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   Table of Contents - Current issue
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October-December 2022
Volume 16 | Issue 4
Page Nos. 371-527

Online since Saturday, September 3, 2022

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EDITORIAL  

This is why you should (not) use spinal anesthesia for laparoscopic surgeries Highly accessed article p. 371
Alessandro De Cassai, Roberto Starnari, Carmine Pullano, Vito Torrano, Federico Geraldini, Fabio Costa
DOI:10.4103/sja.sja_380_22  
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ORIGINAL ARTICLES Top

Continuous local anesthetic wound infusion: Impact on pain score and opioid use in patients undergoing elective mastectomy p. 374
Ahmed AlFaraj, Mona AlFaraidy, Zaki AlZaher, Adnan Al Wosaibai, Abduladem K AlShabeb, Hussain AlHashim, Zainab AlKhulaif
DOI:10.4103/sja.sja_874_21  
Introduction: Opioids are commonly used to control acute postoperative pain but their usage is associated with significant complications and the potential of addiction. This study was designed to assess the effect of a Continuous Local Anesthetic Wound Infusion Catheter (CLAWIC) on pain score and as an opioid-sparing agent in patients undergoing elective mastectomy. Method: The search was done using all patients' record from February 2013 to February 2018. The data were collected through the acute pain service database, operation room lists, surgical site infection database, acute pain service sheet, and anesthesia sheet. The patients inclusion criteria were adults who underwent elective mastectomy surgery at King Fahad Specialist Hospital. Patient age, sex, weight, and height were also recorded. Result: The opioid use intraoperatively and postoperatively was significantly lower in the CLAWIC than in the control group. Also, accumulative opioid use was significantly lower in the CLAWIC group. From transfer to the PACU until 48 hours postoperatively, the percentage of patients requiring opioids was significantly lower in the CLAWIC group. After 48 hours, there was no difference in opioid use between the two groups. Visual Analog Scale (VAS) pain scores were significantly lower in the CLAWIC than in the control group. Conclusion: CLWIC showed opioid-sparing effects following mastectomy, as shown by a significantly lower mean opioid dose and a lower percentage of subjects needing opioid analgesia. The procedure is easy to perform and relatively safe. CLWIC could reduce opioid consumption while maintaining good postoperative pain control.
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What's best, online or on-site? The write a scientific paper course p. 379
Victor Grech, Jeremy Borg Myatt, Sarah Cuschieri
DOI:10.4103/sja.sja_276_22  
Background: The ability to publish is a career-critical skill but requires the acquisition of a wide and disparate skill set. The Write a Scientific Paper (WASP) course was created in Malta in 2010, an intensive, three-day event. WASP is an accredited event held in Malta, London, and Bahrain. The COVID pandemic forced WASP to go online. This study compared satisfaction with WASP online as opposed to in-person by analyzing course feedback pre- and post-pandemic. Methods: Google forms are used to collect anonymous feedback on a Likert scale for various aspects of each WASP. The period 2017 to 2022 was used to compare four courses on-site and five courses online. Feedback on: Rate lectures, handouts, WASP overall and how likely are you to recommend WASP was compared. Results: Response rates were >60% and almost all Cronbach's Alpha values were >0.7. High satisfaction scores were achieved in all four questions (>4/5). There were no significant differences except in lectures, which scored well but fared slightly worse overall online. Conclusions: Migrating online does not necessarily lead to change/s in presentation contents but transforms delivery. Our results indicate that WASP is accepted online but the slightly lower lectures score implies that WASP might be better delivered in-person than online. However, students remained happy to recommend WASP and this accords with other studies that overall, student satisfaction with online education is common. It is hoped that as the pandemic recedes, webinars complement and not continue to totally replace traditional in-person meetings.
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Low-dose spinal block combined with epidural volume extension in a high-risk cardiac patient: A case-based systematic literature review p. 383
Carlos R Almeida, Ligia S Vieira, Pedro Cunha, Ana Gomes
DOI:10.4103/sja.sja_740_21  
Background: Anesthetic management of patients with severe cardiac disease can be challenging during prolonged surgical procedures. Thus, alternative neuraxial anesthetic techniques have been described to avoid general anesthesia in these patients. Methods: A case-based systematic literature review on low-dose spinal block combined with different methods of epidural block extension in high-risk cardiac patients was performed. Results: We describe the successful management of a patient with poor left ventricular function who underwent excision arthroplasty of an infected hip prosthesis under low-dose spinal block with levobupivacaine 5 mg and fentanyl 15 μg combined with saline epidural volume extension (EVE). Epidural ropivacaine 0.75% was administered as a bolus of 5 ml followed by an infusion at 5 ml/h later during the course of surgery. Conclusions: Although continuous spinal anesthesia (CSA) or epidural anesthesia may limit hemodynamic instability, the possibility of devastating central nervous system infection may prevent CSA use, and epidural block alone may be less reliable than CSA. Epidural block alone may require large volumes of concentrated local anesthetic to obtain sacral block, which may produce hemodynamic instability. The EVE, particularly using saline EVE, has rarely been described in high-risk cardiac patients as an alternative to CSA or epidural block alone, with the intention to avoid general anesthesia, but it has demonstrated efficacy and a low rate of complications. Hemodynamic stability was maintained in most cases.
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Validation of translated Obstetric Quality of Recovery (ObsQoR-10A) score after nonelective cesarean delivery (CD) in an Arabic-speaking population p. 390
Shumaila Mukarram, Shoukat Ali, Muhammad Zulqurnain, Ibtihal A M. Alkadi, Abdulelah I Alhatlan, Mohammed Z H. Abbasi, Muhammad Q Mushtaq, Ahmed Y AbuHammad, Khalida Shahid, Asghar Waqas, Atif Shafqat
DOI:10.4103/sja.sja_52_22  
Background: The ObsQoR-11 is a validated scale that assesses recovery after cesarean delivery (CD). This observational study aimed to evaluate the psychometric properties of its Arabic version. Methods: The original ObsQoR-11 was translated into an Arabic version (ObsQoR-10A). All participants completed the ObsQoR-10A at 24 h and 48 h postoperatively after CD. Validity, reliability, responsiveness, and feasibility were assessed. Results: The ObsQoR-10A correlated with Global Health Numerical Rating Scale (NRS) at 24 h (R = 0.68, 95% CI: 0.56–0.80, P < 0.001) and at 48 h (R = 0.66, 95% CI: 0.54–0.78, P < 0.001) and differentiated between good and poor recovery (median scores at 24 h 88 vs. 71, P < 0.001; at 48 h 95.5 vs. 70, P < 0.001). ObsQoR-10A correlated with hospital length of stay at 24 h (R = –0.21, 95% CI: –0.40 to –0.02, P = 0.03) and at 48 h (R = –0.21, 95% CI: –0.40 to –0.03, P = 0.02); gestational age at 24 h (R = 0.22, 95% CI: 0.03–0.40, P = 0.02); change in hemoglobin at 24 h (R = –0.30, 95% CI: 0.51 to –0.10, P < 0.01); and total opioids at 48 h (R = –0.45, 95% CI: –0.62 to –0.27, P < 0.001). There was a significant difference between 24 h and 48 h postoperative ObsQoR-10A scores (median difference: –18; P < 0.001 which shows responsiveness). Other key measures included a Cronbach's alpha of 0.87, split-half 0.75, and intra-class correlation >0.62 with no floor or ceiling effects. Median (IQR) completion time was 3 (3-5) and 3 (2.5-3.5) minutes at 24 h and 48 h. Conclusions: ObsQoR-10A is a valid, reliable, responsive, and a clinically feasible tool in an Arabic-speaking obstetric population.
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A randomized control study to assess the efficacy of the sphenopalatine ganglion block in patients with post dural puncture headache p. 401
Guruvayurappan Annushha Gayathri, Kanthan Karthik, Ravi Saravanan, Mesia D Meshach, Anand Pushparani
DOI:10.4103/sja.sja_780_21  
Background: Post dural puncture headache (PDPH) delays discharge from hospital. We studied the efficacy of sphenopalatine ganglion (SPG) block, a novel technique in management of PDPH using 0.25% Ropivacaine. Methodology: Forty patients presenting with PDPH after urological procedures under spinal anaesthesia were randomized into two groups: Group C and Group S. Group C received conservative treatment with bed rest, adequate hydration and caffeine 200 mg 6th hourly. Group S patients received SPG block (packing bilateral nostril for 10 minutes with 0.25% Ropivacaine). Inj Paracetamol 1 g IV was given as primary analgesic. Intravenous Diclofenac 75 mg was administered as rescue analgesic. Patients were monitored for 72 hours. Total analgesic requirement, time to attain adequate pain relief, headache pain score, patient satisfactory score were compared between the two groups. We compared the PDPH severity score for headache using 5-point scale method and patient satisfaction score using Likert-type scale. Results: Demographic data, onset of PDPH, needle size, intervention time were statistically insignificant. Total paracetamol consumption was significantly reduced in SPG group. Headache pain score was significantly low in Group S up to 54 hours. Patient satisfaction score was statistically better in Group S. Mean block onset time was 12 minutes. One patient in Group C required Epidural blood patch. Conclusion: SPG block is an effective alternative in managing patients with PDPH. The need for epidural blood patch is greatly reduced using SPG block. Procedural safety, immediate and sustained pain relief make it an evolving treatment modality for PDPH.
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Access to pain medicines and follow-up consultation after radiofrequency ablation for trigeminal neuralgia during the COVID-19 pandemic p. 406
Shwethashri Kondavagilu Ramaprasannakumar, Nupur Karan, Nupur Pruthi, Sriganesh Kamath
DOI:10.4103/sja.sja_288_22  
Background: In the recent coronavirus disease 2019 (COVID-19) pandemic, follow-up of patients with trigeminal neuralgia post radio-frequency ablation (RFA) of the Gasserian ganglion was restricted because of closure of pain clinic services (PCSs) at our institution, travel restrictions, and fear of contracting COVID-19 infection by hospital visit. Periodic follow-ups are a must in this group of patients. Because the access to pain medications and consultations remained restricted, we tried identifying the factors predisposing to these difficulties in patients. Methods: We had contacted patients telephonically, who underwent RFA at our institution in the past 5 years as the PCS had not re-started to follow up with in-person consultation. Demographics, socio-economic factors, clinical factors, literacy status, distance to the health care system, and current health status were noted. Collected data were analyzed descriptively, and correlations were calculated between the predictors for difficulty in follow-up to access the medications and consultations. Results: Out of 121 patients who underwent RFA in the past 5 years, 73 were accessible on phone. Of these, 42.46% (31/73) patients had difficulty in accessing either medications or consultation. The literacy status of the patient was the strongest predictor (0.044) with a negative correlation (-1.216). Difficulty in accessing PCS was associated with a poor health status (p-0.032) and higher pain scores (0.066). Conclusion: Along with the clinical factors, we have to overlook other factors in predicting difficulty to access PCS in trigeminal neuralgia patients post the RFA status. Difficulty in access to pain medicines and/or consultations was associated with a poor health status and higher pain scores.
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Feasibility of intraoperative quantitative neuromuscular blockade monitoring in children using electromyography p. 412
Kwaku Owusu-Bediako, Ryan Munch, Jay Mathias, Joseph D Tobias
DOI:10.4103/sja.sja_326_22  
Background: Quantitative train-of-four (TOF) monitoring remains essential in optimizing anesthetic outcomes by assessing the depth and recovery from neuromuscular blockade. Despite this, residual neuromuscular blockade, defined as a TOF ratio <0.90, remains a concern in both adult and pediatric patients. Quantitative TOF monitoring has seen limited use in infants and children primarily due to a lack of effective equipment. This study evaluates a new electromyography (EMG)-based TOF monitor in pediatric patients undergoing inpatient surgical procedures including laparoscopic (restricted arm access) surgery. Methods: Pediatric patients undergoing inpatient surgery requiring the administration of neuromuscular blocking agents (NMBAs) were enrolled. The EMG electrodes were placed along the ulnar nerve on the volar aspect of the arm to provide neurostimulation. The muscle action potentials from the abductor digiti minimi muscle were recorded. Neuromuscular responses were recorded by the device throughout surgery at 20-s intervals until after tracheal extubation. Data recorded on the monitor's built-in memory card were later retrieved and analyzed. Results: The study cohort included 100 pediatric patients (62% male). The average age was 11 years (IQR: 8, 13) and the average weight was 39.6 kg (30, 48.7). Automatic detection of supramaximal stimulus was obtained in 95% of patients. The muscle action potential mean baseline amplitude (in mV) was 7.5 mV (6, 9.2). The baseline TOF ratio was 100% (100, 104). After administration of a neuromuscular blocking agent, monitoring of the TOF ratio was successful in 93% of the patients. After antagonism of neuromuscular blockade, monitoring was possible in 94% of patients when using an upgraded algorithm. The baseline amplitude recovered to 6.5 mV (5, 7.8), and the TOF ratio recovered to a mean of 90.1% (90,97) before tracheal extubation. Conclusion: Our results indicate that neuromuscular monitoring can be performed intraoperatively in pediatric patients weighing between 20 and 60 kg using the new commercially available EMG-based monitor. Automatic detection of neuromuscular stimulating parameters (supramaximal current intensity level and baseline amplitude of the muscle action potential) by an adult neuromuscular monitor is feasible in pediatric patients receiving nondepolarizing neuromuscular blocking agents.
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Evaluation of risk factors for unanticipated hospital admission following ambulatory surgery – An observational study p. 419
Ahmed A Alharthi, Alshaqha Mohammed, Mohammad Jamil, Amjad Mehboob, Anwar U Huda
DOI:10.4103/sja.sja_420_22  
Context: Unanticipated admissions following ambulatory surgery significantly affect hospital admission and operation room flow. Most of the factors responsible for unanticipated admission following ambulatory surgery were preventable. It is, therefore, crucial to improve patient selection criteria and to identify the risk factors for unanticipated admission during preoperative period. These unanticipated admissions have now been considered as quality care indicator and a target to improve healthcare costs. Aims: To assess the reasons and risk factors for unanticipated hospital admission after ambulatory surgery. Settings and Design: Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. Methods and Materials: In this case-control study, cases who were re-admitted within 48 hours following ambulatory surgery were included. The convenience sampling was used to identify controls. Data including patients' demographics, type of anesthesia and surgery, any intraoperative or postoperative complications, etc., were extracted. Statistical Analysis Used: Descriptive statistics is used to summarize the study variables. Mean and standard deviation were used for quantitative variables. Percentage and frequencies were used for qualitative variables. Univariate and multivariate logistic regressions were used to assess risk factors for unanticipated hospital admission after ambulatory surgery. Results: There were 153 cases and 147 controls in this study. The study found postoperative pain as the most common reason for re-admission after ambulatory surgery followed by bleeding, fever, and asthma exacerbation. Multivariate logistic regression showed age, BMI more than 40, and presence of respiratory disease as risk factors (P < 0.05). Conclusions: Age, high BMI more than 40, and presence of respiratory disease increase the risk of unanticipated hospital admission after ambulatory surgery.
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Ketamine as the main analgesic agent during analgesia-based sedation for elective colonoscopy – A randomised, double-blind, control study p. 423
Mirza Kovačević, Nermina Rizvanović, Adisa Šabanović Adilović, Jasmina Smajić, Selma Sijerčić
DOI:10.4103/sja.sja_488_22  
Aim: The aim of the study was to compare the analgesic effects of ketamine over fentanyl combined with propofol in analgesia-based elective colonoscopy with purpose of patient safety and satisfaction. Methods: This is a double-blinded prospective randomized controlled trial. Ninety patients were included and randomized to either fentanyl-propofol (Group FP, n: 30), ketamine-propofol (Group KP, n: 30) or propofol-control group (Group C, n: 30). Group FP patients received fentanyl and propofol, Group KP received ketamine and propofol and Group C, propofol. In all groups, incremental doses of propofol were used to maintain a Ramsay sedation score (RSS) of 5. Respiratory depression and hemodynamic parameters were monitored for the first minute and every 5 min during endoscopy. Fifteen minutes after the procedure, the degree of pain was assessed using a visual analog scale (VAS), the quality of recovery according to the Aldrete score (ARS), complications during and after the procedure and additional doses of propofol were recorded. Results: Mean arterial pressure (MAP) at 5 and 30 min (p < 0.05), heart rate (HR) at 15, 25 and 30 min (p < 0.05) and peripheral oxygen saturation (SpO2) at 30 min (p < 0.05) were statistically significant for Group FP. Desaturation (*p = 0.033), and weakness (*p = 0.004) was also significant for Group FP at 20, 25 and 30 min (p < 0.05). Pain was lower assessed for the Group KP according to the VAS (**p = 0.025). Conclusion: In analgesia-based colonoscopy, ketamine provides appropriate analgesia and less incidence of complications compared to fentanyl.
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Effect of two different levels of positive end-expiratory pressure (PEEP) on oxygenation and ventilation during pneumoperitoneum for laparoscopic surgery in children: A randomized controlled study p. 430
Neerja Bhardwaj, Soumya Sarkar, Sandhya Yaddanapudi, Divya Jain
DOI:10.4103/sja.sja_445_22  
Background: Positive end-expiratory pressure (PEEP) is used to attenuate the changes in respiratory parameters because of pneumoperitoneum during laparoscopic (LAP) surgery. As the ideal level of PEEP during LAP in children is not known, this study compared the effect of 5- and 10–cm H2O of PEEP on oxygenation, ventilator, and hemodynamic parameters during pediatric LAP. Method: After obtaining approval from the Institute Ethics Committee and written informed parental consent, 30 American Society of Anesthesiologists (ASA) I and II children aged 2–10 years, undergoing LAP were randomized to receive PEEP of 5- or 10–cm H2O during pneumoperitoneum. Baseline hemodynamic and ventilatory parameters, PaO2, and PaCO2 were measured 2 min after tracheal intubation, 2 min and 1 h after pneumoperitoneum, and after deflation of pneumoperitoneum. Oxygenation index, dynamic compliance, and alveolar-arterial oxygen gradient (D (A-a) O2) were calculated at the above-mentioned time points. Data were analyzed using Student's t-test and repeated measures ANOVA with Bonferroni correction. Results: The oxygenation index and D(A-a)O2 decreased in PEEP 5 Group and increased in PEEP 10 Group after pneumoperitoneum, the difference between the two groups being statistically significant (P = 0.001). The dynamic compliance decreased in PEEP 5 Group and increased or remained the same in PEEP 10 Group after pneumoperitoneum, the difference between the two groups being significant (P = 0.001). There were no significant changes in the hemodynamic parameters in the two groups. Conclusion: Use of 10-cm H2O PEEP during pneumoperitoneum in children improves ventilation and oxygenation, without significant hemodynamic changes.
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Write a Scientific Paper course – Utility or otherwise? p. 437
Victor Grech, Sarah Cuschieri, Abdelazeem A Eldawlatly
DOI:10.4103/sja.sja_512_22  
Background: Publish or perish is a cliched mantra but publishing requires the acquisition of a wide set of disparate skills that are typically learned in a completely ad-hoc manner in an early period of one's career. The Write a Scientific Paper (WASP) course is delivered online by an experienced, international faculty of academics, including several medical journal editors. This study retrospectively analyzed the attendees' perceptions of the usefulness and the utility of WASP. Methods: An email questionnaire of 11 questions was sent to all previous WASP attendees, 370 subjects, in May 2022. The questions included the geographical locations of the subjects as well as the number of published articles before and since WASP course. Besides a couple of questions on rating and recommending the WASP course, some other related questions were also asked. Results: There were 68 responses (18%) with high agreement (Cronbach α = 0.92). The WASP course fared well across the different research-oriented dimensions and expectations and is mostly welcomed by young career professionals. Following WASP, a 9% increase in scientific writing and published articles engagement was reported. Discussion: WASP is an international and unique course that emphasises presentation skills using newspaper media theory. It highlights to the delegates the importance of understanding the conflicting tripod of forces that govern publishing. Authors wish to publish more; readers are inundated, wishing to read less, whereas journal editors' primary aims are to elevate their journals' impact factors. WASP endorsements and the testimonials are invariably positive. The transition to online barely affected satisfaction rates with WASP while permitting the enrolment of a more international faculty that includes even more journal editors. WASP's ultimate objective is to impart the faculty's collective experience to the delegates in this crucial, early aspect of career progress.
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REVIEW ARTICLES Top

Anesthesia concerns for a patient with monkeypox requiring emergency surgery: A review p. 440
Amit K Malviya, Ankesh Gupta, Abhishek Singh, Anju Gupta
DOI:10.4103/sja.sja_509_22  
Monkeypox is a contagious disease that manifests as a smallpox-like skin rash. The disease has shown a sudden surge worldwide across several countries. These patients may present for emergency surgery. Anesthetic management of these cases in an emergency setting is challenging. There is not much literature on the anesthetic management of monkeypox patients. We aimed to discuss the anesthetic management of monkeypox in this review.
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Pediatric obesity and anesthetic challenges of metabolic surgery p. 444
Ahmed Hashim, Mostafa K Sedky, Waniyah Masood, Islam M Shehata, Alan D Kaye
DOI:10.4103/sja.sja_469_22  
Obesity in the pediatric population is considered a growing problem. It is likely that there will be a significant impact related to obesity on the health of future generations. Obesity has increased the incidence of a spectrum of diseases ranging from microvascular complications over the retina and peripheral nerves to an increased incidence of cancer. We have conducted an electronic search in MEDLINE, PubMed, ISI Web of Science, and Scopus scientific databases targeting studies published between 2000 till 2019. Several modalities have shown a wide spectrum of the effectiveness of weight control among adolescents. Despite achieving short-term success among obese adolescents, maintaining such change is challenging. The emergence of metabolic or bariatric surgeries has opened the door for long-term control over weight gain with considerable remission of unfavorable metabolic mediated or modulated effects associated with obesity such as diabetes mellitus and hypertension. The most commonly practiced metabolic surgery among adolescents is sleeve gastrectomy which is associated with comparable weight and metabolic control and a lesser risk of complication. Anesthesia is considered a major challenge among the pediatric population, especially those with significant obesity. Preoperative evaluation is always warranted to exclude and manage different associated comorbidities. The anesthetic challenges associated with pediatric obesity begin with intubation. Maintenance and emergence from anesthesia along with postoperative antiemetics and analgesia can pose additional challenges. Managing the postoperative period is considered a cornerstone in the early detection and management of any postoperative complication. Especially those complications related to the metabolic and nutritional aspects of the bariatric surgery. Finally, despite being a valuable option in managing obesity, bariatric surgery in adolescents comes with significant anesthetic challenges that need to be consistently evaluated and managed.
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“The show must go on”: Aftermath of Covid-19 on anesthesiology residency programs p. 452
Rishabh Jaju, Medhavi Saxena, Naveen Paliwal, Pooja Bihani, Vidya Tharu
DOI:10.4103/sja.sja_563_22  
COVID-19 has caused tectonic changes in the personal and professional lives of anesthesiologists and, among several aspects, anesthesiology residency and sub-specialty training has also undergone an unforeseen overhaul. We read the articles published on the impact of COVID-19 on training of anesthesiologists and set out to extract and narrate all the significant observations. At the outset, we begin by explaining how this pandemic posed a threat to the safety of the residents and mitigating measures like PPE and barriers that have now become 'the new normal'. Sub-specialties like critical care, cardiac anesthesia, pain and palliative care have also faced difficulty in imparting training due to an initial dearth in elective surgery case load but have adapted innovative measures to overcome that. Initially, conducting thesis and research became difficult due to problems in achieving the desires sample size needed to get significant results, but this pandemic has emerged as a dynamic laboratory where topics like 'psychological impact of COVID-19' and 'development of artificial intelligence models in COVID -19 ICUs' came into the fore. Pattern of examination has also become virtual and webinars showed how knowledge, with the right medium, has the potential of global outreach. As the pandemic took a toll on the mental health of the residents, attention was paid to this previously neglected aspect and ensuring their emotional well-being became a priority to avoid the issue of burn-out. We comment on how what initially was considered a scary problem, actually paved way for growth. It brought attention to safety, innovation, new tools for training, finding solutions within constraints, continuing developing our residents into future leaders who were also trained for mitigating disasters. Changes like online education, research on socio-economic impact, priority to mental health and artificial intelligence are here to stay and by imbibing it, we ensure that 'the show must go on'.
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CASE REPORTS Top

Selective Suprascapular and Axillary nerve (SSAX) block – A diaphragm sparing regional anesthetic technique for shoulder surgeries: A case series p. 457
Ravi Saravanan, Krishnamurthy Nivedita, Krishnamoorthy Karthik
DOI:10.4103/sja.sja_782_21  
Interscalene block, the gold standard for shoulder surgeries is inevitably associated with phrenic nerve palsy, even at low volumes. The major innervation of the shoulder joint is by suprascapular nerve and axillary nerve. Suprascapular nerve block has been used commonly for postoperative analgesia in shoulder surgeries done under GA. Combining axillary block with suprascapular nerve block was found to provide superior analgesia when compared to suprascapular block alone. Selective Suprascapular and Axillary nerve (SSAX) block provides effective analgesia in shoulder surgeries without causing diaphragm palsy, but has limited published literature. We performed ultrasound guided suprascapular block in the supraspinous fossa (posterior approach) using 10 ml of 0.25% Ropivacaine and axillary block in the quadrangular space using 6ml of 0.25% Ropivacaine before administration of general anaesthesia (GA) in 4 cases. Among four cases, 2 were closed shoulder manipulation with intra-articular steroid injection for periarthritis, 1 was closed reduction and K-wire fixation for chronic shoulder subluxation and the 4th was Latarjet procedure for recurrent shoulder dislocation. All patients received paracetamol 1g at the end of the procedure and every 6 h postoperatively. No patient experienced pain during recovery and the analgesia lasted for a mean duration of 347.5 minutes. Tramadol was required for rescue analgesia in only one patient (Latarjet surgery). We found that SSAX block provided effective analgesia in all patients, but needs randomized controlled trials with larger sample size comparing with interscalene block.
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Ultrasound-guided lower thoracic erector spinae block for postoperative analgesia in complex colorectal surgery in a pediatric patient p. 460
Ian Drillings, Alberto Rivera-Cintron, Giuliana Geng-Ramos
DOI:10.4103/sja.sja_815_21  
The erector spinae plane (ESP) block is a relatively novel regional anesthetic technique first described in 2016. There are limited data regarding its use in pediatric surgeries although ESP blocks can likely be safely used to provide effective postoperative analgesia for major thoracic and abdominal surgeries, especially in cases where neuraxial anesthesia is contraindicated. In this report, we describe a case in which bilateral lower thoracic erector spinae plane blocks were performed in a pediatric patient with vertebral anomalies undergoing posterior sagittal anorectoplasty and reconstruction of cloacal malformation.
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Thermal injury from forced-air warmer device precipitated by massive extravasation from peripheral venous cannula p. 463
Parmod K Bithal, Ravees Jan, Mohammed M Kalou, Mohammad S Bafaquh
DOI:10.4103/sja.sja_786_21  
Extravasation injury (EVI) is an iatrogenic complication of venous cannulation. Usually innocuous but occasionally it engenders sequelae. Its severity is determined by various physicochemical properties of infusate. A 50-year-old patient developed leg EVI from crystalloids infused through a pressurized digital infuser (PDI), likely from cannula tip displacement during positioning for craniotomy. We ignored checking gravity-aided free-fluids flow before switching on PDI. Following surgery, the patient had an edematous leg with bullae and epidermal peelings from severe extravasation and burns, respectively. Doppler revealed patent leg arteries. Therefore, EVI was conservatively managed, with complete recovery. Apparently, increased local tissue pressure from extravasation produced conditions of peripheral circulation sufficiency predisposing the leg to thermal injury from the forced-air warmer. On inspecting PDI postoperatively, its upper-pressure alarm limit was 300 mmHg, which prevented it from sounding alarm during extravasation.
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Bilateral pneumothorax in a parturient undergoing cesarean section under general anesthesia Highly accessed article p. 466
Hisham Qassrawi, Ameed Taher, Alaa Aldin Malhis, Hend Aburumh
DOI:10.4103/sja.sja_64_22  
Pneumothorax is quite unusual to occur during or following cesarean section, as only six cases have been reported so far, and only one of them was bilateral. Here, we report a 19-year-old, previously healthy, non-smoking primigravida who underwent a cesarean section under general anesthesia, and whose oxygen saturation level quickly dropped to 81% following endotracheal intubation. Although an initial chest radiograph did not demonstrate pneumothorax, a CT scan performed on the following day showed the patient had developed bilateral pneumothorax. Chest tubes were inserted on both sides, and the patient was discharged on the sixth postoperative day in stable condition. This case underlines the need to include pneumothorax in the differential diagnosis when managing a patient with acute respiratory distress during cesarean section or in the immediate post-operative period.
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Difficult airway management in a patient with unexpected laryngeal deformities p. 469
Seung Eun Song, Hyun Jung Kim
DOI:10.4103/sja.sja_75_22  
We report an experience with difficult airway management due to unexpected laryngeal deformities. A 69-year-old man who had been diagnosed with left vocal cord paralysis was scheduled for eye surgery. After the induction of anesthesia, mask ventilation was inadequate and intubation was impossible, so an emergency tracheostomy had to be performed. In the larynx examination, the left vocal cord was paralyzed close to the midline and the left corniculate tubercle was enlarged and partially blocked the rima glottidis. Laryngeal deformities may cause unexpected difficult airway management. Clinicians always have to pay close attention to the potential risk and prepare for emergency situations including an invasive approach to the airway.
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Postoperative myoclonic movement following mandibular cyst enucleation under general anesthesia: A case report p. 472
Alaa Ali M. Elzohry, Osama G Alghamdi, Mohammed L Helmy, Osama A Ibrahime
DOI:10.4103/sja.sja_888_21  
Postoperative myoclonic movement (PMM) is an uncommon side effect after general anesthesia (GA), and the exact cause of this neurologic complication is still unknown. Many factors such as anesthesia, psychological stresses, and surgical stress could trigger PMM. We are here reporting a case of PMM in the post-anesthetic care unit (PACU) following general anesthesia in an apparently healthy patient.
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Conscious sedation and electroporation: A new perspective p. 475
Priyanka Sethi, Raksha Vyas, Manbir Kaur, Pradeep Bhatia
DOI:10.4103/sja.sja_95_22  
Tumor-specific electroporation (TSE) is a technique involving the application of high voltage pulsed electric impulses to the tumor lesions. We performed TSE in four patients with different indications and airway scenarios. We kept all four patients under conscious sedation using trans-nasal humidified rapid-insufflation ventilatory exchange (THRIVE) and dexmedetomidine infusion. This case series reflects those various untoward effects of general anesthesia that can be avoided by oxygenating the patient with THRIVE and dexmedetomidine infusion, which provide analgesia, sedation, and amnesia.
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Pulmonary artery catheter knot in a liver transplantation, a rare complication p. 478
Felipe L Silva, José L. U. M. Gomes, Walkiria W V. Boas, Gabriela V de Freitas
DOI:10.4103/sja.sja_711_21  
The pulmonary artery catheter (PAC) measures hemodynamic parameters in real time, providing valuable data for the management of the critical patient. Nevertheless, its use is associated with several complications. Knot formation is a rare complication related to PAC insertion. A 51-year-old patient with complicated ethanolic liver cirrhosis underwent orthotopic liver transplantation. Invasive hemodynamic monitoring was performed using a Swan–Ganz pulmonary artery catheter (PAC) inserted through the right internal jugular vein. Chest X-ray in the immediate postoperative period showed the presence of a possible knot adjacent to the tip of the sheath in the internal jugular vein. The patient was then referred to the hemodynamics room, where, through fluoroscopy, a true knot was successfully removed after femoral vein dissection. The medical team should weigh the risk and benefit of using the PAC, taking into account the patient's clinical conditions, the benefits, and possible complications of the procedure.
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Major depressive disorder (MDD), antidepressants, and uncontrolled hypertension: A report of intraoperative autonomic dysregulation p. 481
Anteia Paraskeva, Polyxeni Theodosopoulou
DOI:10.4103/sja.sja_4_22  
Objective: Major depressive disorder (MDD) represents the leading cause of mental disability worldwide. While relations between MDD and alterations to the cardiovascular system have been studied before, the autonomic dysfunction caused by the disease and the medical therapies involved during treatment has not been widely reported. Our case aims to prove such linkage exists and is a potent hazard during major operative procedures. Methods: Studies have associated the disorder with a concomitant dysfunction of the autonomic nervous system, predisposing patients to hypertension. We present the case of a patient presenting with an intraoperative hypertensive spike that could be attributed to such a dysregulation of the autonomic system, in the absence of any other possible explanation. Results: The observed intraoperative hypertensive spike was managed pharmacologically, and the patient did not experience any further hemodynamic instability or postoperative complications. Conclusion: Our case tries to highlight a disregarded aspect of perioperative management for patients suffering from MDD.
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Differential diagnosis of intraoperative cardiac arrest after spine surgery in prone position p. 485
Davi Brasil Khouri, Marina Ayres Delgado, Jadson Lardy Lemes, Marcela Morais Afonso Cruz
DOI:10.4103/sja.sja_893_21  
Intraoperative cardiac arrest is one of the most feared events by anesthesiologists and surgeons. Although there are many possible causes, three differential diagnoses stand out in the presented scenario: pulmonary embolism, gas embolism, and acute myocardial infarction. A 61-year-old female patient was admitted in the hospital to C2-C5 arthrodesis. Despite no major bleeding during surgery, immediately after supination the patient developed refractory hypotension, a decrease in end tidal CO2, progressive bradycardia that ultimately led to pulseless electrical activity. Resuscitation maneuvers were promptly performed, sustained return of spontaneous circulation was attained after 50 minutes, and the patient was transferred to the ICU. This paper discusses the main causes for an episode of cardiac arrest in the context of cervical arthrodesis, with a markedly prolonged resuscitation time, in which the patient survived.
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Anesthetic management of primary cardiac tumor in the coronary sinus and right atrium p. 488
Ayu Yamada, Ikuko Miyawaki, Hiroyuki Mima
DOI:10.4103/sja.sja_130_22  
The patient presented with complete atrioventricular block and dyspnea. They had a primary cardiac tumor originating in the coronary sinus, a rare site of origin. It filled the sinus and involved the right atrium. The patient might have presented with complete atrioventricular block due to tumor invasion and respiratory distress due to elevated LVEDP as the tumor filled the coronary sinus. As for anesthesia management, in addition to the usual management, we observed CS obstruction and also considered myocardial protection methods. It is important to anticipate the risks and develop an appropriate anesthetic plan accordingly.
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Cerebral air embolism through a central venous catheter in the absence of intracardiac shunt p. 491
Abdalhai Alshoubi, Mick'l Scdden
DOI:10.4103/sja.sja_293_22  
Central venous catheters are routinely placed on medically complex patients for a variety of reasons, including facilitating intravenous access in difficult intravenous (IV) access situations, accurate hemodynamic monitoring, large-volume resuscitation, medication administration, nutritional support, and continuous renal replacement. As with other invasive medical procedures, placement, maintenance, and discontinuation of central venous catheters introduces risk and potential complications. We report a case of bilateral cerebral infarct secondary to air embolism through the right internal jugular vein venous catheter in the absence of intracardiac shunt in a patient with ischemic colitis who underwent total abdominal colectomy.
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Incidental finding of severe hyperkalemia in a patient with end-stage renal disease during video-assisted lung lobectomy: A case report p. 494
Wen-Hau Hsu, Chia-Hao Ho, Tzu-Yu Lin, Chia-Ying Chang
DOI:10.4103/sja.sja_274_22  
Patients with end-stage renal disease are at risk of developing hyperkalemia and acidosis, both of which have disastrous sequelae during elective video-assisted thoracic surgery for lung cancer. Herein, we present a case where severe hyperkalemia and combined acidosis were incidentally found in a 68-year-old man with the end-stage renal disease after establishing one-lung ventilation during video-assisted lobectomy. There was no significant instability of vital signs, abnormality of perioperative electrocardiography, or malignant arrhythmia. Therefore, we arranged for related management promptly, and the surgery was relatively smooth. This incidental intraoperative hyperkalemia was thought to have resulted from one-lung ventilation and hypercarbia and/or metabolic acidosis. More frequent arterial blood gas analysis and aggressive blood potassium control during video-assisted thoracic surgery should be considered for patients with end-stage renal disease.
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Single continuous erector spinae plane block for multiple rib, clavicle, and scapula fractures: A case report p. 497
Carlos Almeida, Emília Francisco, Pedro Cunha, Lígia Vieira, Pedro Antunes
DOI:10.4103/sja.sja_290_22  
The aim of this study is to describe the ability of a continuous erector spinae plane (ESP) block to provide analgesia in an extended territory (brachial plexus and thoracic nerves) with a single catheter. A continuous ESP block at T4 was performed in a 74-year-old man, two days after trauma involving clavicle, scapula, and multiple posterior rib fractures (first to ninth). The technique was maintained for 12 days and provided effective analgesia not only to the thoracic region but also the scapula and clavicle area (C5–T12 dermatomes). Concomitant respiratory insufficiency was ameliorated, which helped to avoid mechanical ventilation and intensive care unit admission. Moreover, this analgesia technique promoted patient's ambulation. ESP block, as an alternative to a thoracic epidural, is a more straightforward and safer procedure than paravertebral block (PVB). To obtain an extensive dermatome block using PVB, more than one paravertebral catheter would be necessary. Extensive cephalad–caudad spread of the PVB is primarily related to analgesia due to the concomitant epidural spread. PVB frequently causes bilateral block and may produce significant motor or sympathetic block. Additionally, proximal extension of the block under the erector spinae muscle fascia can provide a significant extension of the block to the cervical region, which allows brachial plexus block (cervical plexus block was not observed clinically). This is a unique feature of ESP block, as there is no communication between adjacent paravertebral levels in the cervical region that could allow the same pattern of analgesia using PVB.
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Role of inhaled levosimendan in peripartum cardiomyopathy p. 500
Parminder Kaur, Tanveer S Kundra
DOI:10.4103/sja.sja_297_22  
Levosimendan is an inodilator agent, which was initially widely used in low contractility states. However, its use has been restricted because of the invariable need to use a vasoconstrictor like norepinephrine, since it causes a marked fall in systemic vascular resistance (SVR). Hence its beneficial effects on the heart are compromised by the excessive fall in SVR. The inhalational route provides a better opportunity to exploit the positive cardiac effects, with a minimal effect on SVR. In this case report, we present a postpartum patient presenting with heart failure, in which inhalational levosimendan improved the hemodynamics and cardiac function, which was associated with relief of symptoms, with no need for other inotropes. As per our knowledge and extensive literature search, this is the first documented use of inhaled levosimendan in peripartum cardiomyopathy.
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LETTERS TO EDITOR Top

Technical aspects of one-lung ventilation (OLV) in a patient affected by viral pneumonia Sars-Cov-2 related p. 504
Luca Guzzetti, Alessandro Bacuzzi, Luca Ghislanzoni, Anna Marcato
DOI:10.4103/sja.sja_113_22  
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Vaccine trials with no serious adverse reactions – estimation of upper 95% confidence intervals for likelihood of such events p. 506
Victor Grech, Elizabeth Grech, Sarah Cuschieri
DOI:10.4103/sja.sja_122_22  
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Influence of normal saline on delayed graft function in kidney transplantation p. 507
Ashraf M El-Molla
DOI:10.4103/sja.sja_167_22  
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Intraoperative return of motor evoked potential following decompressive laminectomy: An early indicator of successful decompression? p. 508
Balaji Vaithialingam, Suparna Bharadwaj
DOI:10.4103/sja.sja_174_22  
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Real-time point-of-care ultrasound for accurate endotracheal tube positioning in a neonate with type C tracheoesophageal fistula p. 510
Debendra K Tripathy, Bhavna Gupta, Ramanand V Jadhav, Pantrangam Hareesh
DOI:10.4103/sja.sja_175_22  
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Cutaneous fluid leak from the epidural puncture site after insertion of a thoracic epidural catheter: A unusual cause p. 512
Lalit Jha, Neeraj Kumar, Sarfaraz Ahmad
DOI:10.4103/sja.sja_230_22  
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Anesthetic challenges in ruptured ovarian cyst with supratherapeutic international normalized ratio in patient a with artificial mitral valve p. 513
Rajnish Kumar, Nishant Sahay, Neeraj Kumar, Mukta Agrawal
DOI:10.4103/sja.sja_197_22  
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Subcutaneous tunneling of epidural catheter in four easy steps – A novel technique p. 514
Ferhan Khan, Mohammed Bilal Delvi, Vineetha Subba Karadka
DOI:10.4103/sja.sja_156_22  
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Ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach for subcostal incision in a pediatric patient p. 516
Amarjeet Kumar, Kunal Singh, Amit K Sinha, Pavan K Kandrakonda
DOI:10.4103/sja.sja_188_22  
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Ultrasound-guided superficial peroneal nerve block: A simple technique for procedural analgesia during dorsalis pedis arterial cannulation p. 518
Chitta R Mohanty, Rakesh V Radhakrishnan, Neha Singh, Subhasree Das, Seshendra S Akelia
DOI:10.4103/sja.sja_227_22  
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Schwartz-Jampel syndrome is a high risk of difficult airway management rather than malignant hyperthermia p. 519
Ashraf Mohamed EL-Molla
DOI:10.4103/sja.sja_163_22  
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Airway security and safety: Is it a priority in the prone position during upper endoscopic procedures under general anesthesia? p. 520
Ashraf Mohamed EL-Molla
DOI:10.4103/sja.sja_296_22  
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Failed epidural but an inadvertent paravertebral block in a patient with severe scoliosis p. 521
Sandeep Diwan, Abhijit S Nair
DOI:10.4103/sja.sja_285_22  
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Epidural blood patch for orthostatic headache with no remarkable findings on magnetic resonance imaging p. 523
Daeseok Oh
DOI:10.4103/sja.sja_329_22  
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Scrambler therapy: An opioid-sparing, non-invasive modality for chronic pain in patients p. 525
Abhijit Nair
DOI:10.4103/sja.sja_366_22  
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NOTICE OF RETRACTION Top

Retraction: Influencing factors of early cognitive deficits after ambulatory anesthesia p. 527

DOI:10.4103/1658-354X.355506  
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