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   2021| January-March  | Volume 15 | Issue 1  
    Online since January 5, 2021

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Pain management in COVID-19 pediatric patients—An evidence- based review
Priyanka Mishra, Anupama Tomar, Ajit Kumar, Amborish Nath, Suresh K Sharma, Girish Kumar Singh
January-March 2021, 15(1):33-39
Despite our growing knowledge about the COVID pandemic, not much concern has been focused upon the effective pain management in pediatric patients suffering from this SARS CoV2 virus. Symptoms with pain like myalgia (10%–40%), sore throat (5%–30%), headache (14%–40%) and abdominal pain (10%) are common in children suffering from COVID. (3-5) We conducted a systematic review regarding analgesia for COVID positive pediatric patients. Cochrane, PubMed, and Google scholar databases were searched for relevant literature. Owing to the novel status of COVID-19 with limited literature, we included randomized controlled trials (RCTs), observational studies, case series and case reports in the descending order of consideration. Articles in languages other than English, abstract only articles and non-scientific commentaries were excluded. The Primary outcome was evaluation of pain related symptoms and best strategies for their management. Our review revealed that a multidisciplinary approach starting from non-pharmacological techniques like drinking plenty of water, removing triggers like inadequate sleep, specific foods and psychotherapy including distraction, comfort and cognitive behavioural strategies should be used. Pharmacological approaches like acetaminophen, NSAIDS, spasmolytics etc. can be used if non-pharmacological therapy is inadequate. As per the current strength of evidence, acetaminophen and ibuprofen can be safely administered for pain management in children with COVID-19. Undertreated pain is a significant contributor to increased morbidity and poor prognosis. Integration of evidence based non-pharmacotherapies in the multidisciplinary pain management will contribute towards improved functioning, early recovery and better quality care for pediatric patients suffering from COVID.
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Perioperative pain management in COVID-19 patients: Considerations and recommendations by the Saudi Anesthesia Society (SAS) and Saudi Society of Pain Medicine (SSPM)
Omar A Alyamani, Mohammed S Bahatheq, Hatem A Azzam, Faisal M Hilal, Sara Farsi, Wadeeah Bahaziq, Ali N Alshoaiby
January-March 2021, 15(1):59-69
The COVID-19 pandemic has swept across the world over the past few months. Many articles have been published on the safety of anesthetic medications and procedures used in COVID-19 positive patients presenting for surgery. Several other articles covered the chronic pain management aspect during the pandemic. Our review aimed to focus on perioperative pain management for COVID-19 patients. We conducted a literature search for pertinent recent articles that cover considerations and recommendations concerning perioperative pain management in COVID-19 patients. We also searched the literature for the relevant adverse effects of the commonly used medications in the treatment of COVID-19, and their potential drug–drug interactions with the common medications used in perioperative pain management. Professional societies recommend prioritizing regional anesthesia techniques, which have many benefits over other perioperative pain management options. When neuraxial and continuous peripheral nerve block catheters are not an option, patient-controlled analgesia (PCA) should be considered if applicable. Many of the medications used for the treatment of COVID-19 and its symptoms can interfere with the metabolism of medications used in perioperative pain management. We formulated an up-to-date guide for anesthesia providers to help them manage perioperative pain in COVID-19 patients presenting for surgery.
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The effect of low versus high tidal volume ventilation on inflammatory markers in animal model undergoing lung ventilation: A prospective study
Waseem M Hajjar, Abdelazeem Eldawlatly, Sami A Alnassar, Iftikhar Ahmed, Alaa Alghamedi, Zahid Shakoor, Ammar C Alrikabi, Adnan W Hajjar, Abdulaziz Ejaz Ahmad
January-March 2021, 15(1):1-6
Background and Aims: Mechanical ventilation (MV) with high tidal volume (Vt.) may induce or aggravate lung injury in critically ill patients. It might also cause an overwhelming systemic inflammation leading to acute lung injury (ALI), diffuse alveolar damage (DAD) and multiple organ failure (MOF) with subsequent high mortality. The objective of this study was to compare the effects of different Vt. on the inflammatory markers of the broncho-alveolar lavage (BAL) fluid and lung biopsy in a group of animal model (Beagle dogs). Methods: A two-phased prospective study involving 30 Beagle dogs (15 dogs/phase), each phase divided into three groups (each 5 dogs/group). In the first phase each group received MV with Vt. of 8 (low), 10 (normal, control group), and 12 (high) ml/kg body weight (b.w.) respectively. BAL fluid was obtained at the time of induction of anesthesia immediately following tracheal intubation and one hour later following MV to count the macrophages, neutrophils and lymphocytes. In the second phase of the experiment, in addition to obtaining (BAL) fluid similar to the phase one, mini thoracotomy and lung biopsy obtained from the upper lobe of the right lung at same timings for histopathological examination study. Mann-Whitney-Wilcoxon test was used for statistical analysis of the data obtained. Results: BAL fluid analysis showed increase in the counts of macrophages and lymphocytes with Vt. of 12 ml/kg b.w. compared to the control group (10 ml/kg b.w.) (P < 0.05). in the second phase, similar findings obtained. The histopathological study of the lung tissue obtained in the second phase of the study from the group that received a high Vt. of 12 ml/kg b.w. showed significant inflammatory changes with presence of neutrophil infiltration and edema in the bronchial wall compared to the control group (10 ml/kg b.w.) (P < 0.05). Conclusions: The use of high Vt. in ventilated animal lung model may increase the risk of inflammation and subsequent damage in healthy lungs, these findings may help physicians to avoid using high Vt. in short-term mechanically ventilated patients in the operating room setting.
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Emergency cesarean section in a COVID-19 patient: A case report
Mohammed Al Harbi, Amr Elkouny, Bader Babtain, Mohamed Jahdaly, Sultan Al-Malki
January-March 2021, 15(1):40-42
Perioperative management of patients with corona virus disease 2019 (COVID-19) can be extremely challenging in order to keep the balance between providing optimal medical care and protecting health-care providers from the risk of infection. We report a 37-year-old COVID-19 patient undergoing an emergency cesarean section.
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Exploring the utility of neuro-monitoring in neurosurgery: The users' perspective in a single center
Chulananda Goonasekera, Holly Jones, Rebekah Lawrence, John Hanrahan, Priyanka Iyer, Aditi Nijhawan
January-March 2021, 15(1):7-13
Background: The purpose of intraoperative neuro-monitoring (IONM) is to minimize injury to eloquent neural structures and optimize tumor resection. Method: We explored the utility of IONM using a qualitative approach in a single center. Eight experienced users of its use in spinal and cranial surgery in adults and children were the informants. Using a constant comparative method, the findings were collated by thematic analysis. Results: The user perspective is that of caution to minimize adverse effects whilst empowering the need for formal training to enhance its efficacy. The process of IONM needs standardization as practices vary amongst users. Most users expressed limited trust on its current capabilities but hoped for its advancement to achieve higher sensitivity and specificity. None were however prepared to abandon its use. Conclusion: IONM needs optimization. Its utility depends on user vigilance, multi-disciplinary validation, and individual expertise. This study draws out key issues from the user perspective that need to be addressed in order to enhance the utility of IONM.
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Anesthesia for GI endoscopy in the era of COVID-19
Basavana Goudra, Preet Mohinder Singh
January-March 2021, 15(1):27-32
As a result of COVID-19, the last few weeks have necessitated a reevaluation of the sedation paradigm for gastrointestinal (GI) endoscopic procedures. Routine screening and some surveillance procedures have taken a backseat and likely to remain so until a vaccine or effective treatment becomes available. Anesthesia providers and endoscopists are required to adapt to this new reality rapidly. The general aim of sedation remains the same-patient comfort, reduced hypoxia, prevention of aspiration along with rapid recovery, and discharge. The present review focuses on necessary modification to reduce the risk of virus contagion for both patients (from health-care providers) and vice versa. A preprocedure evaluation and consenting should be modified and provided remotely. Unsedated GI endoscopy, sedation with minimal respiratory depression, and modification of general anesthesia are explored. Challenges with supplemental oxygen administration and monitoring are addressed. Guidelines for appropriate use of personal protective equipment are discussed. Measures for limiting aerosolization are deliberated.
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Effect of magnesium sulphate on the intracranial pressure of preeclampsia patients using ultrasound-guided optic nerve sheath diameter: A pilot study
Ahmed Salaheldin Omran, Tarek El Ansari, Waleed Riad
January-March 2021, 15(1):14-18
Background: Increased intracranial pressure (ICP) is a known complication of pre-eclampsia with severe features. The use of magnesium sulphate (MgSO4) is the standard treatment and is associated with marked reduction of cerebral perfusion pressure (CPP) and prevention of cerebral damage. Optic nerve sheath diameter (ONSD) ultrasonography is a bedside tool used to reflect changes in the ICP. The aim of this study is to detect the effect of MgSO4 administration on ICP in severe preeclampsia through measuring changes in the ONDS. Methods: Thirty pregnant female patients suffering from severe pre-eclampsia were enrolled in this prospective pilot study. Ultrasound measurement of ONSD was measured before the commencement of MgSO4 and after 1, 6, and 24 h after the administration. Results: There was a significant difference in ONSD measurements between that at baseline and post magnesium administration at 1, 6, and 24 h (P-value 0.001). Additionally, a significant difference in measurements between 1 and 6 and 6 and 24 h after magnesium initiation (P-value 0.001). Conclusions: Ultrasound ONSD measurement in patients with severe preeclampsia is a non-invasive easy tool to detect increased intracranial pressure and monitor the response to magnesium sulphate infusion.
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COVID-19 and the perioperative neuroscience - A narrative review
Indu Kapoor, Charu Mahajan, Hemanshu Prabhakar
January-March 2021, 15(1):19-26
Among the several medical specialties, anesthesiologists are probably the most affected ones from the coronavirus disease (COVID-19) pandemic as they are at the frontline. In the present stage of the pandemic, where we are observing community transmission, more people with elective neurologic and neurosurgical problems are likely to be tested positive for this virulent disease. Neuroanesthesiologists play an important role in the perioperative period and in neuroradiology suite. It is imperative to know the best available ways by which health care providers can manage their patients and also necessary steps to prevent the spread of infection, not only amongst themselves but also between patients. A high index of suspicion in such patients may help avoid delay in diagnosis and catastrophic sequelae. An overall knowledge about the disease will help plan the clinical management of neurologic patients, during the perioperative period.
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Nasogastric tube insertion in an awake COVID.19 patient: Think beyond airway
Hashim Mohammad, Sana Kausar, Ankit Agarwal, Ashutosh Kaushal
January-March 2021, 15(1):71-73
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Utility of gastric ultrasound in evaluating nil per os status in a child
Dolly Munlemvo, Alok Moharir, Yoshikazu Yamaguchi, Sarah Khan, Joseph D Tobias
January-March 2021, 15(1):46-49
Although rare, the aspiration of gastric contents can lead to significant morbidity or even mortality in pediatric patients receiving anesthetic care. For elective cases, routine preoperative practices include the use of standard nil per os times to decrease the risk of aspiration. However, patients may fail to adhere to provided NPO guidelines or other patient factors may impact the efficacy of standard NPO times. Gastric point-of-care ultrasound provides information on the volume and quality of gastric contents and may allow improved patient management strategies. We present a 4-year-old patient who presented for bilateral myringotomy with tympanostomy tube insertion, who was found to have evidence of a full stomach during preoperative gastric ultrasound examination. The use of preoperative gastric point-of-care ultrasound in evaluating stomach contents and confirming NPO times is reviewed and its application to perioperative practice discussed.
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Role of almitrine bismesylate in managing refractory hypoxemia in COVID19 acute respiratory distress syndrome
Abhijit S Nair, Sai Kaushik Pulipaka, Poornachand Anne, Basanth Kumar Rayani
January-March 2021, 15(1):76-77
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Open wide: Anesthetic management of a child with Hecht–Beals syndrome
Caroll N Vazquez-Colon, Angela C Lee
January-March 2021, 15(1):53-55
Hecht–Beals syndrome (HBS) is a rare disorder characterized by trismus and deformity of the extremities. The etiology of trismus is unknown; theories suggest invasion of enlarged coronoid processes into the zygomatic bone. Of primary concern is the limited mouth opening and possible difficult airway. Since the syndrome was first described in 1969, there have been several articles in the pediatrics and dental literature but only 6 case reports describing the anesthetic management of these patients. Successful airway approaches have utilized various techniques including blind nasal intubation, fiberoptic intubation, and tracheal tube introducer guidance. In this case report, we discuss a multidisciplinary approach to the anesthetic management of a child with HBS undergoing MRI and outpatient surgery.
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Management of child after traumatic epidural hematoma with pulmonary edema and arrhythmia
Angela C Lee, Chima Oluigbo
January-March 2021, 15(1):43-45
We present a case of severe neurogenic pulmonary edema and arrhythmia complicating management of a 7-year-old child with acute epidural hematoma and impending cerebral herniation. The underlying mechanisms for this are discussed as well as management of severe neurogenic pulmonary edema. We emphasize the need to recognize this rare complication early and institute prompt aggressive management.
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Successful application of early tracheostomy in an intubated patient who suffered from irritative stimuli by an oral tracheal tube
Keiko Uemura, Satoki Inoue, Masahiko Kawaguchi
January-March 2021, 15(1):50-52
We experienced a case in which simultaneous weaning from sedation and mechanical ventilation were difficult because of instability of tracheal tube fixation that was caused by size mismatch between the trachea and the tube and by severe tracheal deviation. Irritative stimuli caused by the oral tracheal tube prevented conversion from deep sedation to light or no sedation. In this case, very early tracheostomy, which provided better tube fixation and successfully reduced the irritative stimuli to the trachea, was effective to help achieve discontinuation of sedation and facilitated successful weaning from mechanical ventilation. Eventually, the tracheostomy tube was successfully removed immediately after discontinuation of mechanical ventilation.
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Retrieving multiple magnetic foreign bodies from the glottic entrance and stomach: A case report
Stylianos Voulgarelis, Astrid Stucke
January-March 2021, 15(1):56-58
Aspiration and ingestion of foreign bodies present a frequent challenge in pediatric anesthesia practice that requires careful planning of the time and the method of retrieval. We discuss the management of a 20-month-old boy who had ingested multiple small magnetic beads and presented emergently to the operating room with two beads lodged in the vallecula and eighteen more forming a chain in the stomach. Benefitting from their magnetic properties, the beads located close to the glottic entrance could be removed by placing a steel Magill forceps close to the objects and using magnetic pull rather than grasping. The beads in the stomach were removed en bloc due to their magnetic properties using an endoscopic retrieval basket. Small beads can be difficult to remove, however, in this case it was possible to utilize their magnetic properties during the removal process.
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Spread the local, not the virus!
Fabio Costa, Giuseppe Pascarella, Romualdo Del Buono, Alessandro Strumia, Felice Eugenio Agrò
January-March 2021, 15(1):70-71
  704 66 -
Comparing anaesthesia for MRI using inhalational anaesthesia and sedation using propofol - The answer is not in black and white
Gauri R Gangakhedkar
January-March 2021, 15(1):73-74
  676 75 -
Anesthesia practice amid the pandemic mayhem: Time for critical appraisal and reorganization
Anju Gupta, Nishkarsh Gupta
January-March 2021, 15(1):77-79
  620 69 -
Comment on a published article: The VL3 videolaryngoscope for tracheal intubation in adults: A prospective pilot study
Ripon Choudhary, Ridhima Sharma, Rohan Magoon, Poonam Malhotra Kapoor
January-March 2021, 15(1):80-81
  624 63 -
Anticipated difficult airway: Planning, safety and ethics while applying a novel technique
Amit M Narkhede, Amol T Kothekar
January-March 2021, 15(1):74-75
  576 87 -
Pilot line damage at the embedded part of a sutured endotracheal tube intubated via a tracheostomy stoma
Toshiyuki Nakanishi, Kazuya Sobue
January-March 2021, 15(1):79-80
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