steep Trendelenburg position for prolong duration leads to significant rise in intraocular pressure.
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FORUM Top

Genetics of malignant hyperthermia: A brief update p. 552
David Beebe, Vikram V Puram, Srdjan Gajic, Bharat Thyagarajan, Kumar G Belani
DOI:10.4103/joacp.JOACP_360_19  
Malignant hyperthermia susceptibility (MHS) and the associated condition malignant hyperthermia (MH) are rare but well-known disorders in the field of anesthesiology. MHS is usually determined by a history of a family member developing a positive episode during general anesthesia and then confirmed by an invasive caffeine halothane contracture test (CHCT). More recently, within the context of MH as a pharmacogenetic disorder, the question of whether or not MHS can be principally genetically determined is of high importance as knowledge of detailed pathogenesis may prevent against its largely invariable lethality if untreated. Thus, in this brief report, genetic terms, as well as updates in the genetics of MHS, will be reviewed in order to better understand both the condition and the current research.
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CASE REPORT Top

Myopathy, residual effect of rocuronium, or both? A possible ritonavir–rocuronium interaction interfering weaning from mechanical ventilation in a patient with COVID-19 pneumonia p. 556
Esther Domingo-Chiva, José Ángel Monsalve-Naharro, Manuel Gerónimo-Pardo
DOI:10.4103/joacp.JOACP_346_20  
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LETTERS TO EDITOR Top

Continuous erector spinae plane block in pediatric patients with intraspinal tumors – Case reports p. 558
Sumitra G Bakshi, Shilpa Awaskar, Sajid S Qureshi, Kunal Gala
DOI:10.4103/joacp.JOACP_14_20  
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Low-dose epidural anesthesia for percutaneous spinal fusion and kyphoplasty due to metastatic fracture of L2 lumbar vertebrae p. 560
Eleftheria Soulioti, Georgia Efstathiou, John Papanastasiou, Vasilios Igoumenou, Georgia Kostopanagiotou, Chrysanthi Batistaki
DOI:10.4103/joacp.JOACP_157_19  
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Airway challenge in repaired tracheo-esophageal fistula patient p. 563
Choro Athiphro Kayina, Manpreet Kaur, Rajeshwari Subramaniam
DOI:10.4103/joacp.JOACP_139_19  
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Un-“Mask”-ing the leak p. 564
Karthik V Iyer, BS Mrudula, Devalina Goswami
DOI:10.4103/joacp.JOACP_154_19  
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Nasopharyngeal airway size selection and its implication in the management of pediatric difficult airway p. 565
Arun Raja Thangavel, Sakthirajan Panneerselvam, Priya Rudingwa, Ranjith K Sivakumar
DOI:10.4103/joacp.JOACP_187_19  
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Difficult airway: Airtraq—A boon p. 566
Teena Bansal, Kiranpreet Kaur, Prashant Kumar, Mamta Bhardwaj
DOI:10.4103/joacp.JOACP_273_19  
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“PUSH” as a mnemonic for Modified Mallampati classification p. 568
Manpreet Singh, Lakesh Anand, Jasveer Singh, Dheeraj Kapoor
DOI:10.4103/joacp.JOACP_437_19  
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Preoperative planning for central venous cannulation in conjoint twins p. 569
Manpreet Kaur, Renu Sinha, Apala R Chowdhury, Shashikant Sharma, Balaji Nagarajan, Madhurjya Baishya, Rajeshwari Subramaniam
DOI:10.4103/joacp.JOACP_596_20  
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Silent” hypoxemia in COVID-19: Hunt for the shunt! p. 570
ItiShri, Rohan Magoon, Neeti Makhija, Ramesh Kashav
DOI:10.4103/joacp.JOACP_491_20  
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COVID-19-related multisystem inflammatory syndrome in children: The plot thickens! p. 571
Jasvinder Kaur Kohli, Rohan Magoon, ItiShri, Ramesh Kashav
DOI:10.4103/joacp.JOACP_543_20  
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NOTICE OF RETRACTION Top

Retraction: Convalescent plasma therapy in COVID 19: Every dark cloud has a silver lining p. 573

DOI:10.4103/0970-9185.307182  
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BOOK REVIEW Top

Atlas of critical care p. 574
Naveen Malhotra, Tej K Kaul
DOI:10.4103/joacp.JOACP_586_20  
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