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   2016| July-September  | Volume 10 | Issue 3  
    Online since June 2, 2016

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Basic concepts for sample size calculation: Critical step for any clinical trials!
KK Gupta, JP Attri, A Singh, H Kaur, G Kaur
July-September 2016, 10(3):328-331
DOI:10.4103/1658-354X.174918  PMID:27375390
Quality of clinical trials has improved steadily over last two decades, but certain areas in trial methodology still require special attention like in sample size calculation. The sample size is one of the basic steps in planning any clinical trial and any negligence in its calculation may lead to rejection of true findings and false results may get approval. Although statisticians play a major role in sample size estimation basic knowledge regarding sample size calculation is very sparse among most of the anesthesiologists related to research including under trainee doctors. In this review, we will discuss how important sample size calculation is for research studies and the effects of underestimation or overestimation of sample size on project's results. We have highlighted the basic concepts regarding various parameters needed to calculate the sample size along with examples.
  22,697 3,151 28
Lung ultrasound versus chest radiography for the diagnosis of pneumothorax in critically ill patients: A prospective, single-blind study
W Abdalla, M Elgendy, AA Abdelaziz, MA Ammar
July-September 2016, 10(3):265-269
DOI:10.4103/1658-354X.174906  PMID:27375379
Background: Radiologic data remains the gold standard for the diagnosis of pneumothorax (PTX). The use of ultrasonography (US) has recently emerged as the method of choice with physicians who can perform bedside US. Purpose: To compare the diagnostic accuracy of lung US against bedside chest radiography (CR) for the detection of PTX using thoracic computed tomography (CT) as the gold standard. Materials and Methods: We conducted a prospective, single-blind study on 192 critically ill patients; each patient received lung US examination, bedside CR, followed by thoracic CT scan searching for PTX. Results: Of the studied patients, CT of the chest confirmed the diagnosis of PTX in 36 (18.75%) patients of which 31 were diagnosed by thoracic US while CR detected only 19 cases. Overall lung US showed a considerable higher sensitivity than bedside CR (86.1% vs. 52.7%), lung US also showed higher, negative predictive values, and diagnostic accuracy against CR (96.8% vs. 90.1%), and (95.3% vs. 90.6%), respectively. CR had a slightly higher specificity than lung US (99.4% vs. 97.4%), and higher positive predictive values (95.0% vs. 88.6%). Conclusion: Lung US is an accurate modality more than anteroposterior bedside CR in comparison with CT scanning when evaluating critically ill mechanically ventilated patients, patients underwent thoracocentesis, central venous catheter insertion, or patients with polytrauma.
  9,067 448 10
Fear of going under general anesthesia: A cross-sectional study
ME Ruhaiyem, AA Alshehri, M Saade, TA Shoabi, H Zahoor, NA Tawfeeq
July-September 2016, 10(3):317-321
DOI:10.4103/1658-354X.179094  PMID:27375388
Objectives: Fears related to anesthesia have affected a considerable number of patients going for surgery. The purpose of this survey was to identify the most common concerns about general anesthesia during the preoperative anesthetic clinic in different healthcare settings, and whether they are affected by patients' sex, age, education, or previous experience of anesthesia or not. Materials and Methods: Structured questionnaires with consent forms were distributed to patients in their preanesthesia clinic visit in three tertiary hospitals (King Abdul-Aziz Medical City, King Faisal Specialist Hospital, and King Khalid University Hospital) in Riyadh, Saudi Arabia. Patients' demographics and questions related to their fears regarding general anesthesia were included in the questionnaires. All categorical and interval variables were compared statically using a Chi-square test for independence and a t-test, respectively. All statistical tests were declared significant at α level of 0.05 or less. Results: Among 450 questionnaires that were disturbed, 400 questionnaires were collected and analyzed. Eighty-eight percent experienced preoperative fear. The top three causes of their fears were fear of postoperative pain (77.3%), fear of intraoperative awareness (73.7%), and fear of being sleepy postoperatively (69.5%). Patients are less fearful of drains and needles in the operative theater (48%), of revealing personal issues under general anesthesia (55.2%), and of not waking up after surgery (56.4%). Age and gender were significant predictors of the overall fear among preanesthetic patients. Females are 5 times more likely to experience fear before surgery (P = 0.0009). Patients aged more than 40 years old are also at 75% higher risk of being afraid (P = 0.008). Conclusion: The majority of the patients going for surgery experienced a fear of anesthesia. Mostly females, especially those over 40, were at a higher risk of being afraid. Fear can bring anxiety which, in turn, might affect the patient's surgery.
  5,218 415 11
Controlled hypotension in day care functional endoscopic sinus surgery: A comparison between esmolol and dexmedetomidine: A prospective, double-blind, and randomized study
A Das, S Chhaule, S Bhattacharya, SR Basunia, T Mitra, PS Halder, S Chattopadhyay, SK Mandal
July-September 2016, 10(3):276-282
DOI:10.4103/1658-354X.174919  PMID:27375381
Background: Functional endoscopic sinus surgery (FESS) is the cornerstone of therapeutic management for nasal pathologies. This study is to compare the ability of preoperative and intraoperative esmolol versus dexmedetomidine for producing induced hypotension during FESS in adults in a day care setting. Materials and Methods: Sixty patients (20-45 years) posted for FESS under general anesthesia were randomly divided into Group E (n = 30) receiving esmolol, loading dose 1 mg/kg over 1 min followed by 0.5 mg/kg/h infusion during maintenance and Group D (n = 30) receiving dexmedetomidine 1 μg/kg over 15 min before induction of anesthesia followed by 0.5 μg/Kg/h infusion during maintenance, respectively. Nasal bleeding and Surgeon's satisfaction score; amount and number of patients receiving fentanyl and nitroglycerine for analgesia and deliberate hypotension, Postanesthesia Care Unit (PACU) and hospital stay; hemodynamic parameters and side effects were recorded for each patient. Results: Significantly less number and dosage of nitroglycerine was required (P = 0.0032 and 0.0001, respectively) in Group D compared to that in Group E. Again the number and dosage of patients requiring fentanyl were significantly lower in Group D. However, the duration of controlled hypotension was almost similar in both the groups. Group D patients suffered from significantly less nasal bleeding, and surgeon's satisfaction score was also high in this group. Discharge from PACU and hospital were significantly earlier in Group D. Intraoperative hemodynamics were quite comparable (P > 0.05) without any appreciable side effects. Conclusion: Dexmedetomidine found to be providing more effectively controlled hypotension and analgesia and thus allowing less nasal bleeding as well as more surgeons' satisfaction score.
  3,890 337 7
Depth of insertion of right internal jugular central venous catheter: Comparison of topographic and formula methods
M Vinay, CA Tejesh
July-September 2016, 10(3):255-258
DOI:10.4103/1658-354X.174904  PMID:27375377
Background: Central venous catheters (CVCs) are inserted in many critically ill patients, but there is no gold standard in estimating their approximate depth of insertion. Many techniques have been described in literature. In this study, we compare the topographic method with the standard formula technique. Materials and Methods: 260 patients, in whom central venous catheterization was warranted, were randomly assigned to either topographic method or formula method (130 in each group). The position of the CVC tip in relation to carina was measured on a postprocedure chest X-ray. The primary endpoint was the need for catheter repositioning. Results: The majority of the CVCs tips positioned by the formula method were situated below the carina, and 68% of these catheters required repositioning after obtaining postprocedure chest X-ray (P < 0.001). Conclusion: The topographic method is superior to formula approach in estimating the depth of insertion of right internal jugular CVCs.
  3,517 305 1
Efficacy of epidural local anesthetic and dexamethasone in providing postoperative analgesia: A meta-analysis
B Jebaraj, P Khanna, DK Baidya, S Maitra
July-September 2016, 10(3):322-327
DOI:10.4103/1658-354X.179096  PMID:27375389
Background: Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice. Materials and Methods: Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: "Epidural," "dexamethasone," and "postoperative pain," until February 20, 2015. Results: Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference −7.89 mg; 95% confidence interval [CI]: −11.66 to −3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63). Conclusion: The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management.
  3,390 223 1
Comparison of erythromycin versus metoclopramide for gastric feeding intolerance in patients with traumatic brain injury: A randomized double-blind study
Jeetinder Kaur Makkar, Basanta Gauli, Kajal Jain, Divya Jain, Yatinder Kumar Batra
July-September 2016, 10(3):308-313
DOI:10.4103/1658-354X.174902  PMID:27375386
Background: No randomized controlled trial demonstrates the efficacy of erythromycin or metoclopramide in patients with traumatic brain injury (TBI). This study was conducted to determine the efficacy of metoclopramide and erythromycin for improving gastric aspirate volume (GAV) in patients with TBI. Materials and Methods: Patients with Glasgow coma score more than 5 admitted to trauma Intensive Care Unit within 72 h of head injury were assessed for eligibility. 115 patients were prospectively randomized to receive metoclopramide, erythromycin, or placebo eighth hourly. Gastric feeding intolerance was defined as GAV more than 150 ml with abdominal symptoms. Two consecutive high GAV was defined as feeding failure. Feeding failure was treated by increasing the frequency of dose to 6 hourly in metoclopramide and erythromycin group. Combination therapy with both drugs was given as rescue in the placebo group. Results: Incidence of high GAV was as high as 60.5% in placebo group. Use of erythromycin was associated with a decrease in the incidence of feeding intolerance to 28.9% (P = 0.006). Although feed intolerance decreased to 43.6% in metoclopramide group, values did not reach statistical significance. The proportion of patients not having high GAV at different days were significantly higher in erythromycin group (P = 0.027, log-rank test). There was no difference in the proportion of patients not having feeding failure in three groups with increasing number of days. Conclusion: There was a significant decrease in the incidence of high GAV with the use of erythromycin when compared to metoclopramide and placebo.
  3,358 196 4
An infant's airway: A difficult terrain
Zahid Hussain Khan
July-September 2016, 10(3):253-254
DOI:10.4103/1658-354X.174905  PMID:27375376
  3,286 186 -
Premedication in an autistic, combative child: Challenges and nuances
S Prakash, VK Pai, M Dhar, AA Kumar
July-September 2016, 10(3):339-341
DOI:10.4103/1658-354X.174917  PMID:27375393
Children with autistic spectrum disorders are often encountered in anesthesia practice mainly for outdoor procedural sedation or anesthesia in endoscopy and magnetic resonance imaging suites. We describe a case of a 7-year-old autistic boy who required management of dental caries. He had a phobia to intravenous cannulation, displayed increasing anxiety and became combative on the day of surgery. With parental involvement and distraction, we succeeded in giving oral midazolam by concealing it, with the intent of avoiding intramuscular injection or unnecessary restraint. Lack of knowledge about the medical condition of such a patient can lead to inadequate preoperative preparation and use of restraint on the patient, which might cause anxiety or panic attacks in the operative room. To effectively manage children with special needs one needs to have clear guidelines on the management of uncooperative children, involve parents perioperatively, plan ahead with an emphasis on perioperative analgesia and sometimes incorporate the ethical use of restraint.
  3,170 213 1
Intraoperative effect of dexmedetomidine infusion during living donor liver transplantation: A randomized control trial
E Sayed, KA Yassen
July-September 2016, 10(3):288-294
DOI:10.4103/1658-354X.174914  PMID:27375383
Background: Dexmedetomidine hydrochloride (Dex) is a useful adjuvant for general anesthesia. The aim was to evaluate the effects of Dex infusion during living donors liver transplantation (LDLT) on the general anesthetic requirements, hemodynamics, oxygen consumption (VO 2 ), and CO 2 production (VCO 2 ). Materials and Methods: Forty LDLT recipients were allocated randomly to receive either Dex (0.2-0.7 μg/kg/h) or placebo (control [C]). Patient state index (PSI), SEDLine monitored anesthesia depth (25-50) with desflurane (Des) % and fentanyl altered accordingly. Transesophageal Doppler (TED), invasive mean arterial blood pressure (MAP) and heart rate (HR) were monitoring any Dex side effects and altering infusion rate accordingly; TED was used for fluid optimization. Metabolic gas monitoring (VO 2 , VCO 2 ) and Des consumption were recorded. Results: Dex reduced Des and fentanyl consumption versus C (120.0 ± 30.2 vs. 248.0 ± 38.8) ml, (440.0 ± 195.74 vs. 1300.0 ± 32) μg, respectively (P < 0.01). Dex was delivered for 11.35 ± 2.45 h with comparable HR, MAP, and TED variables versus C and with similar mean noradrenaline support (5.63 ± 2.44 vs. 5.83 ± 2.57 mg, P = 0.81). VO 2 was reduced with Dex vs. C during anhepatic, 30 min postreperfusion and end of surgery (193.2 ± 26.78 vs. 239 ± 14.93) (172.1 ± 28.14 vs. 202.7 ± 18.03) and (199.7 ± 26.63 vs. 283.8 ± 14.83) ml/min/m 2 respectively (P < 0.01). VCO 2 was also reduced with Dex versus C during the same periods (195.2 ± 46.41 vs. 216.7 ± 29.90, P = 0.09), (210.6 ± 60.71 vs. 253.9 ± 32.51, P = 0.01), and (158.7 ± 49.96 vs. 209.7 ± 16.78, P < 0.01), ml/min/m 2 respectively. Conclusion: TED and PSI guided Dex infusion helped to reduce Des and fentanyl consumption as well as VO 2 and VCO 2 at a lower cost with no adverse effects on hemodynamics.
  3,135 210 2
Placenta accreta and anesthesia: A multidisciplinary approach
RS Khokhar, J Baaj, MU Khan, FA Dammas, N Rashid
July-September 2016, 10(3):332-334
DOI:10.4103/1658-354X.174913  PMID:27375391
Placenta accreta (an abnormally adherent placenta) is one of the two leading causes of peripartum hemorrhage and the most common indication for peripartum hysterectomy. Placenta accreta may be associated with significant maternal hemorrhage at delivery owing to the incomplete placental separation. When placenta accreta is diagnosed before delivery, a multidisciplinary approach may improve patient outcome.
  3,045 280 1
Combined transversus abdominis plane block and rectus sheath block in laparoscopic peritoneal dialysis catheter insertion
Abdelazeem Ali Eldawlatly, Abdullah Aldohayan
July-September 2016, 10(3):251-252
DOI:10.4103/1658-354X.183403  PMID:27375375
  3,050 238 2
Inaccurate level of intervertebral space estimated by palpation: The ultrasonic revelation
LH Parate, B Manjunath, CA Tejesh, V Pujari
July-September 2016, 10(3):270-275
DOI:10.4103/1658-354X.170104  PMID:27375380
Background: Spinal cord injury resulting from spinal anesthesia is a rare, but an alarming scenario. The most likely cause is believed to be misjudged level of intervertebral space (IVS). We evaluated the accuracy of palpation method to locate IVS with the ultrasonography. Materials and Methods: A total of 109 patients undergoing spinal anesthesia were included in this observational, double-blind study. First anesthesiologist was asked to mark IVS using palpation method. It was followed by ultrasonographic assessment by another anesthesiologist who was unaware of the level estimated for the mark. We evaluated the accuracy of palpation method in sitting and lateral position as well as the impact of the anesthesiologist's experience (Trainee/Consultant). Statistical Analysis Used: Association between the gender, anthropometric parameters, type of anesthesiologists assessing the IVS, and the level of agreement were identified using Chi-square test. The agreement between palpation method and ultrasound assessment of IVS was analyzed using kappa statistic. P < 0.05 was defined as statistical significance. Results: The IVS located by palpation method was in agreement with ultrasound location in 37.14% of the patients. There were no statistically significant differences found in terms of demographic data (sex, age, height, weight, or body mass index [BMI]) between agreement and disagreement group. The rate of errors was found to be significantly higher (P = 0.01) among the trainees (74.51%) than the consultants (51.86%). The rate of errors was not different between the sitting and lateral position. The frequency of errors was more common in cephalad direction (53.31.5%) compared to caudal direction (9.52%). The misidentified spaces were as high as three spaces above the intended space while in caudal direction it differed by only one space. Conclusion: The accuracy of palpation method controlled by ultrasound is 37.14% and differs by 1-3 IVS in cephalad direction (53.31%). The accuracy is affected by anesthesiologist's experience but remains unaffected by age, sex height, BMI, and patient positioning.
  3,019 224 1
Ease of insertion of the laryngeal mask airway in pediatric surgical patients: Predictors of failure and outcome
SM Asida, SS Ahmed
July-September 2016, 10(3):295-300
DOI:10.4103/1658-354X.174898  PMID:27375384
Background: Laryngeal mask airway (LMA) is an useful alternative to endotracheal tube for airway management. The risk of life-threatening adverse respiratory events during its use is rare, but we need to know about the risk-adjusted prediction of its insertion failure requiring rescue tracheal intubation and its impact on patient outcome. Materials and Methods: Five hundred patients; 6 months to 12-year-old, American Society of Anesthesiologists I and II scheduled to undergo elective surgical procedures that require general anesthesia were included in this study. LMA was inserted after induction of anesthesia. The insertion conditions, intra, and postoperative events were recorded. Our primary outcome variable was trial success from the first time. Results: We recorded 426 cases (85.2%) of first trial success with clear airway compared to 46 case (9.2%) of second trial success (P ≤ 0.001). Predictors of failure of first attempt of LMA insertion include abnormal airway anatomy (91%), body weight <16 kg and age below 5 years (44%), the use of LMA size of 1 and 1.5 (3.8%), the intraoperative lateral position (3.8%). Conclusion: The data obtained from this study support the use of the LMA as a reliable pediatric supraglottic airway device, demonstrating relatively low failure rates. Predictors of LMA failure in the pediatric surgical population should be independently considered. Trial Registration: The study is registered in the Australian and New Zealand clinical trial registry with the allocated trial number: ACTRN12614000994684. Web address of trial: http://www.ANZCTR.org.au/A CTRN12614000994684.aspx.
  2,889 206 -
Anesthetic management of vallecular cyst excision in an infant: An airway challenge
Viraj N Namshikar, Nimisha V Dukle, Dattraj S Sukhthanker
July-September 2016, 10(3):356-358
DOI:10.4103/1658-354X.174903  PMID:27375399
Vallecular cyst is uncommon but well-recognized cause of upper airway obstruction in newborn and infants. We hereby present anesthetic management of a case of vallecular cyst in an infant posted for excision and marsupialization. A 4-month-old female infant weighing 3.5 kg presented with inspiratory stridor progressively worsening over 2 months. Anesthesia plan was to carry out inhalational induction maintaining spontaneous respiration and keeping tracheostomy as standby option. In this case, laryngoscopy was challenging due to the size and extent of the cyst thus necessitating gentle laryngoscopy to prevent cyst rupture and pulmonary aspiration. On performing laryngoscopy, epiglottis was not visualized, which made intubation difficult. At the end of surgery, extubation was not carried out as the possibility of laryngomalacia could not be eliminated and also in view of intraoperative airway manipulation. The patient was electively ventilated postoperatively and extubated on the 2 nd postoperative day.
  2,880 132 -
A case of bronchiectasis needing lung isolation for cerebello pontine angle tumor excision: Anesthetic challenges
C Srinivasan, GP Kurian, R Mariappan
July-September 2016, 10(3):359-361
DOI:10.4103/1658-354X.174923  PMID:27375400
The main goals of neuroanesthesia are the maintenance of adequate cerebral perfusion pressure, avoidance of hypercarbia, hypoxemia, and to provide better brain relaxation. Providing anesthesia for a patient with bronchiectasis needing lung isolation for craniotomy can be challenging. A 56-year-old male patient, case of right lung bronchiectasis with a right cerebello pontine angle tumor underwent excision in the left lateral position. Since he had severe bronchiectasis of the right lung, we had isolated the right lung using right-sided double lumen tube to avoid spillage. Intraoperative split lung test was performed to assess the right lung contribution on carbon dioxide (CO 2 ) elimination and found that there was a significant contribution from the right lung. Hence, both lungs were ventilated to control CO 2 . The importance of lung isolation to prevent spillage and avoidance of one lung ventilation to control the arterial CO 2 are highlighted in this case report. By providing a balanced anesthetic keeping both, the neurosurgical and thoracic concerns are important for better postoperative outcome.
  2,917 93 -
Comparative effect of propofol versus sevoflurane on renal ischemia/reperfusion injury after elective open abdominal aortic aneurysm repair
AS Ammar, KM Mahmoud
July-September 2016, 10(3):301-307
DOI:10.4103/1658-354X.174907  PMID:27375385
Background: Renal injury is a common cause of morbidity and mortality after elective abdominal aortic aneurysm (AAA) repair. Propofol has been reported to protect several organs from ischemia/reperfusion (I/R) induced injury. We performed a randomized clinical trial to compare propofol and sevoflurane for their effects on renal I/R injury in patients undergoing elective AAA repair. Materials and Methods : Fifty patients scheduled for elective AAA repair were randomized to receive propofol anesthesia in group I or sevoflurane anesthesia in group II. Urinary specific kidney proteins (N-acetyl-beta-glucosamidase, alpha-1-microglobulin, glutathione transferase [GST]-pi, GST-alpha) were measured within 5 min of starting anesthesia as a base line (T 0 ), at the end of surgery (T 1 ), 8 h after surgery (T 2 ), 16 h after surgery (T 3 ), and 24 h postoperatively (T 4 ). Serum pro-inflammatory cytokines (tumor necrosis factor-α and interleukin 1-β) were measured at the same time points. In addition, serum creatinine and cystatin C were measured before starting surgery as a baseline and at days 1, 3, and 6 after surgery. Results: Postoperative urinary concentrations of all measured kidney specific proteins and serum pro-inflammatory cytokines were significantly lower in the propofol group. In addition, the serum creatinine and cystatin C were significantly lower in the propofol group compared with the sevoflurane group. Conclusion: Propofol significantly reduced renal injury after elective open AAA repair and this could have clinical implications in situations of expected renal I/R injury.
  2,828 166 9
Multiple pterygium syndrome: Challenge for anesthesiologist
P Sethi, PK Bhatia, N Gupta, K Singh
July-September 2016, 10(3):350-352
DOI:10.4103/1658-354X.174901  PMID:27375397
Multiple pterygium syndrome (MPS) is a very rare autosomal recessive disorder characterized by flexion of joint and digit contractures, skin webbing, cleft palate, deformity of the spine, and cervical spine fusion. Difficult airway is associated mainly due to micrognathia, retrognathia, webbing of the neck, and limitation of the mouth opening and neck extension. We are reporting a case of a 5-year-old female diagnosed with MPS and exhibiting a bilateral club foot and congenital vertical talus. The patient was posted for manipulation and above the knee casting under general anesthesia.
  2,793 154 1
To determine block establishment time of supraclavicular brachial plexus block using blunt versus short bevel needle: A prospective randomized trial
V Ahuja, D Thapa, S Gombar, D Dhiman
July-September 2016, 10(3):259-264
DOI:10.4103/1658-354X.174910  PMID:27375378
Background: Unintentional intraneural injection under ultrasound guidance (USG) with fine caliber needles and lower success rate with large caliber Tuohy needles in supraclavicular brachial plexus block (SCB) have been reported. Materials and Methods: We undertook study to standardize the use of 20-gauge short versus blunt bevel needle for SCB. After approval of Institutional Ethics Committee and written informed consent, patients were randomized using computer-generated random number table to either of the two groups; blunt bevel needle group (n = 30): SCB under USG using 20-gauge Tuohy needle or short bevel needle group (n = 30): SCB under USG using 20-gauge short bevel needle. The primary outcome of the study was time to establishment of sensory and motor block of individual nerves, and secondary outcome was tolerability and any adverse effects. Results: The time to establishment of sensory and motor block in individual nerve territory was similar in both the groups. The complete sensory and motor anesthesia was achieved in 78.3% patients and complete sensory and motor anesthesia after supplementary block was achieved in 86.6% patients. Paresthesias during SCB were recorded in 15 patients. Out of these eight patients were of blunt bevel group and seven patients were of short bevel group. None of the patients experienced any neurological adverse effects. Conclusion: The establishment of sensory and motor blockade of individual nerves was similar to 20-gauge short and blunt bevel needle under ultrasound guide with no neurological adverse events.
  2,628 202 -
Arthroscopic medial meniscus trimming or repair under nerve blocks: Which nerves should be blocked?
AM Taha, AM Abd-Elmaksoud
July-September 2016, 10(3):283-287
DOI:10.4103/1658-354X.174912  PMID:27375382
Background: This study aimed to determine the role of the sciatic and obturator nerve blocks (in addition to femoral block) in providing painless arthroscopic medial meniscus trimming/repair. Materials and Methods: One hundred and twenty patients with medial meniscus tear, who had been scheduled to knee arthroscopy, were planned to be included in this controlled prospective double-blind study. The patients were randomly allocated into three equal groups; FSO, FS, and FO. The femoral, sciatic, and obturator nerves were blocked in FSO groups. The femoral and sciatic nerves were blocked in FS group, while the femoral and obturator nerves were blocked in FO group. Intraoperative pain and its causative surgical maneuver were recorded. Results: All the patients (n = 7, 100%) in FO group had intraoperative pain. The research was terminated in this group but completed in FS and FSO groups (40 patients each). During valgus positioning of the knee for surgical management of the medial meniscus tear, the patients in FS group experienced pain more frequently than those in FSO group (P = 0.005). Conclusion: Adding a sciatic nerve block to the femoral nerve block is important for painless knee arthroscopy. Further adding of an obturator nerve block may be needed when a valgus knee position is required to manage the medial meniscus tear.
  2,646 152 4
Anesthetic management of Amplatzer atrial septal defect closure device embolization to right ventricular outflow tract
S Das, P Kumar, V Bhardwaj, R Palleti
July-September 2016, 10(3):335-338
DOI:10.4103/1658-354X.174911  PMID:27375392
Percutaneous device closure of atrial septal defect (ASD) is an alternative treatment to surgery with advantages of avoidance of surgery, short procedure time, early discharge from hospital, and lower rates of complications. However, percutaneous device closure is associated with infrequent life-threatening complications such as device embolization. We report a case device embolization of the ASD occlude device into right ventricular outflow tract resulting progressive hypoxia. The role of anesthesiologist as a team leader in managing such emergency is discussed.
  2,640 115 1
Inadvertent intrathecal injection of labetalol
S Verma, PK Bhatia, V Sharma, P Sethi
July-September 2016, 10(3):345-346
DOI:10.4103/1658-354X.174899  PMID:27375395
Labetalol is a combined α and β adrenergic receptor blocker. It is used to treat hypertension, especially in pregnant patients. We report a case of a female patient who was given labetalol intrathecally in place of bupivacaine due to a similar appearance of ampoules which resulted in a drop in blood pressure and pulse rate. The patient responded to fluid resuscitation and there occurred no neurological sequelae.
  2,612 133 2
Malignant hyperthermia in a 6-month-old infant
PR Mathur, M Rundla, N Jain, V Mathur
July-September 2016, 10(3):353-355
DOI:10.4103/1658-354X.174915  PMID:27375398
Malignant hyperthermia (MH) is a rare hypermetabolic disorder of skeletal muscles that manifests as a life-threatening crisis in susceptible individuals, after exposure to triggering agents, most commonly halothane and succinylcholine. MH presents with multiple nonspecific signs and laboratory findings such as tachycardia, hyperthermia, hypercarbia, acidosis, and muscle rigidity. Caffeine halothane contracture test is not available at most centers in India. Larach et al. have described a clinical grading scale for determining the MH raw score based on clinical findings and biochemical tests. The high degree of suspicion, early recognition and aggressive treatment should commence immediately. It is imperative to avoid triggering agents, such as volatile anesthetics and succinylcholine, and promote the use of total intravenous anesthesia in MH susceptible patients. We report a case of 6-month-old child undergoing laparotomy under general anesthesia, who presented with signs and symptoms of MH, had MH rank 5 and raw score 36.
  2,524 190 2
An accidental intra-arterial injection of phenytoin in a 43-year-old woman
ZH Khan, S Faghihnassiri
July-September 2016, 10(3):342-344
DOI:10.4103/1658-354X.174916  PMID:27375394
We report an accidental intra-arterial injection of phenytoin in a 43-year-old woman undergoing ventriculoperitoneal shunt for hydrocephalus. To flush the arterial line with heparin, mistakenly phenytoin was injected which caused cutaneous gangrene along the radial side of the forearm and an absence of pulsation in the radial artery. After flushing the artery with normal saline and lidocaine, the patient was transferred to the Intensive Care Unit. There the patient was put on intravenous heparin that resolved the problem leading to complete recovery of the patient. The case is being reported to emphasize the importance of close surveillance in injecting drugs through the arterial line access.
  2,560 126 1
Sonographic detection of tracheal or esophageal intubation: A cadaver study
CA Tejesh, AC Manjunath, S Shivakumar, PS Vinayak, B Yatish, CR Geetha
July-September 2016, 10(3):314-316
DOI:10.4103/1658-354X.174922  PMID:27375387
Background: The correct position of the endotracheal tube is confirmed by various modalities, most of which are not entirely reliable. Ultrasound is now increasingly available to anesthesiologists in the operating theater and is an attractive alternative. To investigate the usefulness of sonography in identifying the correct tracheal tube position in human cadavers. Materials and Methods: Endotracheal tubes placed randomly into trachea or esophagus was identified with a linear ultrasound probe placed transversely just above the suprasternal notch by a single anesthesiologist. Results: Of the 100 intubations performed at random, 99 were correctly identified to give a sensitivity of 100% and a specificity of 97.9%. Conclusion: Sonography is a useful technique to identify correct position of the tracheal tube.
  2,508 162 4
Copper-T, an unusual cause of profuse bleeding during cesarean section
Somvanshi Mukesh, Tripathi Archana, Kumar Hemant
July-September 2016, 10(3):362-363
DOI:10.4103/1658-354X.174908  PMID:27375401
  2,485 114 -
Novel use of epidural catheter: Air injection for neuroprotection during radiofrequency ablation of spinal osteoid osteoma
JR Doctor, SL Solanki, VP Patil, JV Divatia
July-September 2016, 10(3):347-349
DOI:10.4103/1658-354X.174900  PMID:27375396
Osteoid osteoma (OO) is a benign bone tumor, with a male-female ratio of approximately 2:1 and mainly affecting long bones. Ten percent of the lesions occur in the spine, mostly within the posterior elements. Treatment options for OO include surgical excision and percutaneous imaging-guided radiofrequency ablation (RFA). Lesions within the spine have an inherent risk of thermal damage to the vital structure because of proximity to the neural elements. We report a novel use of the epidural catheter for air injection for the neuroprotection of nerves close to the OO of the spine. A 12-year-old and 30 kg male child with an OO of the L3 vertebra was taken up for RFA. His preoperative examinations were within normal limits. The OO was very close to the L3 nerve root. Under general anesthesia, lumbar epidural catheter was placed in the L3-L4 space under imaging guidance. Ten ml of aliquots of air was injected under imaging guidance to avoid injury to the neural structures due to RFA. The air created a gap between neural elements and the tumor and served as an insulating material thereby protecting the neural elements from damage due to the RFA. Postoperatively, the patient did not develop any neurological deficit.
  2,371 115 -
H1N1 with adult respiratory distress syndrome for emergency lower segment cesarean section: A case report
Anindita Mukherjee, Sneha Padma, Santosh C Karayi
July-September 2016, 10(3):366-367
DOI:10.4103/1658-354X.179091  PMID:27375404
  2,183 107 -
Shoulder soreness due to shoulder braces following robotic surgery in steep Trendelenburg position
SD Savarkar, SG Bakshi, RV Thosar, R Sareen
July-September 2016, 10(3):363-364
DOI:10.4103/1658-354X.174909  PMID:27375402
  2,084 137 -
Complete recovery after cardiopulmonary resuscitation in the lateral decubitus position: A report of two cases
V Bhatnagar, K Jinjil, P Raj
July-September 2016, 10(3):365-366
DOI:10.4103/1658-354X.174921  PMID:27375403
  2,052 121 -