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   Table of Contents - Current issue
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January-March 2023
Volume 17 | Issue 1
Page Nos. 1-144

Online since Monday, January 2, 2023

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ORIGINAL ARTICLES  

Efficacy of in-situ simulation training using evaluation checklists for sudden oxygen supply failure during general anesthesia: A preliminary report Highly accessed article p. 1
Keisuke Nishida, Fumio Watanabe, Taiki Kojima
DOI:10.4103/sja.sja_541_22  
Introduction: Sudden oxygen supply failure (OSF) is a life-threatening consequence that may be triggered by natural disasters. Anesthesiologists are required to manage OSF promptly in such catastrophic situations. However, the current evidence regarding the efficacy of anesthesia training for sudden OSF is insufficient. This preliminary study aimed to introduce our in-situ simulation training utilizing evaluation checklists for a sudden OSF situation during general anesthesia and to evaluate the efficacy of the training program for anesthesia providers. Methods: This is a preliminary single-center, prospective study. We developed an OSF simulation scenario utilizing evaluation checklists with key actions to manage OSF. The training session comprised four components: orientation, benchmark evaluation (pre-test) according to the checklists, a short didactic lecture, and post-lecture evaluation (post-test). The scenario comprised two steps wherein the participants were supposed to utilize different oxygen supply sources immediately after OSF (Step 1) and minimize the amount of oxygen consumption (Step 2). Results: Fifteen anesthesia providers were enrolled. The score for all anesthesia providers in the post-test was significantly higher than that in the pre-test (median 8 [IQR: 8, 8], 3 [IQR: 3, 4], P < 0.001, respectively). The successful performance rates of all anesthesia providers in one key action of all the four in Step 1 and four of all the six in Step 2 were significantly higher in the post-test than in the pre-test. Conclusions: Our in-situ training method utilizing evaluation checklists for a sudden OSF situation improved overall performance of anesthesia providers.
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Perfusion index during endotracheal intubation and extubation: A prospective observational study Highly accessed article p. 7
Prerana N Shah, Azho Kezo
DOI:10.4103/sja.sja_539_22  
Introduction: Perfusion index (PI) can be detected using a pulse oximeter. Its value decreases in response to noxious stimuli. Here, we investigated its efficacy in detecting hemodynamic responses during endotracheal intubation and extubation. Methods: An approval from the institutional ethics committee was obtained along with a written informed consent from the patients involved in this study. A sample size of 30 was calculated. Reading of PI, heart rate, and blood pressures (systolic, diastolic, and mean arterial) were recorded at pre-intubation, post-intubation, during neuromuscular block reversal, pre-extubation and at extubation. Clinically significant heart rate, blood pressure (systolic, diastolic, and mean) and PI was defined as increase by >10 bpm, rise by ≥15 bpm and a decrease by ≥10%, respectively, from pre-intubation value. Results: Clinically significant change in PI was seen at all intervals with maximum decrease in PI occurring during neuromuscular block reversal (42.6% at the start and 56.7% at the end of neuromuscular block reversal). A negative correlation was noted between PI and the other non-invasive hemodynamic parameters. Conclusion: PI decreases on noxious stimuli and correlates negatively with the other non-invasive hemodynamic parameters. Hemodynamic response at neuromuscular block reversal is maximum.
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Simulating high-fidelity emergency front-of-neck access: Training in an obstetric setting p. 12
Mai O'Sullivan, Sarah Gaffney, Ross Free, Stephen Smith
DOI:10.4103/sja.sja_494_22  
Introduction: In a cannot intubate, cannot oxygenate scenario (CICO), emergency front of neck access (eFONA) is the final lifesaving step in airway management to reverse hypoxia and prevent progression to brain injury, cardiac arrest and death. The Difficult Airway Society (DAS) guidelines advise the scalpel cricothyroidotomy method for eFONA. Anatomical and physiological changes in pregnancy exacerbate the already challenging obstetric airway. We aim to assess the impact made by introducing formal eFONA training to the perioperative medicine department of an obstetric hospital. Methods: Ethical approval and written informed consent were obtained. 17 anesthetists participated, (two consultants, one senior registrar, four registrars and eight senior house officers). Study design was as follows: Initial participant survey and performance of a timed scalpel cricothyroidotomy on Limbs & Things AirSim Advance X cricothyroidotomy training mannikin. Difficulty of the attempt was rated on a Visual Analogue Scale (VAS). Participants then watched the DAS eFONA training video. They then re-performed a scalpel cricothyroidotomy and completed a repeat survey. The primary endpoint was duration of cricothyroidotomy attempt, measured as time from CICO declaration to lung inflation confirmed visually. After a three-month period, participants were reassessed. Results: Four anesthetists had previous eFONA training with simulation, only one underwent training in the previous year. The mean time-to-lung inflation pre-intervention was 123.6 seconds and post-intervention was 80.8 seconds. This was statistically significant (p = 0.0192). All participants found training beneficial. Mean improvement of VAS was 3. All participants' confidence levels in identifying when to perform eFONA and ability to correctly identify anatomy improved. On repeat assessment, 11/13 participants successfully performed a surgical cricothyroidotomy, mean improvement from first attempt was 12 seconds (p = 0.68) which was not statistically significant. Conclusion: This method of training is an easily reproducible way to teach a rarely performed skill in the obstetric population.
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Preprocedural ultrasonography as an adjunct to landmark technique for identification of epidural space in parturients for labor analgesia p. 18
Midathala N Jayanth, Shiny P Arumulla, Pravallika Kesana, Krishna C Kandukuru, Hariprasad Reddy Basireddy, Shreevani Peddi
DOI:10.4103/sja.sja_141_22  
Background: Pregnancy-induced softening of tissues and ligaments may increase the false-positive rates when identifying the epidural space in parturients by the landmark technique. To mitigate these problems, Ultrasonography (USG), which has now become the eye of anesthesiologists, can be used as a reliable tool to facilitate more accurate epidural needle placement in parturients. This study was conducted to know the efficacy of USG when compared to the traditional landmark method. Methods: After the approval from the institutional ethics committee and CTRI registration, 62 parturients of ASA-2 requesting labor analgesia were randomized into 2 groups of 31 each: Group-L (conventional landmark technique) and Group-U (preprocedural USG done before epidural). In group-U, Tuohy's needle was introduced through the USG predetermined insertion point and epidural space was located using the LOR technique. Results: USG increased the success rate of epidural at first attempt from 51.6% in group “L” to 87% in group “U.” Fewer needle attempts (P-value - 0.001) were required in group “U” as compared to group “L.” No accidental dural puncture in group-U, compared to 2 in group-L. Mean Depth of epidural space (cm) ultrasound depth (UD) = 3.89 ± 0.45 cm and needle depth (ND) = 4.05 ± 0.37 cm. Side effects profile in the ultrasound group was better. Conclusion: Preprocedural ultrasonography is a simple safe,accurate tool with less number of attempts to determine the needle insertion site, decrease the incidence of accidental dural punctures, and assess epidural space depth in parturients.
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The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review p. 23
Puneet Khanna, Chandni Sinha, Akhil K Singh, Ajeet Kumar, Soumya Sarkar
DOI:10.4103/sja.sja_529_22  
Background: The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload. Methods: A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included. Results: We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32–0.95, I2 = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00–0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04–0.14, I2 = 89%), platelets (OR = 0.51, 95% CI 0.28–0.91, I2 = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55–0.88, I2 = 89%), and had better cost-effective treatment [Mean difference (MD) = −357.5, 95% CI − 567.75 to −147.25, I2 = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46–1.29, I2 = 82%). No mortality was detected across the studies. Conclusions: Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.
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A low peripheral perfusion index can accurately detect prolonged capillary refill time during general anesthesia: A prospective observational study p. 33
Yusuke Iizuka, Koichi Yoshinaga, Takeshi Nakatomi, Kyosuke Takahashi, Kyoko Yoshida, Masamitsu Sanui
DOI:10.4103/sja.sja_634_22  
Background: Capillary refill time (CRT) is the gold standard for evaluating peripheral organ perfusion; however, intraoperative CRT measurement is rarely used because it cannot be conducted continuously, and it is difficult to perform during general anesthesia. The peripheral perfusion index (PI) is another noninvasive method for evaluating peripheral perfusion. The PI can easily and continuously evaluate peripheral perfusion and could be an alternative to CRT for use during general anesthesia. This study aimed to determine the cutoff PI value for low peripheral perfusion status (prolonged CRT) by exploring the relationship between CRT and the PI during general anesthesia. Methods: We enrolled 127 surgical patients. CRT and the PI were measured in a hemodynamically stable state during general anesthesia. A CRT >3 s indicated a low perfusion status. Results: Prolonged CRT was observed in 27 patients. The median PI values in the non-prolonged and prolonged CRT groups were 5.0 (3.3–7.9) and 1.5 (1.2–1.9), respectively. There was a strong negative correlation between the PI and CRT (r = −0.706). The area under the receiver operating characteristic curve generated for the PI was 0.989 (95% confidence interval, 0.976–1.0). The cutoff PI value for detecting a prolonged CRT was 1.8. Conclusion: A PI <1.8 could accurately predict a low perfusion status during general anesthesia in the operating room. A PI <1.8 could be used to alert the possibility of a low perfusion status in the operating room. Trial Registration: University Hospital Medical Information Network (UMIN000043707; retrospectively registered on March 22, 2021, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno = R000049905).
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Can low dose of intratracheal dexmedetomidine be used to attenuate peri-extubation cough? - A prospective, double-blinded, randomized clinical trial p. 39
Afreen R Nahar, V Gopinath, Merlin Shalini Ruth
DOI:10.4103/sja.sja_619_22  
Background: Peri-extubation cough is an undesirable event during extubation, prevention of which has been studied with multiple drugs, amongst which intravenous dexmedetomidine has emerged as one of the favourable drugs. Intratracheal route is attractive because of its ease of administration, provided it avoids the hypotension and bradycardia that occurs during intravenous bolus administration. There is a paucity of data exploring the utility, doses, and adverse effect of intratracheal dexmedetomidine. Methods: After obtaining ethical committee approval, 60 eligible, consenting adult patients undergoing surgery under general anesthesia in a tertiary teaching hospital were recruited and randomised into three groups—DEX0.3, DEX0.5, and NS. The plan of general anesthesia was standardized. Half an hour prior to extubation, study drug was instilled intratracheally—dexmedetomidine 0.3 mic/kg, 0.5 mic/kg, and NS in groups DEX0.3, DEX0.5, and NS, respectively. 4-point cough score was used to assess extubation response. Hemodynamic response and time to Ramsay sedation score 3 was also recorded. Results: Majority of patients in DEX0.3 (60%) and DEX0.5 (85%) group had no cough (cough score 0), while majority of the patients in the NS group (70%) had either mild or moderate cough (cough score 1, 2). Kruskal Wallis test followed by post-hoc pairwise comparison showed statistically significant difference in 4-point cough score between GroupDEX0.3 and GroupNS (P < 0.001) and between GroupDEX0.5 and GroupNS (P = 0.038). DEX0.5 group, compared to DEX0.3 group, had significantly higher time from reversal to extubation (P < 0.001) and time to achieve Ramsay sedation score of 3 (P < 0.001). Conclusion: We conclude that both 0.3 mic/kg and 0.5 mic/kg of dexmedetomidine when given intratracheally are effective in preventing peri-extubation cough. Further, 0.3 mic/kg dexmedetomidine showed a better recovery profile compared to 0.5 mic/kg dexmedetomidine when administered intratracheally.
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Awareness, preconception, and fear of epidural analgesia among childbearing women in Saudi Arabia: An observational cross-sectional study p. 45
Fatma Aldammas, Abdulrhman A Alshihri, Rayan K Alhowaish, Basheer M Alotaibi, Abdullah F Alhamdi, Faisal F Algharbi, Hamad Y Alhassoun, Mohammed H Alhamad, Abdullah A Alhaddab
DOI:10.4103/sja.sja_782_22  
Background: Labor pain is one of the most excruciatingly painful sensations a woman can have. A woman's attitude toward childbirth might be influenced by her lack of understanding of the birth process and the pain she experiences throughout labor and delivery. The control of pain is an important aspect of appropriate obstetrical care. Our study aims to measure the level of awareness, preconception, and fear of epidural analgesia (EDA) among childbearing women. Methods: An observational cross-sectional, hospital-based study was conducted using a self-administered questionnaire. The study included all pregnant women who were attending an obstetrical clinic for routine antenatal follow-up at King Khalid university hospital in Riyadh, Saudi Arabia, during the month of August 2022. They were asked about five main parts that tapped their awareness, preconception, and fear of EDA. Data were analyzed by SPSS version 26 using descriptive methods, including mean, frequency, and percentage, and also Pearson's correlation coefficient for regression analysis to find the correlation between socio-demographics and awareness and between awareness and fear. Results: Participants in our study included 202 childbearing women. Most women, about 113 (55.9%), participating in the study were aged between 25 and 34 years old. The majority of the participants of this study were Saudi, about 196 (97.0%). In terms of education, 120 (59.4%) of the participants graduated from university. One hundred and forty two (70.3%) of the participants had a monthly income of less than 10000. When it comes to parity, the majority of participants, about 102 (50.5%), have had more than two pregnancies. The average percentage of awareness among the participants showed 45.9%, with an insignificant very moderate correlation between parity and awareness (r = -0.088, P = 0.107); women's knowledge, income, and age were also insignificantly related to awareness. Also, the result showed a moderate level of fear with an average percentage of 44.6% among the participants, with a moderate correlation between awareness and fear with a value of (r = 0.184, P = 0.004). Conclusion: This study results demonstrate a good level of desirability toward using EDA for labor pain, yet there is a limited level of preconceptions and a low level of awareness and knowledge about EDA. In addition, the results showed that the average percentage of fear is 44.6%. Therefore, we suggest that more awareness, knowledge, and guidance about EDA should be provided to pregnant women through antenatal clinics. Furthermore, educational campaigns should be made to dispel misconceptions and fears about EDA.
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REVIEW ARTICLES Top

COVID-19 associated Mucormycosis (CAM): Implications for perioperative physicians – A narrative review p. 58
Anju Gupta, Bhavana Kayarat, Nishkarsh Gupta
DOI:10.4103/sja.sja_640_22  
Mucormycosis once considered a rare disease with an incidence of 0.005 to 1.7 per million, has become one of the greatest menaces during the coronavirus disease (COVID-19) pandemic. India alone has contributed to nearly 70% of the global caseload of COVID-associated mucormycosis (CAM) and it had even been declared as a notifiable disease. Second wave of COVID-19 pandemic saw a steep rise in the incidence of mucormycosis and these patients have been presenting to anesthesiologists for various surgical procedures due to its primary or secondary sequelae. Rhino-orbito-cerebral mucormycosis (ROCM) is the commonest manifestation and is caused by Rhizopus arrhizus. Injudicious use of corticosteroids in vulnerable patients could have been a major contributing factor to the sudden rise in ROCM during the pandemic. Concerns related to anesthetic management include COVID-19 infection and post COVID sequalae, common presence of uncontrolled diabetes mellitus, possibility of difficult mask-ventilation and/or intubation, various drug therapy-associated adverse effects, and interaction of these drugs with anesthetic agents. Thorough preoperative optimization, multidisciplinary involvement, perioperative care, and vigilance go a long way in improving overall outcomes in these patients.
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Buprenorphine for acute post-surgical pain: A systematic review and meta-analysis p. 65
Mohammed S Albaqami, Adel A Alqarni, Musab S Alabeesy, Ayidh N Alotaibi, Hazzaa A Alharbi, Mishari M Alshammari, Ahmed H Aldhfery
DOI:10.4103/sja.sja_822_22  
Our study was designed to evaluate the efficacy of buprenorphine for the management of acute post-surgical pain reported in published studies in the years 2015–2022. Comprehensive research was performed by using online resources like PUBMED and the Wiley Library database to gather the relevant literature. Two authors were assigned to independently collect the information. Cochran's Q-test and I square statistic were used to determine the heterogeneity across the studies. Publication bias was estimated by using the Egger regression analysis and found to be significantly present once the P value <0.05. In this review, 15 studies were included. The pooled ratio of pain reduction after 12 hours of surgery was reported as 11.2% with 97% heterogeneity. Day one shows 5.9 reductions in pain with 98% heterogeneity. The 3% more pain was reduced on day 2. The day 3 pooled pain reduction score was observed as 1.9%. The overall pool prevalence of pain reduction was noted as 6.2% at different time duration with significant heterogeneity of 100%. Buprenorphine transdermal and sublingual both have significant pain relief scores. The analgesic drug consumption was reduced at the end of the follow-up duration.
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CASE REPORTS Top

Anesthesia management of pediatric subglottic stenosis: A case report p. 72
Patricia B Viana, Francisco A Sousa, Ana I N. Pinto, Teresa B Leal
DOI:10.4103/sja.sja_260_22  
Subglottic stenosis balloon dilation in selected patients may be an option for the treatment of acquired subglottic stenosis, reducing the need for open surgical approaches or tracheostomy. This treatment is a major challenge to otolaryngologists and anesthesiologists, with an interactive collaboration being critical throughout the procedure. When performed, it is fundamental that otolaryngologists and anesthesiologists communicate properly during the procedure to achieve acceptable results. The complex management of the airway and inherent delicacy and risks of the intervention may be challenging. A proper preparation of the procedure and familiarization with the step-by-step technique could optimize the results and prepare the team to deal with intervening complications. We report a case of management and treatment of an 8-month-old baby with subglottic stenosis proposed for endoscopic balloon dilation treatment from Porto, North of Portugal.
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Point-of-care transthoracic echocardiography: An essential management tool for acute massive pulmonary thromboembolism p. 75
Carlos Almeida, Pedro Cunha, Lígia Vieira, Pedro Antunes, Emilia Francisco
DOI:10.4103/sja.sja_186_22  
The pulmonary thromboembolism may be a life-threatening condition. A hip fracture surgery patient aged >90 years old had a sudden post-operative episode of shock, de-saturation, and reverted cardiac arrest. A point-of-care transthoracic echocardiography (TTE) undertaken by an anesthesiologist revealed inferior vena cava dilation/flattening, right cardiac chamber dilation, and McConnell signs (right ventricular apex hyperkinesia and lateral wall hypokinesia); the ventricular septal wall was shifting to the left side, and the left ventricular chamber collapsed at the end-systole, indicating a high ejection fraction in the context of obstructive shock. As such, it revealed signs of pulmonary thromboembolism. Despite the absolute contraindication for thrombolysis and therapeutic hypocoagulation, the treatment was started immediately along with vasopressor support, which was life-saving in this patient. A summary TTE played a pivotal role in our patient's case, helping with the differential diagnosis of the cause of shock.
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Cause of profound hypoxemia following a bilateral bidirectional Glenn shunt: Clue suggested by agitated saline echo contrast p. 77
Madan M Maddali, Pravin Saxena, Khalid S Al Alawi, Abdoulah Mohsen
DOI:10.4103/sja.sja_371_22  
Following a bilateral bidirectional Glenn shunt, a child had persistent hypoxemia. Agitated saline contrast injection into the jugular vein during transesophageal echocardiography displayed a rapid appearance of saline particles in the cardiac chambers suggesting the presence of pulmonary arteriovenous malformations. However, the clinical picture was not in agreement and an angiographic contrast injection during an immediate cardiac catheterization revealed the underlying pathology which was immediately corrected surgically.
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Severe bradycardia and hypotension induced by autonomic neuropathy in a diabetic patient during general anesthesia – A case report p. 80
Nawon Lee, Kanghui Kim, Hyuckgoo Kim
DOI:10.4103/sja.sja_502_22  
Cardiovascular autonomic neuropathy (CAN) is characterized by dysregulation of sympathetic and parasympathetic nervous systems that causes cardiovascular and respiratory disorders. The number of diabetic patients undergoing surgery is increasing in line with the prevalence of DM. Anesthesiologists should pay attention to diabetic patients with CAN because it is related to serious cardiovascular morbidity and mortality. We report an 80-year-old male who underwent cervical laminoplasty. He had severe bradycardia and hypotension from induction to the suspension of surgery. His blood pressure dropped to 70/40 mmHg and his heart rate to 20 bpm. Ephedrine, phenylephedrine, and atropine administration had minimal effect, but after epinephrine administrations, his heart rate and blood pressure increased to 70 bpm and 170/90 mmHg. The operation was discontinued because of the patient's unstable, fluctuating vital signs. The results of autonomic nervous system function examination indicated postganglionic cholinergic sympathetic dysfunction, sympathetic adrenergic dysfunction, and parasympathetic cholinergic dysfunction.
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Anesthetic challenges in the management of Larsen syndrome: A rare congenital anomaly p. 83
Subhasree Das, Aparajita Panda, Sritam S Jena, Mantu Jain
DOI:10.4103/sja.sja_518_22  
Larsen syndrome is a rare inherited disease associated with dislocations of multiple joints, typical syndromic facies, and multiple spine abnormalities. They often required multiple corrective orthopedic surgeries to regain their functional ability, thus needing repeated anesthesia. Apart from skeletal deformities, they have predicted difficult airway and need extreme care during intubation and positing of the patient. Abnormal posturing due to spinal deformity and poor pulmonary reserve due to kyphoscoliosis creates an extremely challenging situation for the anesthetist to manage the case during the perioperative period. Here we are describing the perioperative anesthetic management of a patient with Larsen syndrome.
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Managing acute pancreatitis pain with bilateral erector spinae plane catheters in a patient allergic to opioids and NSAIDS: A case report p. 87
Samaresh Das, Nilay Chatterjee, Subhro Mitra
DOI:10.4103/sja.sja_292_22  
Acute pancreatitis is one of the major causes of abdominal pain and is mainly related to either gallstone or heavy alcohol intake. We have managed a patient with acute pancreatitis with a bilateral erector spinae catheter because he was not suitable for other analgesics. A 72-year-old male with a known alcoholic patient was admitted with severe acute pancreatitis. He also had the chronic obstructive pulmonary disease (COPD) and oesophageal reflux disease. He was allergic to nonsteroidal anti-inflammatory medications and opioids. Therefore, his pain was managed successfully with bilateral erector spinae block with a continuous infusion with 0.125% levobupivacaine 1 ml/hr background infusion and 30 ml every 4 hours using a CADD Solis regional analgesia pump. Although erector spinae block is relatively new and to date, the optimal dose is not determined. We inserted the catheters at the T8 level; however, further study is needed to determine the ideal insertion site and drug volumes. We have mentioned key features, techniques, and management plans and reviewed the latest literature in this case report.
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Peripheral nerve block with ropivacaine in Brugada syndrome patient: Anesthetic consideration p. 91
Eun Kyung Choi, Sang-Jin Park, Jong Yoon Baek, Myungjin Seo
DOI:10.4103/sja.sja_573_22  
Brugada syndrome has a lethal arrhythmogenic risk during surgery or anesthesia. Perioperative drugs, electrolytic disturbances, and autonomic imbalance can trigger cardiac rhythm disturbances and even sudden cardiac death. Patients with this syndrome are at high risk during the perioperative period. However, the safest anesthetic management is still unknown. We report successful anesthetic management with peripheral nerve block (five points) using ropivacaine for lower-limb surgery in a patient with Brugada syndrome.
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Combined neuraxial-general anesthesia in opsoclonus–myoclonus syndrome: A case report p. 94
Joao B Abreu, Catarina R Cordeiro, Ana I Amorim, Tiago G Catanho, Karina D Gama
DOI:10.4103/sja.sja_558_22  
Opsoclonus-myoclonus syndrome (OMS) is a very rare neurological disorder thought to be the result of autoimmune responses in the nervous system. The relationship between this disorder and anesthesia procedures has not been studied in detail. To our knowledge, there are only 4 case reports, none of them with epidural-general combined anesthesia. We present a 9-year-old female with OMS due to low-grade neuroblastoma, for 7 years, who underwent tumor remotion due to the large size. Intravenous induction was done with alfentanil, lidocaine, propofol and rocuronium and ropivacaine was administered via lumbar epidural catheter. Adding to the sparse anesthetic management information in OMS, we now show one more possible approach, that can be valuable in high-risk cases, where general anesthesia can be involved with higher risk for the patient.
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A successful pregnancy and delivery after heart transplantation: The first case report in Saudi Arabia p. 97
Abdullah AlRaffa, Samahir AlJubairy, Sara J Alwatban
DOI:10.4103/sja.sja_523_22  
Pregnancy following heart transplant (HT) surgery poses a high risk to the patient, and limited data are available on practices for post-HT pregnant patients. We report a case of a 34-year-old female patient in her 20th week of pregnancy, diagnosed with restrictive cardiomyopathy at 20 years of age. An HT procedure was performed 5 years ago on the patient. The patient had multiple miscarriages and in-vitro fertilization in 2021. The patient presented in the 20th week of gestation with shortness of breath and delivered prematurely via cesarean section. The procedure was successfully performed under spinal anesthesia with no complications, and the patient was stable. Implementing a multidisciplinary team in managing such challenging cases would further improve anesthesia management in the future.
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Anesthesia management of living donor liver transplantation in a patient with scimitar syndrome p. 101
Muhammad Shabbir, Amer Majeed, Mudassir A Baig, Matloob A Shajar, Tahir Iqbal
DOI:10.4103/sja.sja_553_22  
Scimitar syndrome is a rare congenital anomaly with a hallmark of an abnormal drainage of pulmonary veins into inferior vena cava instead of the left atrium; this creates a curvilinear radiological pattern resembling a sword (scimitar) on a chest radiograph, thus attracting the name. This case report highlights the challenges during liver transplantation, and perioperative anesthetic management of a patient with an uncorrected Scimitar Syndrome.
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Anesthetic considerations for non-cardiac surgeries in orthotopic heart transplant recipients p. 104
Vinod Deep, Pujari S Vinayak, Karante Ramachandra
DOI:10.4103/sja.sja_474_22  
The number of heart transplants performed each year is steadily increasing around the world. Anesthesia and perioperative management are different in these cases. For an optimal perioperative management and improved postoperative outcome, a full understanding of the physiology of the denervated heart, post-transplant morbidities, and immunosuppressant pharmacology is required. We hereby discuss the perioperative management of a patient who had undergone orthotopic heart transplant and presented to our setup for left ureteroscopy.
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Refractory hypertension after phenylephrine infusion in cesarean section under subarachnoid block p. 107
Vikash Bansal, Kirti N Saxena, Bharti Wadhwa
DOI:10.4103/sja.sja_461_22  
A 21-year-old female was scheduled to undergo elective cesarean section for breech presentation under the subarachnoid block (SAB). The pre-operative examination was unremarkable and baseline vitals were normal. Under all aseptic precautions and American society of anesthesiologists standard monitoring, SAB was administered with 2.2 ml of 0.5% hyperbaric bupivacaine. Soon after administration of SAB, prophylactic infusion of phenylephrine was started at the rate of 50 μg/min; after pre-treatment with 0.2 mg glycopyrrolate intravenous immediately after the start of the infusion, the patient complained of severe headache. Blood pressure (BP) recorded at that time was 191/102 mm of Hg. Phenylephrine infusion was stopped immediately but the BP remained high and came to within 20% of baseline value only after 9 min of discontinuing the infusion. We report this case of refractory hypertension following phenylephrine infusion in a healthy parturient undergoing elective cesarean section under SAB.
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The lumbar subcutaneous fat gradient in spinal anesthesia seen for morbidly obese patient with pre-procedure ultrasonography – A case report p. 110
Hiroki Nakamura, Shuhei Hisago, Shunsuke Ishitsuka
DOI:10.4103/sja.sja_562_22  
It has been reported that pre-procedure ultrasonography rises the success rate of spinal anesthesia in obese patients. In this article, we performed spinal anesthesia for morbidly obese patient with pre-procedure ultrasonography. And recognizing the lumbar subcutaneous fat gradient in morbidly obese patient was the key to success. A cesarean section was scheduled for a primigravida in her 30 s with BMI 61 kg/m2. The lumbar spine was not palpable. Pre-procedure ultrasonography revealed lumbar subcutaneous tissue getting thicker caudally in the sagittal view. Considering this fact, we adjusted the puncture site and succeeded. Postoperative complications were not observed. The pre-procedure ultrasonography is effective even in morbidly obese patients. It is important to recognize the lumbar subcutaneous fat gradient, the so-called back fat slope, for spinal anesthesia in obese patients.
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Peri-humeral block for postoperative analgesia in patients with distal humerus surgery: A case series p. 113
Sandeep Diwan, Himaunshu V Dongre, Abhijit S Nair, Suhrud Panchwagh
DOI:10.4103/sja.sja_564_22  
The brachial plexus blocks (BPBs) are routinely performed for all surgeries in the vicinity of the elbow joint. Phrenic nerve paresis is a major problem with above-clavicle blocks especially the interscalene approach. The primary aim of this pilot study was to assess feasibility and to evaluate if perioperative pain management with the articular and cutaneous nerve block, the peri-humeral block (PHB) resulted in decreased use of opioid consumption in the intraoperative and postoperative period for the first 24 hours. Twenty-four patients with distal humerus fracture received ultrasound (US)-guided PHB as part of their perioperative anesthetic management. The primary aim was to evaluate block efficacy in terms of time to first analgesia and opioid consumption in first 24 hours. US in real time revealed that in all patients the local anesthetic was optimally deposited. Due to a stable intraoperative hemodynamics, none of the patients required additional opioid doses. The median pain scores over 24 hours were 2.4 with IQR (0-3.8). The mean time to first analgesic was 425.417 ± 229.005 min. There were no adverse effects reported at the time of hospital discharge. Though the US-guided PHB would not replace the BPB, in some special circumstances, it would be desirable to implement the former block which has opioid and motor sparing features and incorporate with multimodal analgesia.
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Anaphylaxis in the operating room treated with an anaphylaxis response kit: A case report p. 117
Akae Shu, Takuo Hoshi, Keiichi Hagiya
DOI:10.4103/sja.sja_631_22  
Anaphylaxis is a rapidly fatal complication of anesthesia, and it needs to be appropriately diagnosed and treated by anesthesiologists. A 37-year-old man underwent surgery for pneumothorax under general anesthesia. Postoperatively, the train-of four count was four, and sugammadex was administered. Soon after, the patient's oxygen saturation and blood pressure decreased, and skin flushing was noted. We suspected anaphylaxis and administered adrenaline. Once the blood pressure normalized, we administered hydrocortisone, famotidine, and d-chlorpheniramine maleate. Thereafter, his condition stabilized, he recovered well, and he was discharged. Blood samples obtained after the onset of the episode indicated anaphylaxis, and a prick test performed 10 weeks postoperatively confirmed sugammadex as the causative agent. We report a case of sugammadex-induced anaphylaxis, which we could properly diagnose and treat because an anaphylaxis kit was available in our department.
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LETTERS TO EDITOR Top

Ultrasound-guided superficial radial nerve block: A novel analgesia technique for cephalic vein cannulation in hand p. 120
Chitta R Mohanty, Rakesh V Radhakrishnan, Neha Singh, Tarangini Das, Seshendra S Akelia
DOI:10.4103/sja.sja_344_22  
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Management of a broken stylet in endotracheal tube p. 121
Shashank Paliwal, Navneh Samagh, Nimish Singh, Juhi Sharma
DOI:10.4103/sja.sja_356_22  
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Anesthesia in radiofrequency catheter ablated Wolff–Parkinson–White syndrome patient p. 123
Deepti Srinivas
DOI:10.4103/sja.sja_400_22  
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Airway management in a child with large occipital encephalocele associated with restricted neck movements and receding mandible p. 125
Manbir Kaur, Rhythm Mathur, Arin Gopal Sarkar, Priyanka Sethi
DOI:10.4103/sja.sja_463_22  
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Use of laryngoscope blade as a rescue intubating airway during fiberoptic orotracheal intubation p. 126
Amarjeet Kumar, Kunal Singh
DOI:10.4103/sja.sja_475_22  
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POCUS measurements of the left brachiocephalic vein provide a novel site for monitoring fluid responsiveness in pediatric patients p. 128
Amarjeet Kumar, Chandni Sinha, Ajeet Kumar
DOI:10.4103/sja.sja_478_22  
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The reverse esmarch: A lesser known technique of intravenous cannulation p. 129
Ruchi Kumari
DOI:10.4103/sja.sja_468_22  
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Left brachiocephalic vein is a novel site for ultrasound-guided central venous catheterization in the prone position p. 131
Amarjeet Kumar
DOI:10.4103/sja.sja_465_22  
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Continuous retrolaminar block in percutaneous nephrolithotomy surgery p. 132
Poonam Kumari, Amarjeet Kumar, Chandni Sinha, Ajeet Kumar, Anu Kumari
DOI:10.4103/sja.sja_486_22  
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Ultrasound-assisted transverse process line as a guide for performing lumbar neuraxial block p. 133
Swathy A Santhosh, Debesh Bhoi, Kathiravan Thangavel, Lipika Soni
DOI:10.4103/sja.sja_462_22  
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Common flexor plane block: A novel approach to median and ulnar nerve block at elbow p. 136
Amarjeet Kumar, Chandni Sinha, Ajeet Kumar
DOI:10.4103/sja.sja_507_22  
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Modified supraclavicular brachial plexus block for humerus fracture surgery: A report of two cases p. 137
Berna Caliskan, Ece Yamak Altinpulluk
DOI:10.4103/sja.sja_508_22  
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Transmuscular quadratus lumborum block (QLB) in supine position for abdominal surgeries: Pros and cons p. 138
Nita D'souza, G Himashweta, Sandeep Diwan
DOI:10.4103/sja.sja_505_22  
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Ten facts about monkeypox that every anesthesiologist should know p. 140
Akshaya K Das, Ankur Sharma, Nikhil Kothari, Shilpa Goyal
DOI:10.4103/sja.sja_549_22  
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Continuous erector spinae plane block for analgesia following cervical rib resection p. 141
Sweta Bhararia, Sadik Mohammed, Richa Kewalramani, Surendra Patel
DOI:10.4103/sja.sja_546_22  
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OBITUARIES Top

Obituary: Dr. Mohamad Said Maani Takrouri p. 144
Abdelazeem A Eldawlatly
DOI:10.4103/sja.sja_795_22  
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