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   Table of Contents - Current issue
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April-June 2022
Volume 16 | Issue 2
Page Nos. 145-273

Online since Thursday, March 17, 2022

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ORIGINAL ARTICLES  

Use of EMLA cream for skin anesthesia and epidural insertion in the patients with cesarean delivery: A prospective double-blind randomized clinical trial p. 145
Katsushi Doi, Yoko Ueda, Noritaka Imamachi
DOI:10.4103/sja.sja_728_21  
Background: Pain relief of epidural anesthesia in cesarean delivery is difficult. EMLA, a eutectic mixture of lidocaine and prilocaine, is effective for pain reduction during venipuncture and superficial surgery. However, its effectiveness during epidural insertion is not well elucidated. The aim of this randomized, double-blind study was to evaluate the efficacy of EMLA for epidural insertion in elective cesarean delivery. Methods: With Institutional Review Board approval and written patients' informed consent, forty-two ASA physical status 2 patients (aged 23–45) scheduled for elective cesarean section were included in this study. The patients were randomized to applied ELMA (EMLA group) or placebo cream (Placebo group) about one hour prior to anesthesia. Pain during skin infiltration with 1% mepivacaine and subsequent insertion of Tuohy needle was assessed immediately after each procedure. The presence of patient's response with physical withdrawal on both procedures was recorded. Statistical analysis was performed using Mann–Whitney U test and Fisher's exact test. A value of P < 0.05 was considered significant. Results: Median VAS values on skin infiltration and on insertion of Tuohy needle did not differ between groups. The incidence of patient's response with physical withdrawal on skin infiltration was not different between groups. However, that on insertion of Tuohy needle was significantly lower in EMLA group than in Placebo group (0%, 21%). Conclusions: EMLA cream could not reduce the pain during epidural insertion.
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Non-intubated general anesthesia in prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience p. 150
Valentina Melis, Cristalli Aldo, Lorenzo Dioscoridi, Sergio Arlati, Pietro Molinari, Marcello Cintolo, Francesco Pugliese, Giulia Bonato, Edoardo Forti, Mutignani Massimiliano
DOI:10.4103/sja.sja_714_21  
Background and Study Aim: Advance biliopancreatic endoscopies are nowadays performed in non-operating room anesthesia (NORA) under general anesthesia (GA). We evaluate the outcomes of non-intubated patients in prone position who received GA for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in a tertiary referral center for digestive endoscopy. Patients and Methods: Anesthesiological records, anamnestic, and intraoperative data of patients who underwent advanced therapeutic biliopancreatic endoscopies at our tertiary referral center from January 2019 until January 2020 were collected in the present observational study. Results: One hundred fifty-three patients (93 M; median age: 68-year-old; mean ASA status: 2) were considered eligible for a procedure in the prone position with GA in spontaneous breathing. Prone position was always the initial setting. Propofol administration through a target-controlled infusion (TCI) pump was the choice to achieve GA. In our experience, desaturation appears to be the most frequent adverse event, accounting for 35% of cases (55/153). Treatment foresaw additional oxygen through a nasopharyngeal catheter, which proved to be a sufficient measure in almost all patients (52/55). Other adverse events (i.e., inadequate sedative plan, pain, and bradycardia) accounted for 2.6% of cases (4/153). Conclusions: Non-intubated GA in the prone position may be regarded as a safe procedure, as long as the anesthesiological criteria of exclusion are respected and the anesthesiological team has become acquainted with the peculiar NORA setting and familiar with the management of possible adverse events.
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Effect of preemptive intramuscular diclofenac on minimal effective-dose bupivacaine saddle block for minor perianal surgeries p. 156
Roshdi R Al-metwalli, Alaa M Khidr, Summayah M Fallata, Hitham M A. Elsayed
DOI:10.4103/sja.sja_722_21  
Background: Preemptive analgesics are commonly used to increase analgesic efficacy and patient satisfaction. The aim of this study was to evaluate the preemptive analgesic effect of intramuscular diclofenac on minimal effective dose spinal anesthesia for perianal surgeries. Materials and Methods: Fifty patients ASA I&II were divided randomly into two groups, control group (GC N = 25) and Diclofenac group (GD N = 25), both groups received saddle block with 5% hyperbaric bupivacaine 0.5 mL (2.5 mg). Thirty minutes before the saddle block, patients in GD received 75 mg (3 mL) diclofenac intramuscularly, whereas patients in GC received 3 mL saline intramuscularly. The differences in the time for the first analgesic request, postoperative analgesic consumption as well as, visual analog scale, were our primary outcomes. Results: Fifty patients (25 in each group) undergoing perianal surgery completed the study successfully. The time to the first request of analgesia was significantly longer in GD 511.8 (108.07) min. compared to the GC 179.56 (49.24) min with P = 0.00001, as well as the total consumption of rescue analgesic (tramadol hydrochloride) was significantly less in GD 66 (23.8) mg compared to 104 (28.5) mg in the GC with P = 0.00001. Conclusion: Preemptive intramuscular diclofenac sodium with minimal dose bupivacaine saddle block significantly minimized the postoperative analgesic consumption and delayed the first analgesia request after perianal surgery.
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Comparison of continuous preperitoneal infiltration versus patient controlled analgesia for pain control in elective colorectal surgery p. 161
Ng Li Hwee, Teh Jin Zhe, Tan Jih Huei, Henry Tan Chor Lip, Elyaraitul Nadia Bt Rahim, Ivan Ho Khor Ee, Hanis Maisarah Ismail, Raymond Lim Zhun Ming, Jothinathan Muniandy, Chan Koon Khee, Tan Lin Jun, Omar Sulaiman
DOI:10.4103/sja.sja_395_21  
Background: Post-operative analgesia is crucial in enhanced recovery after surgery and to minimize post-operative complications. There remains data paucity on the efficacy of preperitoneal analgesia (PPA) compared to patient-controlled analgesia (PCA). This study aims to examine the efficacy of preperitoneal infusion as analgesia following elective colorectal surgery. Methods: This is a prospective cross-sectional study of all patients which underwent elective colorectal surgeries, performed in a tertiary surgical referral center with dedicated colorectal unit. Patients from May 2017 to April 2021 who underwent elective colorectal surgery were included in this study. Pain scores were reviewed and analyzed at regular intervals post-operatively for comparison. Results: Amongst the 200 patients included, there were 174 patients in the PPA arm and 26 patients using PCA. Patients in the PPA group were older age (63.29 vs 56.00, P = 0.003). A total of 118 patients in PPA cohort (67.8%) and 21 from PCA cohort (80.8%) underwent open surgery and the remaining 82 patients underwent laparoscopic surgeries. Although postoperative pain scores were consistently below 5 and reduced in trend from 2 hours to 96 hours postoperatively in both groups, the pain scores on coughing markedly reduced in the PPA group when compared PCA alone. The total dosage of opioid required in PPA cohort was also significantly lower when compared to PCA group at the first 24 hours postoperatively 12.21 (±13.0) vs 20.0 (±14.43), P = 0.048. Conclusions: PPA is a comparable modality for analgesia after elective colorectal surgery that reduces the opioid requirement postoperatively giving adequate pain relief. PPA should be considered as an alternative modality for multi-modal analgesia.
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Vertebral column length and abdominal girth as predictors for cephalad spread of intrathecal hyperbaric bupivacaine: A prospective observational study p. 166
Chanchal Nigam, Asha Tyagi, Shuchi Bhatt, Mahendra Kumar
DOI:10.4103/sja.sja_726_21  
Introduction: In recent literature, there is some suggestion of vertebral column length (VCL) and abdominal girth (AG) in determining cephalad spread of spinal anesthetic. Bodily habitus including abdominal fat distribution, AG, and VCL may vary among individuals from different races/ethnicity. We thus aimed to evaluate the role of AG, and VCL measured with the patient in sitting as well as lateral position, in determining the cephalad spread of intrathecal hyperbaric bupivacaine. Methods: Prospective blinded study conducted in 60 consenting adult male patients of ASA status I or II, undergoing lower limb surgery using standardized combined spinal epidural performed. The cephalad spread of subarachnoid block was assessed using loss of discrimination to pin-prick and cold temperature. The VCL was measured from C7 vertebra to the sacral hiatus in sitting as well lateral decubitus position. The AG was measured at level of umbilicus during end of expiration. Results: The mean AG and VCL in sitting/lateral positions were: 78.4 ± 11.0, 60.9 ± 3.2, and 59.2 ± 3.2 cm, respectively. VCL in sitting position was significantly longer than in lateral position (P = 0.000). There was no significant correlation between the Smax (pin-prick) and AG (P = 0.138), or VCL in sitting position (P = 0.549), or VCL in lateral position (P = 0.323). Similar lack of correlation was noted with the Smax (cold) as well (P > 0.05). Conclusions: Contribution of AG or VCL on the extent of intrathecal drug spread is not a consistent finding.
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Can ACS-NSQIP score be used to predict postoperative mortality in Saudi population? p. 172
Anwar U Huda, Mohammad Yasir, Nasrullah Sheikh, Asad Z Khan
DOI:10.4103/sja.sja_734_21  
Background: Various scoring systems help in classifying the patient's risk preoperatively and hence to decide the best available treatment option. ACS-NSQIP score has been introduced in clinical practice for few years. This study was done to find out whether there is any difference between predicted mortality from ACS-NSQIP score and observed mortality in Saudi population. Methods: This prospective observational study was conducted at Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. We included patients undergoing elective and emergency surgical procedures in our hospital. Thirty days mortality data was collected and then observed to expected (O/E) mortality ratio was calculated. The sample size for our study was nine hundred and three (903) patients. Results: The mean ACS-NSQIP mortality risk score (%) for the study was 0.49. Expected number of mortalities was 4.42 while observed mortalities were 11, yielding an O/E ratio of 2.48 (p-value 0.000). We did not find a significant difference between expected and observed mortalities except for ASA class 3 and 4 patients where expected numbers of mortalities were lower than observed (p-value < 0.05). Conclusion: ACS-NSQIP can be reliably used for postoperative mortality prediction especially in lower risk groups.
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Perioperative anesthetic concerns in postcovid mucormycosis patients posted for surgical intervention: An observational Study p. 176
Shilpi Misra, Shivani Rastogi, Deepak Malviya, Rachana Gupta, Sandeep K Yadav, Sharif Alam
DOI:10.4103/sja.sja_783_21  
Background: COVID 19 pandemic caused by severe acute respiratory syndrome coronavirus -2 has proven to be the deadliest pandemic till date. Multiple covid waves have hit people hard on each part of the continent throughout the world. The second wave in India turned out to be highly infectious and virulent. Sudden surge in cases of mucormycosis after recovery of COVID surprised many clinician. Mucormycosis being a rapidly progressive and fulminant fungal infection required surgical debridement of necrotic tissue on emergency basis. The fatal combination of immunocompromised status, multisystemic involvement, and difficult airway in these patients pose numerous new challenges regarding anesthetic management. The present study was conducted to outline major concerns and the anesthetic management of patients undergoing surgical resection for rhinoorbital mucormycosis (ROM). Materials and Methods: A retrospective observational study was conducted in our institute for a duration of 2 months (June and July 2021). The data of all the cases posted for ROM was collected from the ENT and Anesthesia record register. Total 70 patients presented with mucormycosis, for surgical debridement out of which 25 patients were posted for surgery under general anesthesia or monitored anesthesia care (MAC). Demographic characteristics, comorbidities, duration of COVID illness, treatment taken during COVID (oxygen therapy/steroid intake), hemodynamic parameters, monitoring methods, and surgical procedures were recorded for each patient. Statistical Evaluation: SPSS version 21.0 was used for data analysis. Mean and SD were used to analyze the difference in mean values, and independent Student's t-test were utilized to compare the quantitative variables. Frequency distribution and percentage were used for qualitative parameters. Significant difference was accepted at P ≤ 0.05 with 95% CI (confidence interval) in the study. Results: Demographic data were comparable with respect to age, gender distribution, and ASA status. Mean duration of Covid illness was (12.18 ± 3.68) days. The mean HbA1C measured was (10.8 ± 1.42). Strong correlation was found between steroid intake and raised HbA1c in all patients (r = 0.77). Regarding the comorbidities, 24 (96%) patients had associated type 2 diabetes mellitus, 16 patients (64%) had pneumonitis, and 1 patient had pulmonary TB and hepatitis. Conclusion: Considering the perioperative risk associated with high HbA1C and pneumonitis, MAC was preferred in majority of cases. Strict hemodynamic monitoring, perioperative glucose control, difficult airway cart, metabolic and electrolyte balance and vigilant peri-operative monitoring are cornerstone for better outcome and short length of hospital stay.
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Comparison of the effectiveness of intravenous fentanyl versus caudal epidural in neonates undergoing tracheoesophageal fistula surgeries p. 182
Saraswathi Nagappa, Sandhya Kalappa, HN Vijayakumar, HN Nethra
DOI:10.4103/sja.sja_847_21  
Background: Caudal epidural has become an inseparable part of pediatric pain relief as it depresses the stress response better than any other form of analgesia, resulting in the reduction in the need for systemic opioids; in addition, it facilitates early recovery and promotes good postoperative respiratory functions. Aim: To evaluate the effectiveness of epidural analgesia in neonates undergoing tracheoesophageal fistula repair in terms of requirement of perioperative fentanyl opioid, postoperative neonatal infant pain score (NIPS), on-table extubation, duration of intubation, reintubation, perioperative hemodynamic response, and any other side effects. Materials and Methods: A comparative, prospective, single-blind, randomized trial on 30 neonates scheduled for tracheoesophageal surgeries were randomly allocated to two groups: group I: neonates receiving caudal epidural block with ropivacaine 0.2%, 1 mg/kg bolus followed by infusion 0.1 mg/kg/h; group II: neonates receiving initial intravenous [IV] fentanyl 1 ug/kg and maintenance with 0.5 μg/kg/h IV bolus. Results: None of the neonates received opioids in group I. There were statistically significant differences in the mean NIPS at 30, 60, 90, 120 150, and 240-min intervals between group I and group II. Further, 80% of neonates were extubated in group 1 compared to 50% in group II, which was statistically significant (P = 0.025). The duration of intubation was more in group II compared to group I, with a suggestive significance of P = 0.093. Conclusion: Caudal epidural infusion provides adequate perioperative analgesia, promotes rapid weaning from the ventilator, and contributes to a successful outcome.
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Optic nerve ultrasound and cardiopulmonary bypass: A pilot study p. 188
Mayuko Wakimoto, Joseph H Patrick, Yoshikazu Yamaguchi, Catherine Roth, Marco Corridore, Joseph D Tobias
DOI:10.4103/sja.sja_14_22  
Introduction: Despite advances in surgical, anesthetic, perfusion, and postoperative care, adverse neurological consequences may occur following cardiac surgery and cardiopulmonary bypass (CPB). Consequences of the physiologic effects of CPB may alter the blood–brain barrier, autoregulation, and intracranial pressure (ICP) in the immediate postoperative period. Methods: We evaluated the effects of cardiac surgery and CPB on the central nervous system by measuring the optic nerve sheath diameter (ONSD) by using ultrasound as a surrogate marker of ICP. ONSD was measured after anesthetic induction and endotracheal intubation (time 1), after separation from CPB (time 2), and at the completion of the surgical procedure prior to leaving the OR (time 3). Results: The study cohort included 14 patients, ranging in age from newborn to 6 years. When comparing the Fontan group (n = 5) to the non-Fontan group (n = 9), four elevated ONSD observations were recorded for the Fontan patients during the study period, including one at time 1, one at time 2, and two at time 3. In Fontan versus non-Fontan patients, ONSD was greater at all three time points compared to non-Fontan. The change in the ONSD from time 1 to time 2 was greater (+0.2 mm vs. −0.1 mm), and the mean value at time 2 was significantly higher (4.2 vs. 3.5 mm, P = 0.048). Conclusions: Patients with Fontan physiology may be more prone to higher levels of baseline intracranial pressure due to elevated systemic venous pressure and decreased cardiac output. Alternatively, the chronically high central venous pressures may artificially elevate ONSD without clinical changes in ICP, necessitating the development of separate normative values based on the type of congenital heart disease.
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The use of mandibular nerve block in unilateral mandibular fracture to evaluate the mouth opening for assessment of airway p. 194
Mukesh Kumar Prasad, Payal Jain, Alauddin Alam, Rohit Kumar Varshnay, Kanchan Rani, Amit Kumar Chaudhary
DOI:10.4103/sja.sja_773_21  
Background: Facial area is one of the most frequently injured area of the body, accounting for 23–97% of all facial fractures. Treatments under general anesthesia as those for maxillofacial fractures or infections is a highly complicated and a major challenging task in trismus associated patients. The main culprit in trismus is the increase muscle tone of masticatory muscles which are supplied via the mandibular nerve, blocking which could help increase the mouth opening thus, changing the whole of airway management. Material and Method: A prospective study was done on 50 patients of ASA grade I-II with unilateral mandibular fracture with trismus posted for maxillofacial surgery. Mandibular nerve block was given via extraoral approach with 5 ml of 0.5% bupivacaine using peripheral nerve stimulator to determine the difference in Pre block and Post block mouth opening and the VAS score at 2, 5, 10, 15, 20, 25, and 30 minutes. Results: The Interincisor distance measured Pre block was 1.20 ± 0.32 mm and was significantly increased after 5 mins onwards from the block (P < 0.005). The VAS score determined Pre block was 5.14 ± 1.37 which significantly decreased just 2 minutes after the application of block (P < 0.005). Conclusion: Mandibular nerve block decreases the pain and will aid in the decision making by an anesthetist regarding airway management as it helps in increasing the inter incisor distance significantly. Moreover, given the feasibility and effectiveness of the block it could be included in standard of care protocol for mandibular fracture patients.
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REVIEW ARTICLES Top

Emerging mucormycosis posing threat to community: Anesthetist's perspective in a tertiary care center p. 200
Shilpa Goyal, Ankur Sharma, Nikhil Kothari, Amit Goyal
DOI:10.4103/sja.sja_604_21  
Mucormycosis has become an ever-growing threat to human health, particularly after the COVID-19 pandemic. As the number of cases of mucormycosis increased, it put a burden on anesthesiologists. Here we describe the etiopathogenesis, clinical presentation, and anesthesia management of patients suffering from mucormycosis.
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Publish or perish, information overload, and journal impact factors – A conflicting tripod of forces p. 204
Victor Grech
DOI:10.4103/sja.sja_632_21  
The academic mantra, to the point of cliché, is “publish or perish.” Academia is generally too preoccupied with research and publishing to stand back and consider the driving forces behind the actual processes and systems involved. Indeed, academics are generally unaware of the factors that influence one's ability to publish: The drive to publish itself, readers' information overload, and editors' desire to increase journals' impact factors. This paper will detail these forces, and it behooves potential researchers to keep this veritable tripod of forces in mind since understanding the tripod may facilitate publication chances through the invocation and active implementation of news media theory. Media writers' remuneration is dependent on readers clicking on their articles. The media reel in readers by displaying an intriguing/bold/provocative headline and then keep the readers interested and hooked with initial sentences that not only give information but also tantalize with the promise of more to come. A paper's title and abstract should adhere to these precepts so as to increase the chances of avoiding immediate rejection at editorial or initial reviewer level.
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Road map toward establishing fellowship programs in an academic anesthesia department p. 208
Abdulaziz E Ahmad
DOI:10.4103/sja.sja_746_21  
An impactful fellowship management should provide fellows with: Strong commitments and engagement from senior teams, ample and diverse opportunities to interact with mentors, strong exposure and sufficient access to the latest in academic training and experience, flexibility to fit the fellow's area of specialty and research, and extensive opportunities for professional development. One of the important features of our fellowship programs curriculum will be the use of simulation based training programs for the courses and workshops of the target fellowship.
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CASE REPORTS Top

Combined pericapsular nerve group and lateral femoral cutaneous nerve blocks for hip fracture in a polytraumatized patient—A case report p. 211
Juri Valoriani, Duccio Conti, Lara Gianesello, Vittorio Pavoni
DOI:10.4103/sja.sja_625_21  
Locoregional anesthetic techniques in hip fracture are significant in order to control pain, reduce postoperative opioid use, and perioperative adverse events. Pericapsular nerve group (PENG) block has been described and proved as an effective analgesic method for hip surgery as an alternative to other regional nerve blocks. The association of PENG and lateral femoral cutaneous nerve (LCFN) block can be performed to achieve skin and subcutaneous tissues analgesia or anesthesia. Direct anterior approach PENG block is considered a safe and effective anesthesia technique for total hip arthroplasty surgery. In this paper, we aim to describe a case report of a PENG and LFCN block successful association for anesthesia in a major trauma patient who undergone surgical percutaneous fixation of femoral neck fracture.
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Extremely low bispectral index value during robotic-assisted laparoscopic prostatectomy: A case report p. 214
Takuo Hoshi
DOI:10.4103/sja.sja_659_21  
The steep Trendelenburg position and pneumoperitoneum during surgery may affect intracranial pressure and cerebral oxygenation, which in turn may affect the values of the bispectral index (BIS). Prolonged maintenance of the Trendelenburg position and pneumoperitoneum may impair cerebrovascular autoregulation. We present a case of a patient with an extremely low BIS value during robotic-assisted laparoscopic prostatectomy (RALP). We managed the patient under general anesthesia and he showed a prominent decrease in BIS values 6 h after the start of surgery. Suppression ratio (SR) of electroencephalography (EEG) is also decreased, suggesting that the brain activity decreased. The BIS value increased quickly after the Trendelenburg position was released and the anesthesia was terminated. The patient recovered without any neurological deficits and was discharged. Steep Trendelenburg position and pneumoperitoneum can cause EEG abnormalities.
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Perioperative total intravenous anesthesia in a child with Walker-Warburg syndrome: A case report p. 217
Wadeeah Bahaziq, Ahmed R Hassan, Majd Y Jubili, Abdulaziz Boker
DOI:10.4103/sja.sja_529_21  
Purpose: Walker-Warburg syndrome is a rare autosomal recessive congenital muscular dystrophy presenting with hydrocephalus, type II lissencephaly, cerebellar malformation, and ocular anomalies. Here, we describe the use of perioperative total intravenous anesthesia in a pediatric patient with Walker-Walburg syndrome. Clinical Features: A 2-month-old girl with Walker-Walburg syndrome was admitted for urgent ventriculoperitoneal shunt insertion. Anesthesia was induced using intravenous atropine (100 μg), ketamine (10 mg), and fentanyl (15 μg). The patient was monitored for various clinical parameters based on American Society of Anesthesiologists standards. Anesthesia was maintained using intermittent doses of 0.5 mg intravenous midazolam and 5–10 μg fentanyl in incremental boluses. The postoperative course was uneventful. Conclusions: To our knowledge, no published cases have reported the use of total intravenous anesthesia in patients with Walker-Walburg syndrome who have potential risks for anesthetic-induced malignant hyperthermia. This report described the key features, potential anesthetic management plan, and current literature review of Walker-Walburg syndrome.
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Preemptive pericapsular nerve group block to facilitate sitting position for neuraxial anesthesia in patients with acetabular fractures: A case series Highly accessed article p. 221
Tuhin Mistry, Kartik Sonawane, Apurva Raghuvanshi, Jagannathan Balavenkatasubramanian, Palanichamy Gurumoorthi
DOI:10.4103/sja.sja_614_21  
Acetabular fractures are uncommon types of pelvic fractures associated with restricted mobility due to severe pain. The high analgesic demands can be fulfilled by using multimodal analgesia incorporating regional analgesia. The choice of regional analgesia technique depends on the type of acetabular fracture and innervation of the affected components. We report a case series of five patients with acetabular fractures, in whom pre-emptive administration of pericapsular nerve group block provided effective analgesia to facilitate the sitting position for the neuraxial block.
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Supraglottic airway device and venoarterial extracorporeal membrane oxygenation support for curative surgery in a patient with huge thyroid mass: A case report p. 226
Eun Kyung Choi, Do Young Kim, Jun Oh Kim
DOI:10.4103/sja.sja_638_21  
In the case of complete surgical resection of locally aggressive thyroid mass with severely compromised airways, airway management is difficult and can be considerably risky. We report a case of airway management using i-gelTM and cardiopulmonary bypass (CPB) with venoarterial extracorporeal membrane oxygenation (ECMO), which is a safe and feasible method of airway management for providing general anesthesia in a patient with a large thyroid mass.
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Fluoroscopic-guided erector spinae plane block for spine surgery p. 229
Eric Kim, Abdalhai Alshoubi
DOI:10.4103/sja.sja_694_21  
Erector spinae plane block (ESPB) is an ultrasound-guided block that can be also done under fluoroscopic guidance, which is usually used to manage postoperative pain of the thoracic and abdominal regions. We describe a successful Fluoroscopic-guided lumbar erector spinae plane block for lower back spinal surgery.
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Ultrasound-guided bilateral infraclavicular brachial plexus block: A report of three cases p. 232
Abdulhakim Şengel, Selçuk Seçilmiş
DOI:10.4103/sja.sja_737_21  
Anesthesiologists avoid multiple upper extremity peripheral nerve block applications due to complications such as increased phrenic nerve palsy and local anesthetic systemic toxicity risk. With the introduction of ultrasound into clinical life and the increase in the number of experienced anesthesiologists, such complications are less common. We also discussed three cases that we think may contribute to the literature on this subject. Our first case was scheduled for operation due to a trigger finger in his left hand and carpal tunnel syndrome in his right hand. Our second case was scheduled for surgery due to distal radius and ulnar fractures in both forearms. Our third case scheduled for operation for a fracture of the right forearm distal radius and a second metacarpal fracture in the left hand. In this report series, we present our experience of bilateral infraclavicular block, which we successfully performed in three cases and did not encounter any complications.
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Ultrasound-guided sacral multifidus plane block for sacral spine surgery: A case report Highly accessed article p. 236
Tuhin Mistry, Kartik Sonawane, Senthilkumar Balasubramanian, Jagannathan Balavenkatasubramanian, Vipin K Goel
DOI:10.4103/sja.sja_723_21  
Sacral surgeries are a relatively rare type of spine surgery associated with a significant amount of perioperative pain. The paraspinal interfascial or erector spinae plane block is currently being practiced with promising results in cervical, thoracic, and lumbar spine surgeries. It provides not only effective analgesia but also helps in reducing perioperative opioid consumption. Sacral multifidus plane block is one such variant of paraspinal blocks, which may have an equianalgesic profile. This case report describes a novel application of this block for providing perioperative analgesia in sacral spine surgery.
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Anesthetic challenges in bilateral pheochromocytoma with history of percutaneous transluminal coronary angioplasty (PTCA): A case report and literature review p. 240
Anil K Bhiwal, Naveen C Patidar, Aanal S Vyas, Ravina R Bhokan
DOI:10.4103/sja.sja_760_21  
Pheochromocytoma are catecholamine-producing neuroendocrine tumors that can be adrenal or extra-adrenal (paraganglioma) in origin. The mainstay of definitive therapy is surgical resection, and successful management depends on careful preoperative optimization, meticulous intraoperative and postoperative hemodynamic management.
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Cricoarytenoid subluxation presenting as vocal cord palsy following endotracheal intubation – A case report p. 243
Ravi Saravanan, Mahesh Parameshwaran, Krishnamurthy Nivedita, Krishnamoorthy Karthik
DOI:10.4103/sja.sja_777_21  
Airway interventions commonly present with self-limiting throat pain and hoarseness of voice. Persistent hoarseness is rare and should be evaluated for serious complications. Cricoarytenoid injuries may present as vocal cord palsies which need careful evaluation. We encountered a case of intubation-related cricoarytenoid subluxation in a 49-year-old diabetic female with a past history of pulmonary tuberculosis was planned for a modified radical mastectomy after a course of neoadjuvant chemotherapy. During intubation by a third-year resident, Cormack Lehane's grade was 3, and bougie-guided railroading of 7 mm endotracheal tube was done blindly. The patient developed haemoptysis and desaturation following intubation and was on ventilator support for 24 hours. Following extubation, the patient had throat pain and hoarseness in voice for more than 2 days. Fibreoptic laryngoscopy revealed right vocal cord palsy. A detailed evaluation revealed right cricoarytenoid subluxation which was treated successfully by closed reduction after 1 week. Cricoarytenoid subluxation, though rare is a serious complication after interventional airway procedures. According to the literature, unfavourable intubating conditions, predisposing patient factors and inadequate experience of the anaesthesiologist are the major contributors to this complication. Injury may produce submucosal haemorrhage and haemarthrosis, which cause adhesions and scarring leading to fixing of vocal cord in abnormal position and permanent disability. Early diagnosis by fibreoptic laryngoscopy and CT imaging and prompt interventions like closed reduction or laryngoplasty should be done to restore vocal cord function.
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Seizure following general anesthesia for cystoscopy and urethral dilatation: A case report p. 246
Ahmed Sabry Elbashary, Khaloud A Alshwairikh, Raed Almaanie, Adel Alhazzani, Abdullah Alsufyani, Abdullah Almousa, Majed Alotaibi, Abdelazeem A Eldawlatly
DOI:10.4103/sja.sja_848_21  
Seizure and anesthesia is a topic necessitating more studies to understand its mechanism. Some anesthetic agents triggers seizures, while others can control it. We are here reporting a case of apparently healthy young adult patient who underwent diagnostic cystoscopy and urethral dilatation under general anesthesia and who developed seizure immediately after admission to the postanaesthetic care unit.
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LETTERS TO EDITOR Top

Tapia's syndrome: An unanticipated airway complication p. 249
Ravindra Chauhan, U Anushaprasath, Manbir Kaur, Swati Chhabra
DOI:10.4103/sja.sja_794_21  
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Emergency airway management in COVID-19 patients and risk to healthcare workers: A low-middle income country data from the intubate COVID registry p. 251
Faisal Shamim, Mohsin Nazir, Naseem A Sheikh, Asma Salam, Badar Afzal
DOI:10.4103/sja.sja_743_21  
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Continuous erector spinae plane block in paediatric patient undergoing thoracotomy surgery p. 253
Poonam Kumari, Amarjeet Kumar, Chandni Sinha, Ajeet Kumar, Subhajit Ghosh
DOI:10.4103/sja.sja_820_21  
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Anaesthetizing post laryngectomy patient: Unique challenges p. 254
Nisha Jain, Manpreet Kaur, S Gurudarshan, Prayosikta Lenka
DOI:10.4103/sja.sja_834_21  
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Continuous bilateral transversus thoracis muscle plane block in median sternotomy p. 255
Poonam Kumari, Amarjeet Kumar, Chandni Sinha, Ajeet Kumar, P Saravanan, Shuchi Smita
DOI:10.4103/sja.sja_825_21  
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Quality of a randomized-controlled trial- how to assess and improve reporting? p. 257
Abhijit Nair
DOI:10.4103/sja.sja_870_21  
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Ciprofol- a game changing intravenous anesthetic or another experimental drug! p. 258
Abhijit Nair, Suresh Seelam
DOI:10.4103/sja.sja_898_21  
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Central venous catheterization in a patient with double right internal jugular vein and persistent left-sided superior vena cava draining into the left atrium p. 260
Sohan Lal Solanki, Mihika J Divatia, Kunal Gala, Jigeeshu V Divatia
DOI:10.4103/sja.sja_5_22  
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Reflections on: “Is intranasal dexmedetomidine superior to oral chloral hydrate for procedural sedation in children: A systematic review” p. 261
Raghuraman M Sethuraman
DOI:10.4103/sja.sja_13_22  
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Spinal ultrasound for lumbar puncture in infants: To see or not to see p. 262
Ramón Eizaga Rebollar, Patricia Martín Falcón, Beatriz Gómez Tapia, Luis Miguel Torres Morera
DOI:10.4103/sja.sja_29_22  
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The feasibility of ROX index to predict intubation in patients initiated on high-flow oxygenation p. 264
Abhijit Nair, Antonio Esquinas
DOI:10.4103/sja.sja_67_22  
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Bilateral ultrasound-guided continuous cervical erector spinae plane block in suboccipital craniotomy p. 266
Amarjeet Kumar, Ajeet Kumar, Chandni Sinha, Vikas Chandra Jha, Gayatri D Sagdeo
DOI:10.4103/sja.sja_699_21  
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HACOR score to predict failure of non-invasive ventilation in patients with acute hypoxemic respiratory failure: When simplicity is best p. 267
Abhijit Nair, Antonio Esquinas
DOI:10.4103/sja.sja_88_22  
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Calcitonin as an alternative in pain management- present status p. 269
Abhijit Nair
DOI:10.4103/sja.sja_101_22  
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Anesthesia for triggered electromyography-guided cord detethering in a three-month-old infant p. 270
Balaji Vaithialingam
DOI:10.4103/sja.sja_49_22  
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OBITUARIES Top

Dr. Mohammed El Gammal MD 8th November 1951–25th January 2022 p. 272
Ali Al Shoaiby
DOI:10.4103/sja.sja_100_22  
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