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   Table of Contents - Current issue
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January-March 2022
Volume 16 | Issue 1
Page Nos. 1-180

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ORIGINAL ARTICLES  

Prediction of endotracheal tube size in pediatric population using ultrasonographic subglottic diameter and age-related formulas: A comparative study Highly accessed article p. 1
BM Bharathi, Sharmila Somayaji, T Tulasi, N Kaleemullah Sheriff, Jaidev S Bagliker
DOI:10.4103/aer.aer_11_22  
Background: Choosing the correct Endotracheal tube (ETT) size is important in paediatric patients because an inappropriately large and small sized tube has its own disadvantages and chances of re-intubation with different size tube is high. The currently available modalities do not reflect the actual tracheal diameter for selection of endotracheal tube. Ultrasonography (USG) guided evaluation of transverse diameter at subglottic region may be helpful to estimate the proper size of ETT. We tested the hypothesis that Ultrasound guided subglottic diameter better predicts optimal ETT size than existing methods. Aims: To predict the appropriate size of ETT in pediatric patients to avoid multiple attempts of intubation and airway edema using simple noninvasive USG-guided methods. Settings and Design: Design: Prospective study. Settings: Tertiary care hospital. Materials and Methods: Institutional ethical committee clearance no. BMCRI/PS/138/2020-21 was taken. Laryngoscopy and endotracheal intubation were done in 27 pediatric patients of age 2-15 years using a predetermined-sized ETT, estimated by ultrasonography. ETT size was considered optimal when the cuff leak test was negative. If there was resistance to ETT passage into the trachea, the tube was exchanged with one that was 0.5 mm smaller. If the cuff leak test was positive, then the ETT was exchanged for one with the 0.5-mm larger tube. The comparison was done between the size of ETT calculated by USG-guided subglottic diameter, age, height-related formulas, and clinical methods to look for accuracy of prediction for proper ETT size after cuff leak test. Statistical Analysis: The data collected were entered into Microsoft Excel and analyzed using SPSS version 22. IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Appropriate parametric and nonparametric tests were applied wherever necessary. Categorical data: Represented in the form of frequencies and proportions. Continuous data: Represented as mean and standard deviation. Paired sample test: Test to identify the mean difference between two quantitative variables. Kappa statistics: To measure the level of agreement. Results: A total of 27 children of age between 2 and 15 years were selected, out of which 15 were male and 12 were female. The accuracy of predicting appropriate ETT size is greater in ultrasound-guided subglottic diameter when compared to conventional clinical assessment and age- and height-related formula and almost the same accuracy as the clinical method. Conclusion: Ultrasound-guided subglottic diameter is an easy, effective, and noninvasive way of predicting accurate ETT size in the pediatric population.
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Early versus late tracheostomy in patients with acute brain injury: Importance of SET score p. 7
Saurav Shekhar, Raj Bahadur Singh, Ranjeet Rana De, Ritu Singh, Akhileshwar , Nitin Kumar
DOI:10.4103/aer.aer_22_22  
Introduction: Patients with acute brain injury presents are unique subset of neurocritical care patients with its long-term functional prognosis difficult to determine. They often have long intensive care unit (ICU) stay and presents as challenge to decide when to transfer out of ICU. This prospective study aims to assess the benefits of early tracheostomy in terms of ICU-length of stay (ICU-LOS), number of days on ventilator (ventilator days), incidence of ventilator-associated pneumonia (VAP), and mortality rates. Materials and Methods: After institutional ethical clearance, 80 patients were randomized into two groups: Group A, early tracheostomy group (tracheostomy within 3 days of intubation) and Group B, standard of care group (tracheostomy after 10 days of intubation: late tracheostomy). A cutoff of 10 in the SET score was used in predicting need of early tracheostomy; both groups were compared with respect to ICU-LOS, number of ventilator days (ventilation time), need of analgesia and sedation, incidence of VAP, and mortality data. Results: Both the groups were comparable in terms of demographic profile and various disease severity scores. ICU-LOS was 14.9 ± 3.6 days in Group A and 17.2 ± 4.6 in Group B. The number of days on ventilator and incidence of VAP was significantly lower in Group A as compared to Group B. There was significantly lower mortality in Group A subset of patients in ICU. Conclusion: SET score is a simple and reliable score with fair accuracy and high sensitivity and specificity in predicting need of tracheostomy in neurocritical patients. A cutoff of 10 in the score can be reliably used in predicting need of early tracheostomy as in few other studies. Early tracheostomy is clearly advantageous in neurocritical patients, but has no advantage in terms of long-term mortality rates.
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Randomized controlled study comparing 2-chloroprocaine and bupivacaine for spinal anesthesia in gynecological surgeries p. 12
Subin Thomas, Devanand Bhimrao Pawar, Dipakkumar Hiralal Ruparel, Shweta Sedani
DOI:10.4103/aer.aer_20_22  
Background: Ambulatory surgeries are increasing all over. While searching for an ideal anesthetic, the use of lidocaine was linked to a greater rate of transitory neurological symptoms and bupivacaine delays discharge due to a longer duration of motor blockade. 2-chloroprocaine (2CP) with a shorter duration of action is gaining popularity. We aimed to compare intrathecal bupivacaine and 2CP for the subarachnoid block for elective ambulatory gynecological surgeries. Methods: A single-blind study was conducted on 90 patients comparing 40 mg 2CP and 10 mg 0.5% bupivacaine heavy measuring pinprick sensation, motor block, time to ambulation, and voiding of urine so as to get ready for discharge. Results: In both groups, the beginning of sensory blockage occurred at a similar time, while motor blockade achieved was faster in the 2CP group. The resolution of motor blockade was 1.7 times faster in the 2CP group than in the bupivacaine group. Time taken for ambulation was delayed significantly in the bupivacaine group, i.e., 263.04 ± 29.08 min compared to the 2CP group, i.e., 225.44 ± 29.48 min which was a delay of almost 38 min. Voiding of urine was also delayed in the bupivacaine group by 60 min compared to the 2CP group and was significant finding leading to delay of discharge of patients. Adverse effects were comparable in both groups. Conclusion: Intrathecal preservative-free 2CP provides satisfactory surgical block, and has a considerably faster rate of block regression, resulting in earlier ambulation and voiding, allowing the patient to be discharged from the hospital sooner as compared to intrathecal bupivacaine.
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Comparison of palonosetron versus palonosetron and dexamethasone for prevention of postoperative nausea and vomiting after middle ear surgeries: A randomized controlled study p. 17
Kanhaiya Kumar, Rajnish Kumar, Mumtaz Hussain, Bibha Kumari, Arvind Kumar
DOI:10.4103/aer.aer_131_21  
Background: Postoperative nausea and vomiting (PONV) are one of the common distressing conditions after anesthesia. The PONV are related to several potential risk factors are patient related, anesthesia related, and surgery related. In surgery-related risk, middle ear surgery is associated with a high incidence of PONV. Aims: This study aimed to compare the efficiency of palonosetron versus palonosetron with dexamethasone in the prevention of PONV in middle ear surgeries. Settings and Design: This was a prospective, randomized, double-blind study. Methods: A prospective randomized double-blind study was conducted for the prevention of nausea and vomiting in patients with middle ear surgeries. The study comprised 50 patients of Group A (palonosetron 0.075 mg) and patients of Group B (palonosetron 0.075 mg and dexamethasone 4 mg). Statistical Analysis: The data were presented as descriptive statistics for continuous variables and percentages for categorical variables and were subjected to Z-test/Chi-square test/Fisher's exact test. The value of P < 0.05 was considered statistically significant. Results: Demographic parts in comparison to age, duration of surgery, and duration of anesthesia were similar in both the groups. Our study showed that the incidence of PONV during 0–6 h was 38% (n = 19) in Group A and 12% (n = 6) in Group B and the incidence during 6–12 h postoperatively was 14% (n = 7) in Group A and 8% (n = 4) in Group B. During 12–24 h, the incidence was 8% (n = 4) and 6% (n = 3) in Group A and B, respectively. Hence, the difference of total early PONV in Group A was 60% (n = 30) and in Group B, it was 26% (n = 13) which was statistically significant (P < 0.03). Conclusions: The above result proves that palonosetron and dexamethasone group is superior in the prevention of PONV in middle ear surgery.
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Smartphone use among anesthesiologists during work hours: A survey-based study p. 22
Suruchi Ambasta, Ashish Kumar Kannaujia, Chetna Shamshery, Divya Shrivastava, Prabhakar Mishra, Swagat Mahapatra
DOI:10.4103/aer.aer_15_22  
Context: Smartphone use has revolutionized life in all spheres, including the medical field. Smartphones provide immense opportunities but may also lead to negative consequences due to the element of distraction. In the medical profession and more so among anesthesiologists, multitasking has become very common, but the presence of mind is equally important. This study attempts to analyze the smartphone practices and trends among anesthesiologists during work hours in our country. Aims: The study aimed to identify recent trends and practices of smartphone use among anesthesiologists during working hours and its distribution as per designation and institutions. It also intends to determine the purposes of smartphones and their impact on patient care. Settings and Design: Online survey consisting of open-ended multiple-choice questions was conducted and circulated as Google Forms via E-mail and WhatsApp. Subjects and Methods: This survey was conducted to compare the respondents' views as per designation and workplace distribution. In addition, participants were asked about the current practices in smartphone use at their workplace, purposes of use, time spent on smartphones, and any negative medical consequences faced due to the same. Statistical Analysis Used: One-way ANOVA test was used to compare the means between the groups. Chi-square test/Fisher's exact test was used to compare the proportions. Results: Two hundred and sixteen (54%) were resident doctors, whereas 184 (46%) were consultants. Most of the respondents were young, with a mean age around 36 years. 31.5% of the residents used smartphones very often during anesthetized patient care compared to 10.3% of the consultants. Purposes of using smartphones were multiple, with phone calls (100%) being the most common followed by WhatsApp messaging (79.2%). 86.1% of the residents, as compared to 61% of the consultants, had anesthesia/intensive care unit-related apps on their smartphones. There was almost an equivocal response to how the smartphone has impacted patient care. 50.9% of the residents and 43% of the consultants felt improved patient care, whereas 38% of the residents and 43.5% of the consultants believed it had worsened. Conclusion: There was no clear-cut consensus whether smartphone use improved or worsened patient care. On the one hand, there can be distractions leading to adverse medical consequences, while on the other hand, the use of medical apps has been made possible because of the handy and easily accessible smartphones. Thus, the use of smartphones may be carried out with a sense of responsibility by the anesthesiologists during work hours.
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A comparative study of sodium bicarbonate and hyaluronidase on pain perception, anesthesia, and akinesia during peribulbar anesthesia for cataract surgery p. 31
Priyanka Sodani, Sandeepika Dogra, Dev Raj, Vabita Bhagat
DOI:10.4103/aer.aer_128_21  
Background: An ideal anesthetic solution should provide good anesthesia and akinesia with minimal pain on injection. Aims: The aim of this study is to determine the effect on pain perception and efficacy of sodium bicarbonate over hyaluronidase in the local anesthetic mixture during peribulbar anesthesia. Settings and Design: A prospective, randomized, double-blind study. Materials and Methods: An independent observer labeled two injections as A (hyaluronidase 1500 IU in 30 mL of lignocaine) and B (7.5% sodium bicarbonate 1 mL in 30 mL of lignocaine). Group 1 was injected with injection A while Group 2 was injected with injection B. The visual analog scale (VAS) was used to determine the intensity of pain. Onset and degree of anesthesia and akinesia were recorded. Statistical Analysis: Computer software Microsoft Excel SPSS version 26 (Chicago Inc) for windows was used. The qualitative data and quantitative data were reported as proportions and mean ± (standard deviation), respectively. Chi-square test for proportions was used for the comparison of qualitative variables and unpaired Student's t-test was used to test the significance between quantitative variables. P < 0.05 was considered statistically significant. All P were two-tailed. Results: Out of 123 patients, 23 were excluded from the study. Hundred patients were divided into Group 1 and Group 2. The mean age in Group 1 was 64.92 ± 10.77 years while in Group 2 was 62.86 ± 11.17 years. The mean heart rate and mean systolic blood pressure in both groups were statistically insignificant. Group 2 experienced very less pain (mean pain score VAS = 5.12 ± 1.17) as compared to Group 1 (mean pain score was 7.16 ± 1.09) and the difference between both the groups was found to be statistically significant. There was a significant difference in the onset of anesthesia in both groups (P = 0.001). In the sodium bicarbonate group, the onset was faster. The onset of akinesia was better in Group 1 (4.76 ± 2.06 min). Grading of akinesia was better in Group 1. Conclusion: Sodium bicarbonate reduces pain on injection in peribulbar anesthesia and also results in a quicker onset of anesthesia.
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A clinical comparison between single-space technique and double-space technique for combined spinal and epidural anesthesia p. 36
Pyarejan Basheer, GC Brijesh, Raman Kumar, Shailesh Kumar, Priyesh Kumar, Jay Prakash
DOI:10.4103/aer.aer_19_22  
Background: Combined spinal and epidural anesthesia (CSEA) is commonly performed by double space technique (DST) and single space segment technique (SST) or needle-through-needle technique (NNT). Aims and Objectives: We designed a double-blind randomized controlled study to compare the effect of the double-space technique with that of the single-space technique on time required by the procedure, the number of attempts, and a level of sensory, side effects and cost-effectiveness. Materials and Methods: Patients undergoing elective lower abdominal and lower limb surgeries under regional anesthesia were randomized to receive CSEA with either the double-space technique (double group, n = 30) or the single-space technique (single group, n = 30). In the single group, the procedure was performed at the L3-4 interspace using the needle-through-needle technique. In the double group, an epidural catheter was inserted at the L1–2 interspace, and dural puncture was performed at the L3–4 interspace. Results: The single space (needle-through-needle) technique for CSE takes less time, less number of spinal punctures. There was no difference between the two groups in terms of side effects. Sensory level at T10 on 5 min in group I was 90% and group II was 100% whereas at T8 it was 10% in group I; sensory level at T10, T8 and T6 on 10 min. in group I were 53.3%, 43.3% and 3.3% respectively whereas in group II were 80%, 16.7% and 3.3% respectively; sensory level at T10, T8, T6 and T4 on 15 min. in group I were 6.7%, 43.3%, 50% and 0% respectively whereas in group II were 23.3%, 50%, 23.3% and 3.3% respectively; and sensory level at T4, T6 and T8 on 20 min. in group I were 0%, 73.3% and 26.7% respectively whereas in group II were 16.7%, 33.3% and 50% respectively. Conclusions: Single-space (needle-through-needle) CSEA takes less time, less number of spinal punctures and results in improved patient satisfaction. There were no differences in intraoperative variables between the DST and SST for CSEA.
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Comparison of LMA supreme, i-gel, and baska mask for airway management during laparoscopic cholecystectomy: A prospective randomized comparative study from North India p. 42
Parul Sharma, Sujeet Rai, Manoj Tripathi, Deepak Malviya, Sumita Kumari, Smarika Mishra
DOI:10.4103/aer.aer_23_22  
Background: The supraglottic airway device (SAD) has proved to be an appropriate alternative to endotracheal intubation in laparoscopic surgeries owing to various advantages, namely, decreased airway manipulation and stable hemodynamics. Aims: We compared the efficacy in terms of oropharyngeal leak pressure (OLP) and safety of laryngeal mask airway (LMA)-Supreme (LMA-S), i-gel, and Baska mask in patients undergoing laparoscopic cholecystectomy. Settings and Design: Ninety patients posted for elective laparoscopic cholecystectomy were selected for a prospective randomized comparative study in a tertiary care center. Materials and Methods: The study comprised three groups of 30 each based on the different SADs used Group-LS with LMA-Supreme, Group-IG with i-gel, and Group-BM with Baska mask. The secondary objectives were device insertion time, ease of insertion, changes in the peak airway pressure (PAP), heart rate, mean arterial pressure, and airway complications (sore throat, dysphagia. dysphonia, lip/tongue or dental injury, etc.) between three groups. Statistical Analysis: The quantitative data were analyzed using the one-way analysis of variance test and Bonferroni post hoc multiple comparison test. Qualitative data were compared using Chi-squared test. Results: OLP was significantly higher (P = 0.005) in the Baska mask than i-gel and LMA-S groups just after insertion and during carboperitonium. There was no significant difference in time for device insertion, number of attempts, ease of insertion, and use of manipulation (P > 0.05). However, the gastric tube insertion time was significantly lower in Group BM (9.59 ± 2.78) than Group IG with 12.79 ± 3.47 and Group LS with 10.84 ± 3.68 (P < 0.05). There were no significant differences between the groups with regard to changes in the PAP, heart rate, mean arterial pressure at different time intervals, and complications. Conclusion: Baska mask provided a significantly higher OLP compared to i-gel and LMA-S without significant airway morbidity in laparoscopic surgeries.
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Carotid artery blood flow changes associated with head positioning in patients undergoing thyroidectomy p. 49
Abhilash Asokan, Melveetil S Sreejit
DOI:10.4103/aer.aer_42_22  
Background and Aims: There are possibilities of insufficiency in blood flow through carotid arteries during head positioning in thyroid surgeries under general anesthesia which is usually compensated by collateral circulation in normal conditions. This compensation may be hampered in patients with congenital abnormalities or diseases such as atherosclerosis. We aimed to elucidate the changes in common carotid artery blood flow related to head positioning during thyroid surgery by Doppler examination. Methods: In this observational prospective study, Doppler examination of both common carotid arteries including arterial diameter, peak systolic velocity, average velocity, and blood flow volume of forty patients who had undergone elective thyroidectomy under endotracheal anesthesia was done. Three sets of data (baseline, after induction, and after surgery) were collected and analyzed. Results: There was a significant reduction in the diameter (P = 0.002) and the blood flow (P = 0.0001) in both carotid arteries and an increase in peak and mean velocity which was more pronounced immediately after head positioning and persisted till the end of the procedure. There was no correlation between the hemodynamic parameters with the carotid artery diameter, blood flow, and velocity. Conclusions: The head-and-neck positioning during thyroidectomy surgery reduces the blood flow through the carotid arteries which continued till the end of the procedure.
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Preoperative ultrasonographic evaluation of subclavian vein and inferior vena cava for predicting hypotension associated with induction of general anesthesia p. 54
Nadia Rose, Mahesh Chandra, Chris C Nishanth, Rangalakshmi Srinivasan
DOI:10.4103/aer.aer_9_22  
Introduction: Induction of general anesthesia is often associated with hypotension and is a common scenario faced by anesthesiologists. Intraoperative hypotension can have detrimental effects and cause various adverse effects leading to an extended hospital stay. Patients' preinduction volume status can have an effect on postinduction blood pressure. Ultrasonography is a useful tool for measuring intravascular volume status. We studied the ability of ultrasonographic measurement of subclavian vein (SCV) and inferior vena cava (IVC) diameter, collapsibility index (CI) to predict hypotension after induction of general anesthesia. Materials and Methods: We included 120 patients in our study. SCV measurements during spontaneous and deep inspiration and IVC measurements were taken before induction and postinduction blood pressure was monitored. Patients with mean arterial blood pressure <60 mmHg or with a 30% decrease from baseline were considered to be having hypotension. Results: The CI of IVC with a cutoff 37% showed sensitivity of 94% and specificity of 84% which was statistically significant. The CI of 36% of SCV during deep breathing was found to have high sensitivity and specificity of 90% and 87%. Conclusion: Our study in spontaneously breathing preoperative patients shows that SCV CI in deep breathing and IVC CI is very sensitive and reliable in predicting postinduction hypotension. Bedside ultrasound measurements can be easily done to obtain valuable information to recognize patients who could be at risk from postinduction hypotension.
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A comparative clinical study of methylprednisolone with ondansetron versus ramosetron in preventing postoperative nausea and vomiting in patients undergoing middle-ear surgeries p. 60
RG Somsundar, G Shivakumar, M. C. B. Santhosh, K Krishna
DOI:10.4103/aer.aer_2_22  
Background: One of the most troublesome complications after middle-ear surgeries has been postoperative nausea and vomiting (PONV). A notable decrease in PONV has been observed with the use of 5-hydroxytryptamine type 3 receptor antagonists and glucocorticoids. Aim: This study aimed to evaluate the effectiveness of the combination of intravenous methylprednisolone and ondansetron with ramosetron alone in preventing PONV in patients undergoing middle-ear surgeries. Settings and Design: This was a prospective, randomized, double-blind study that comprised sixty patients in the age group of 18–60 years belonging to the American Society of Anesthesiologists (ASA) physical status classification I or II and undergoing middle-ear surgery. Materials and Methods: With the help of computer-generated randomization table, sixty patients in the age group of 18–60 years belonging to ASA physical status classification I or II and undergoing middle-ear surgery were randomly allotted to receive a combination of methylprednisolone 40 mg (given at the beginning of surgery) and ondansetron 4 mg (given near the end of surgery) (Group MO, n = 30) or ramosetron 0.3 mg (near the end of surgery) (Group R, n = 30). In both the groups, the incidence of PONV was studied. Statistical Analysis: Chi-square test or Fisher's exact test was utilized to analogize the categorical variables. Independent t-test was utilized to analogize the continuous variables. Results: In the first 2 h after the surgery, the difference between the two groups regarding the incidence of PONV was insignificant. Between 2 h and 24 h, the incidence of nausea was lowered significantly in the group MO compared to the group R (P = 0.01). Between 24 h and 48 h, the incidence of nausea was more in group R compared to the combination therapy group, which was statistically significant. Conclusion: The combination therapy is better than ramosetron alone for the prevention of PONV after middle-ear surgery. Therefore, we advocate a combination of methylprednisolone and ondansetron for prophylaxis for PONV in middle-ear surgeries.
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Pattern of conventional coagulation and thromboelastographic parameters in patients with COVID-19 diseases and association of COVID-associated coagulopathy with mortality in intensive care unit p. 65
Awale Rupali Balchandra, Tanmoy Ghatak, Sukhen Samanta, Ratender K Singh, Anupam Verma, Prabhakar Mishra, Rajendra Chaudhary, Alok Nath
DOI:10.4103/aer.aer_52_22  
Background: Knowledge of underlying pathophysiology of coagulopathy is evolving and the pattern of coagulation parameters in coronavirus disease 2019 (COVID-19)–associated diseases is still not very clear. Aims: In the present study, we aimed to find out the pattern and distribution of conventional coagulation parameters and thromboelastographic (TEG) parameters in COVID-19–associated coagulopathy (CAC) in survivors and nonsurvivors at 28 days. Setting and Design: The present prospective observational study was conducted at a tertiary care COVID-19 intensive care unit (ICU) facility from March 21, 2020, to July 15, 2021. Materials and Methods: Admission clinical and laboratory data (conventional coagulation, inflammatory and TEG parameters, and disease severity parameters) of 64 COVID-19 patients admitted to the ICU were collected. Patients were divided into two groups, i.e., survivors and nonsurvivors. Statistical Analysis: Data were compared between two groups, i.e., survivors versus no survivors on 28 days using Student's t-test/Mann–Whitney U-test or Chi-square test/Fisher's exact test. Results: Admission mean plasma fibrinogen levels (474.82 ± 167.41 mg.dL−1) and D-dimer were elevated (1.78 [0.66, 3.62] mg.mL−1) in the COVID-19 ICU patients. Overall, COVID-19 patients had mean lower normal platelet count (150 ± 50 × 103 cells.mm−3), with marginally elevated prothrombin time (16.25 ± 3.76 s) and activated partial thromboplastin time (38.22 ± 16.72 s). A 65.6% (42/64) TEG profile analysis showed a normal coagulation profile, and the rest 21.9% (14/64) and 12.5% (8/64) had hypercoagulable and hypocoagulable states, respectively. Plasma D-dimer level was markedly elevated in nonsurvivors compared to survivors (P < 0.05), while no other conventional coagulation parameters and TEG profile demonstrated statistically significant between the two groups. Conclusion: Markedly elevated plasma D-dimer level was observed in nonsurvivors of COVID-19 ICU patients. A large portion of COVID-19 ICU patients had a normal TEG profile. Conventional coagulation parameters and TEG profile were similar between survivors and nonsurvivors.
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Prevalence of chronic postsurgical pain among cancer patients: A cross-sectional study p. 71
Mahmoud I Ramadan, Hussein Y Abu Khudair, Abdullah T Obaid, Ola A Yousef, Raja A Sammour
DOI:10.4103/aer.aer_24_22  
Background: Cancer patients accept surgeries as part of their treatment. They may not be aware of the possibility of surgical pain persisting long after the surgery. Understanding chronic postsurgical pain is essential for effective pain management. Aims: We aimed to assess the prevalence of chronic postsurgical pain in cancer patients and the associated symptom burden. Settings and Design: This study was carried out at a tertiary cancer center. It was a cross-sectional study. Materials and Methods: Participants who underwent surgeries were asked to provide feedback on the MD Anderson Symptom Inventory at 3 months. Statistical Analysis Used: Descriptive statistics were used. Statistical tests included Kruskal–Wallis test, Chi-square test, Fisher's exact test, and Spearman's correlation. Logistic regression was used to assess the influence of variables on the presence or absence of chronic postsurgical pain. Results: Nine hundred and eighteen participants completed the study. Ninety-two percent (n = 840) were asymptomatic. Eight percent (n = 78) had postsurgical pain. Chronic postsurgical pain was influenced by the type of surgery (P = 0.01), specifically orthopedic and thoracic surgeries. Patients who receive epidurals are three times less likely to continue to have pain at 3 months. Conclusions: The prevalence of chronic postsurgical pain at 3 months in this study is lower than the rates in the literature. It is still associated with symptom burden that interferes with daily life. The risk of developing chronic postsurgical pain increases with thoracic and orthopedic surgeries. The risk may be lowered with epidural analgesia.
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Evaluation of effect of hip/shoulder-width ratio on the sensory level of spinal anesthesia – A prospective observational study p. 80
Archana Shivashankar, Geetha Chamanahalli Rajappa, Shruthi Sudarshan, MM Madhu, Ridhi Rao
DOI:10.4103/aer.aer_146_21  
Background: Certain anthropometric measurements that are practically obtainable explain the variability in the spread of spinal anesthesia. These are useful for quick assessment of the spread of spinal anesthesia to avoid the risk of high block and also the inadequate level of block. Aims: The study aims to evaluate the effect of hip/shoulder-width ratio (HSR) on the sensory level of spinal anesthesia. Settings and Design: This prospective observational study was undertaken at a tertiary care hospital. Statistical Analysis: Pearson's correlation and multiple linear regression analyses were used to analyze the relationship between study variables with the level of sensory block. Materials and Methods: One hundred patients undergoing various surgical procedures were enrolled for the study. With a patient in a sitting position, hip-width was measured between the two iliac crests, shoulder-width was measured between two acromion processes, and vertebral column length was noted by measuring the distance from C7 vertebra to sacral hiatus. 3 mL of 0.5% hyperbaric bupivacaine was administered intrathecally at L3–L4 with 25G Quincke's needle in the lateral position. Assessment of block level was done by loss of cold sensation and loss of pinprick sensation every 5 min till 30 min. The numbers of segments blocked were noted from the S5 segment. The relationship between various factors with the level of sensory block was analyzed by the Pearson's correlation coefficient. Results: HSR and body mass index (BMI) have a significant correlation with the sensory level of spinal anaesthesia, HSR (r = 0.297, P < 0.05) and BMI (r =0.385, P < 0.05). Conclusion: HSR can help predict the cephalad spread of spinal anesthesia. We can expect a higher level of sensory blockade of spinal anesthesia in females who generally have an HSR more than one.
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Comparison of hemoglobin values obtained by arterial blood gas analysis versus laboratory method during major head-and-neck surgeries p. 84
Sunil Rajan, Pulak Tosh, Maria Isaac, Niranjan Kumar Sasikumar, Avanthi Subramanian, Jerry Paul, Lakshmi Kumar
DOI:10.4103/aer.aer_67_22  
Background: Accuracy of hemoglobin (Hb) measured by arterial blood gas (ABG) analyzer is considered inferior to laboratory (lab) measurements as it could overestimate Hb levels. Aim of the Study: The study aims to compare Hb measured using ABG versus conventional lab method at the time of major blood loss and in the preoperative and immediate postoperative periods. Settings and Design: It was a prospective, nonrandomized observational study conducted in a tertiary care center. Materials and Methods: The study was conducted in 24 patients undergoing major head-and-neck surgeries. Simultaneous blood samples were sent for Hb measurement by ABG analysis and lab method at induction of anesthesia, when intraoperative blood loss exceeded maximum allowable blood loss, and in the immediate postoperative period. Statistical Analysis Used: Chi-square test, independent sample's t-test, and paired t-test were used for statistical analysis. Results: Mean Hb values obtained by both techniques were significantly different at all time points. Hb obtained by ABG analysis was significantly higher than lab value preoperatively (12.78 ± 2.51 vs. 12.05 ± 2.2, P = 0.038), at maximum blood loss (11.00 ± 2.57 vs. 9.87 ± 2.06, P = 0.006), and in the immediate postoperative period (11.96 ± 2.00 vs. 10.96 ± 2.24 P < 0.001). ABG Hb values were found to be approximately 1 g.dL−1 greater than lab values. Conclusion: Hb measured by ABG analysis was significantly higher than that measured by lab method at the time of major blood loss, preoperatively, and at the immediate postoperative period in patients undergoing major head-and-neck surgeries, with a good correlation of values obtained by both the techniques.
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Premedication with diclofenac and precurarization with atracurium on succinylcholine-induced myalgia in laparoscopic cholecystectomy: A double-blinded randomized study p. 89
Amit Tirkey, Mukesh Kumar, Ekramul Haque, Tushar Kumar, Ladhu Lakra, Usha Suwalka
DOI:10.4103/aer.aer_35_22  
Background and Aims: Succinylcholine is the only available depolarizing neuromuscular blocker that has been widely used in the induction of anesthesia, and it is the drug of choice for rapid-sequence induction of anesthesia due to its rapid onset of effect and ultrashort duration of action owing to its rapid hydrolysis by acetyl-cholinesterase. Postoperative muscle pain (myalgia) and muscle stiffness are the most common side effects and are observed most frequently on the 1st postoperative day in ambulatory surgery. The use of succinylcholine in the induction of anesthesia and intubation in routine cases has been discouraged because of such adverse effects. However, because of its cost-effectiveness and easy availability, it is still used by some institutions routinely. This study aimed to study the efficacy of preoperative diclofenac along with atracurium precurarization in alleviating succinylcholine-induced myalgia. Materials and Methods: It is a double-blind randomized comparative study carried out in a tertiary care hospital. The study sample was 60 and divided into two equal groups. All data entered in MS-Excel Sheet and Wilcoxon signed-rank test were done for nonparametric data and one-way ANOVA for the parametric data. The normal distribution of the study sample was tested by the Shapiro − Wilk test. Results: The fasciculations in the test group were much less than in the control group with P < 0.00001. The results for the incidence of myalgia in the two groups were as follows: P value at 24 h was 0.00018 and at 48 h was 0.0028, respectively. Creatine kinase levels at preoperative and 24 h postoperative periods were 49.47 ± 7.24 in Group D, 53.30 ± 7.98 in Group B and 87.38 ± 15.16 in Group D, and 188.41 ± 33.27 in Group B, respectively. Conclusion: Succinylcholine-induced myalgia has a complex pathophysiology. However, the preemptive use of diclofenac in combination with precurarization can alleviate the incidence and severity of succinylcholine-induced myalgia. Therefore, its use may be considered in routine cases for induction of anesthesia for facilitating laryngoscopy and endotracheal intubation.
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Comparing different doses of dexmedetomidine combined with ropivacaine for ultrasound-guided supraclavicular brachial plexus block in upper limb surgeries - A Prospective randomized controlled trial p. 94
P Akshara, Dilip Kumar Govindan, Jagan Govindasamy, Mohamed Arif, Raghuraman M Sethuraman
DOI:10.4103/aer.aer_40_22  
Background: Dexmedetomidine is used as an adjuvant to local anesthetic agents to provide prolonged analgesia in peripheral nerve blocks. This study aimed at determining the optimal dose of dexmedetomidine, which when combined with ropivacaine will produce a superior quality block in terms of extended pain-free period and reduced perioperative analgesic/opioid use, which in turn improves patient satisfaction. Objective: The objective of the study is to assess the duration of analgesia with two different doses (25 μg and 50 μg) of dexmedetomidine with ropivacaine in supraclavicular brachial plexus block. Subjects and Methods: This prospective randomized controlled study included 50 patients undergoing upper limb surgeries under supraclavicular brachial plexus block randomly divided into two groups. Group D25 received 29 mL of 0.5% ropivacaine +25 μg dexmedetomidine diluted in 1 mL of normal saline (total 30 mL); Group D50 received 29 mL of 0.5% ropivacaine +50 μg dexmedetomidine diluted in 1 mL of normal saline (total 30 mL). Onset and duration of sensorimotor block, duration of analgesia, and time interval for the rescue analgesia and hemodynamic stability were observed. Results: The mean onset of motor and sensory block was significantly higher in the D25 group (P = 0.001). The Visual Analog Scale pain scores and rescue analgesia consumption were significantly lower in the D50 group (P = 0.013, 0.001). The duration of analgesia was significantly higher in the D50 group (P = 0.001). Conclusion: Dexmedetomidine 50 μg is an effective adjuvant dose to ropivacaine with insignificant hemodynamic changes with better duration of analgesia and lesser pain scores.
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Dexmedetomidine as an adjuvant to 0.25% bupivacaine in ultrasound guided femoral nerve block for preoperative positioning and postoperative analgesia in patients undergoing elective surgery for fracture shaft of femur p. 98
M Vinod, G Malashree, E Sundeep Goud, K Ravikumar
DOI:10.4103/aer.aer_152_21  
Background: Femur fracture causes excruciating pain and surgical repair is recommended. To obtain satisfactory patient co-operation in the perioperative period, various analgesics have been used. Femoral nerve block (FNB) provides an excellent alternative for analgesia in the perioperative period. Dexmedetomidine of up to 2 μg.kg−1 has been used in FNB as adjuvants in lower limb surgeries. Aims: The aim was to study the effect of addition of Dexmedetomidine to Bupivacaine in FNB on the comfort of positioning for subarachnoid block (SAB) and postoperative analgesia. Materials and Methods: Prospective, randomized, double-blind design was followed. Seventy American Society of Anesthesiologist I and II patients aged 18–70 years of either gender were randomly allocated into Group B (20 mL 0.25% Bupivacaine + 2 mL Normal Saline) and Group BD (received 20 mL 0.25% Bupivacaine + Dexmedetomidine 2 μg.kg−1 diluted to 2 mL) for FNB. Numerical rating scale (NRS) was recorded before and after FNB and comfort of positioning graded. After 10 min, subarachnoid block (SAB) was administered. NRS was recorded postoperatively until 24 h. Results: The comfort of positioning improved in both the groups after FNB but was statistically not significant when compared among the groups (P = 0.7). Duration of postoperative analgesia was significantly higher in the Group BD (741 min ± 97 min) compared to the Group B (440 min ± 45 min) (P = 0.001) and was statistically significant. Conclusion: FNB improved the comfort of positioning for SAB, but the addition of Dexmedetomidine did not have any added advantages with respect to comfort of positioning. However, the addition of Dexmedetomidine significantly increased the duration of postoperative analgesia with minimal hemodynamic changes.
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Comparison of oral versus intramuscular clonidine for the prolongation of bupivacaine spinal anesthesia in patients undergoing lower abdominal and lower limb surgeries p. 104
Raj Bahadur Singh, Saurav Shekhar, Ranjeet Rana De, Siddharth Singh, Ritu Singh, Akrity Singh
DOI:10.4103/aer.aer_31_22  
Background: Spinal subarachnoid block (SAB) is the first choice anesthesia in lower abdominal and lower limb surgeries. It produces a varying degree of sensory analgesia, motor blockade, and sympathetic blockade depending on the dose, concentration, and volume of the local anesthetic given. This study was undertaken to assess the degree of sensory and motor block with 150 μg of oral versus intramuscular clonidine as an adjuvant to bupivacaine for spinal anesthesia. Aims and Objective: To compare the efficacy of oral versus intramuscular clonidine as an adjuvant to bupivacaine for the prolongation of sensory and motor block in patients undergoing lower abdominal and lower limb surgeries under SAB. Materials and Methods: After institutional ethical clearance, 90 patients were randomized into three groups scheduled for lower abdominal and lower limb surgeries under spinal anesthesia. • Group O: Bupivacaine 0.5% (heavy) 3.0 mL and oral clonidine 150 μg 1 h before spinal anesthesia. • Group I: Bupivacaine 0.5% (heavy) 3.0 mL and intramuscular clonidine 150 μg 1 h before spinal anesthesia. • Group C: Control group – 3 mL bupivacaine 0.5% (heavy) alone. Result: The onset of sensory block in Group O was 4.9 ± 0.52 min, whereas in Group I, it was 4.6 ± 0.42 min than Group C (5.1 ± 0.60). Onset of motor block was also significantly lower in Group O and Group I (3.9 ± 0.53 and 3.7 ± 0.42 min) than in Group C (4.4 ± 0.6 min) which was a control group. There was also a significant difference in the duration of the sensory block between Group O (206.4 ± 9.2 min), Group I (219 ± 8.6 min), and Group C (184.3 ± 9.1 min). The duration of motor block was significantly higher in Group O (183.6 ± 8.2 min) and Group I (197.8 ± 9.6 min) when compared to Group C (162.8 ± 8.9 min). The timing of rescue analgesia in Group O was 222.4 ± 11.7 min, whereas in Group I, it was 243.46 ± 10.9. Conclusion: On the basis of finding of our study, we conclude that the use of clonidine as a premedication at a dose of 150 μg significantly increased the duration of sensory block, motor block, and duration of analgesia and shortened the time of onset of sensory and motor blockade.
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Radiological versus traditional parameters for airway assessment: A comparison p. 109
Vandana Rana, Shreesh Mehrotra, Veena Asthana, Shailendra Raghuvanshi
DOI:10.4103/aer.aer_28_22  
Background: The incidence of difficult tracheal intubation includes not only difficult and failed intubation but also difficult laryngoscopy (DL) and difficult mask ventilation. Aim: The study was done to compare the sonographic assessment of tongue thickness (TT) and condylar mobility with traditional airway assessment scores for prediction of difficult intubation (DI). Settings and Design: This experimental, randomized prospective study was conducted in the Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun. Materials and Methods: After obtaining approval from the Institutional Ethical and Research Committee, this study was conducted in the Department of Anaesthesiology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Dehradun. After obtaining written and informed consent, 385 subjects of either sex between 18 and 60 years of age, undergoing various elective surgeries under general anesthesia with endotracheal intubation, were selected. The number of attempts at intubation, the need for alternative DI approaches, and invasive airway access or cancellation of the procedure due to inability to secure the airway were noted. Statistical Analysis Used: Data analysis was done using SPSS 20.0. Categorical data were assessed by Chi-square test, while independent t-test/Mann–Whitney test was used to determine the association between continuous data. Results: Age, inter-incisor distance (IID), body mass index (BMI), and Mallampati score were positively correlated with TT. BMI (kg.m−2) >26.0, modified Mallampati scoring >2, IID ≤5 cm, TT >6 cm, and condylar mobility >10 mm were significantly more among subjects with DL and difficult tracheal intubation. Conclusion: Ultrasonography can be used in elective settings to rule out any possibility of difficult airway and to prevent airway-related complications.
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Laryngoscopic view after application of manual in-line stabilization – A comparison with early morning sniffing position in the same patient p. 115
Sauharda Bikram Karki, Suniti Kale, Deepti Saigal
DOI:10.4103/aer.aer_36_22  
Background: The application of manual in-line stabilization (MILS) for minimizing spinal cord injury is known to increase difficulty in airway management. Aim: The study aims to assess the change in Modified Cormack–Lehane (CL) laryngoscopic view with the application of MILS from the early morning sniffing position (EMSP) in adult patients. Setting and Design: This was a prospective, interventional, self-controlled study conducted on 220 patients aged 18–65 years, belonging to the American Society of Anesthesiologists Physical Status Class I or II, having a normal airway, and scheduled for elective surgery under general anesthesia. Materials and Methods: After inducing general anesthesia, MILS was applied to the patient's neck, and a Modified CL view of the vocal cords was recorded under direct laryngoscopy. The view was again noted after applying backward-upward-rightward pressure (BURP). MILS and BURP were released. The view was obtained again with and without BURP in EMSP. Statistical Analysis: Normality of data was tested by Kolmogorov–Smirnov test. Wilcoxon ranked-sum test for quantitative variables and Chi-square test for qualitative variables were used. Results: On application of MILS, the majority of patients had Modified CL Grade 3a (121 patients) and 3b (53 patients) views. The majority of patients had Modified CL Grade 1 (114 patients) and 2a (71 patients) views on placing in EMSP. These findings were statistically significant (P < 0.0001). Consequent to the placement of BURP upon MILS, patients with lower CL Grade views (2b: 101 patients) were significantly higher (P < 0.0001) in comparison with MILS alone. Conclusion: In patients with a normal airway, MILS leads to a significantly greater incidence of higher grades of laryngoscopic views in comparison to EMSP. Use of BURP after MILS causes significantly less incidence of higher grades of laryngoscopic view when compared with MILS alone. All patients requiring MILS should be considered to be a difficult airway, and hence, preparation should be done accordingly.
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Effect of different doses of buprenorphine in combination with bupivacaine in the management of postoperative analgesia: A comparative study p. 121
Smitirupa Borkotoky, Daisy Karan, Swarna Banerjee, Prerna Biswal, Nupur Moda
DOI:10.4103/aer.aer_39_22  
Background: Longer duration of analgesia, ceiling effect on respiratory depression, and the antihyperalgesia property make buprenorphine a good adjuvant for managing moderate-to-severe postoperative pain. Aims: The aim of this study is to evaluate the onset and duration of postoperative analgesia of three different doses of buprenorphine of 60, 100, and 150 μg given intrathecally along with hyperbaric bupivacaine in patients undergoing lower limb surgeries. Setting and Design: This prospective observational study was carried out in the anesthesia department of a tertiary care hospital. Materials and Methods: The study included 90 patients of either sex, aged 18–60 years, scheduled for elective lower limb surgery under subarachnoid block. Patients were randomly allocated into three groups (30 each) receiving different doses of buprenorphine. In addition, all patients received 3 mL of 0.5% hyperbaric bupivacaine. Statistical Analysis Used: The Chi-square test or Fisher's exact test was used to find out the association between the categorical variables. The association of quantitative variables between the groups was assessed by Kruskal–Wallis test while within the groups was assessed by repeated-measures analysis of variance test. Results: Baseline characteristics such as age, gender, and American Society of Anesthesiologist physical status classification were comparable among the three groups. Sensory block, motor block, and total duration of analgesia were significantly higher with higher doses of buprenorphine. The mean difference in the duration of analgesia was comparable in patients receiving 100 μg (720 min) and 150 μg (825 min) of buprenorphine. Bradycardia as a side effect was only in patients receiving 150 μg of buprenorphine. Conclusion: Risk–benefit of different doses of buprenorphine suggests that 100 μg may be the ideal dose for a better quality of spinal block and maintaining hemodynamic stability.
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A study to evaluate the efficacy of dexamethasone as an adjuvant in ultrasound-guided bilateral superficial cervical plexus block using 0.25% bupivacaine in patients undergoing thyroid surgeries under entropy-guided general anesthesia p. 127
MN Satish Kumar, M Archana, VP Dayananda, C Surekha, R Ramachandraiah
DOI:10.4103/aer.aer_85_21  
Context: Ultrasound-guided bilateral superficial cervical plexus block (BSCPB) is a technique described for thyroid surgeries for postoperative analgesia as the surgery can cause severe pain and discomfort. Perineural dexamethasone is known to prolong analgesic duration and reduce postoperative nausea/vomiting. Aims: To assess the efficacy of dexamethasone as an adjuvant to BSCPB with 0.25% bupivacaine on isoflurane consumption, intraoperative hemodynamic parameters, and postoperative analgesia in patients undergoing thyroid surgeries under general anesthesia. Settings and Design: This was a randomized control trial. Subjects and Methods: Eighty patients were randomized to two equal groups using random number table into Group A with BSCPB receiving 20 mL of 0.25% bupivacaine and Group B with BSCPB receiving 19 mL of 0.25% bupivacaine + injection dexamethasone 4 mg in the preinduction period. Hemodynamic parameters, isoflurane consumption, postoperative visual analog scale (VAS) score, and antiemetic effect over 24 h were compared between two groups. Statistical Analysis Used: Microsoft excel data sheet, Chi-square test, and independent t-test were used for statistical analysis. Results: The intraoperative hemodynamic parameters were comparable between the two groups. There was a significant difference in mean VAS score between two groups from 6 h to 20 h postoperatively. The time of rescue analgesic in Group A was 7.09 ± 1.04 min and Group was 13.19 ± 1.46 min with P < 0.0001. In Group A, 40% had nausea and 35% had vomiting, and in Group B, 7.5% had nausea and 5% had vomiting. Conclusions: Preinduction ultrasound-guided BSCPB with bupivacaine and dexamethasone provides longer duration of postoperative analgesia and lesser nausea and vomiting compared to bupivacaine alone.
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Comparison of hemodynamic changes in patients undergoing laparoscopic cholecystectomy using rocuronium and vecuronium for intubation and maintenance under general anesthesia p. 133
Nikhita Juneja, Md Shahbaz Alam, Vipin Kumar Varshney, Pratiksha Gogia, Mukesh Kumar Prasad, Gurdeep Singh Jheetay
DOI:10.4103/aer.aer_70_22  
Context: The context of the study is to compare and find better muscle relaxant between rocuronium and vecuronium for intubation and maintenance under general anesthesia in patients undergoing laparoscopic cholecystectomy. Aims: The aim of the study is to measure intubating condition, hemodynamic changes during intubation and also during maintenance of general anesthesia and to record complications, if any. Settings and Design: A prospective clinical study conducted in the Department of Anesthesiology in tertiary care center. Materials and Methods: A total of 100 patients of the American Society of Anesthesiologists Classes Grade I and II were planned for laparoscopic cholecystectomy were divided into two groups of 50 each. The subjects in the control and study group were put under anesthesia using injection propofol 2.0 mg.kg −1 along with injection vecuronium 0.10 mg.kg−1 and injection propofol 2.0 mg.kg−1 along with injection rocuronium 0.60 mg.kg−1, respectively. Hemodynamic monitoring and oxygen saturation (SPO2) were recorded at various intervals. Statistical Analysis Used: All the collected data were imported into Microsoft Excel, and the statistical analysis was done by using SPSS 25.0 version. Results: The mean heart rate before and after carboperitoneum at different time intervals and before and after extubation was significantly lower in vecuronium group. The mean systolic blood pressure and mean arterial pressure at 1 and 5 minutes after extubation were significantly more among vecuronium group. Conclusions: Rocuronium is reasonably cardiostable, produces excellent intubation conditions, has a shorter duration of action, and shows minimal cumulative effect.
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Dura-to-spinal cord distance at different vertebral levels in Indian children: A retrospective computerized tomography scan-based study p. 138
Heena Garg, Shailendra Kumar, Naren Hemachandran, Prabudh Goel, Devasenathipathy Kandasamy, Minu Bajpai, Puneet Khanna
DOI:10.4103/aer.aer_26_22  
Background: Neuraxial techniques provide good postoperative analgesia for painful procedures in the pediatric population. However, any injury to the spinal cord can lead to irreversible long-term effects. Aims: We aimed to evaluate dura-to-cord (DTC) distance from computerized tomography (CT) images of thoracolumbar spine in pediatric age group (1–16 years) at T8–9, T9–10, and L1–2 interspaces to identify the safe space for epidural insertion in Asian children. Settings and Design: It was a retrospective study including 141 children aged 1–16 years who underwent routine CT scan of the thoracolumbar region for unrelated diagnostic indications. Materials and Methods: Patients with spinal abnormalities were excluded. Sagittal CT images of the thoracolumbar spine were obtained to calculate the DTC at T8–9, T9–10, and L1–2 interspaces. The measurements at all levels were obtained perpendicular to the long axis of the vertebral body. Statistical Analysis Used: Continuous data were depicted as mean with standard deviations. The categorical data were presented as counts with percentages. Results: The mean DTC distance at T8–9, T9–10, and L1–2 interspaces was 3.51 ± 0.98 mm (95% confidence interval [CI]: 3.35–3.67), 2.73 ± 0.94 mm (95% CI: 2.57–2.89), and 2.83 ± 1.08 mm (95% CI: 2.66–3.02), respectively. A significant difference was found between the genders at T9–10 (P = 0.02) and L1–2 levels (P = 0.04). No difference in DTC was found in toddlers, preschool children, school-going children, and adolescents. DTC at T8–9 showed a significant correlation with age (R2 = 0.0479; P = 0.04), weight (R2 = 0.038; P = 0.02), and height (R2 = 0.037; P = 0.03). Conclusion: Thoracic epidural space can be used in children and adolescents for epidural catheter placement. T8–9 level showed maximum DTC distance and significant correlation with age, height, and weight in CT imaging in the present study.
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Target-controlled inhalational anesthesia-isoflurane consumption with adequacy of anesthesia monitoring in conventional and multimodal analgesia – A comparative study p. 143
Reshma Vithayathil, Keelara Shivalingaiah Savitha, Nischala Dixit, Litty John
DOI:10.4103/aer.aer_43_22  
Background: In a time of increased concern over the environmental impact of chlorofluorocarbons, there is an impetus to minimize inhalational anesthetic consumption. It is possible with multimodal analgesia (MMA) and the use of end-tidal controlled anesthesia (EtCA) which is a low-flow anesthesia technique with adequacy of anesthesia (AoA) monitoring. In MMA, all four elements of pain processing namely transduction, transmission, modulation, and perception are targeted with drugs having a different mechanism of action. In EtCA, anesthetic gases are automatically adjusted for the set minimal alveolar concentration by newer anesthesia work station (GE Healthcare Aisys CS2). AoA is a derived parameter of entropy and surgical pleth index which measures the depth of anesthesia and analgesia, respectively. Aim: The aim is to assess the difference in isoflurane consumption between MMA and conventional groups for a given period of time with EtCA and AoA monitoring. Setting and Design: This was a prospective randomized controlled trial involving 60 patients undergoing laparoscopic cholecystectomy. They were divided into MMA group and conventional group. Materials and Methods: Both the groups received preemptive intravenous diclofenac sodium 75 g and 2% xyloadrenaline infiltration at entry ports. MMA group in addition received paracetamol 1 g and clonidine 0.75 μg.kg − 1. Intraoperatively, patients were on EtCA with AoA monitoring. Statistical Analysis: Mean differences in isoflurane consumption between the two groups were compared using an independent t-test. Postextubation adverse effects of analgesic drugs and awareness under general anesthesia were compared using the Chi-square test and presented as numbers and percentages. P < 0.05 was considered a statistically significant. Results: Mean isoflurane consumption in the conventional group was 12.7 ± 5.3 mL which was significantly higher than the MMA group which was 8.9 ± 4.1 mL (P = 0.002). The duration of anesthesia between the groups was not significant clinically (P = 0.931). Conclusion: EtCA with MMA significantly reduces isoflurane consumption compared to the conventional group of anesthesia.
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A prospective observational study of the efficacy of combined interscalene block and superficial cervical plexus block using peripheral nerve stimulator and landmark-based technique, as a sole anesthetic for surgeries on the clavicle in the COVID-19 pandemic p. 149
Uma Majumdar, Anuradha Mitra
DOI:10.4103/aer.aer_80_22  
Background: Fractures of the clavicle are usually operated under general anesthesia (GA) as they need dense anesthesia, and the airway is difficult to access intraoperatively. There is no established regional anesthesia (RA) technique for clavicular fractures, also as the innervation is contentious. Some studies have been done using RA techniques, but they are all small case numbers. RA is superior to GA in many ways, and we wished to avoid GA specifically during the COVID-19 pandemic. Aims: This study aimed to use a peripheral nerve stimulator and a landmark-based technique to give interscalene block (ISB) and superficial cervical plexus block (SCPB) as a sole anesthetic for clavicular fracture surgeries during the COVID-19 pandemic. Settings and Design: This was a prospective observational study in a tertiary care teaching hospital in eastern India. Materials and Methods: After approval from our ethics committee and informed consent, thirty patients of American Society of Anesthesiologists Class I or II, aged 18–65 years, after exclusion criteria were selected who had to undergo clavicular surgery. Three 10-mL syringes were made, each with 5 mL of 0.75% ropivacaine, 2 mL of 2% lignocaine with 1:200,000 adrenaline, and 3 mL of saline. Using the HNS Stimuplex (B. Braun Melsungen AG, Melsungen, Germany) nerve stimulator, 20 mL was given for an ISB and 5 mL for the SCPB. RA was considered successful if there was no conversion to GA and surgery could be performed. Results: With an onset time of 6.53 ± 2.17 min, good operating conditions were obtained in all our patients. Horner's syndrome was noted in two patients. Surgery was successfully carried out in all thirty patients under RA. Pain relief lasted postoperatively for 5 ± 0.92 h. Conclusion: ISB combined with SCPB is safe and effective as a sole anesthetic for clavicular surgery. We successfully avoided the use of a general anesthetic in these patients during the COVID-19 pandemic and gave them a safe and effective alternative.
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Levobupivacaine versus levobupivacaine plus dexmedetomidine in transversus abdominis plane block in patients undergoing abdominal aortic surgery p. 154
Maha Younis Youssef Abdallah, Mohamed Younes Yousef Abdallah
DOI:10.4103/aer.aer_89_22  
Background: Severe postoperative pain is a major dilemma for patients undergoing abdominal aortic surgery. Transversus abdominis plane (TAP) block has been described a successful pain management technique after major abdominal surgery. Dexmedetomidine was proved to enhance the analgesic action of local anesthetics. Aim: This study was aimed to assess the impact of adding dexmedetomidine to levobupivacaine during TAP block in patients undergoing abdominal aortic operations. Patients and Methods: We included 114 patients in this prospective trial, and they were enrolled into two groups; the L group received levobupivacaine only, and the LD group received levobupivacaine plus dexmedetomidine. The block was performed before anesthetic induction. Postoperative pain score was our main outcome. Statistical Analysis: The collected data were tabulated and analyzed through the SPSS software program IBM's Statistical Package for the Social Sciences (SPSS) statistics for Windows (version 25, 2017) (IBM Corporation, Armonk, NY, USA). The categorical data were expressed as numbers and percentages and then compared using the Chi-square test. The continuous data were expressed as mean and standard deviation if normally distributed, or median and range if abnormally distributed. The former data were compared through the one-way ANOVA, while the latter were compared through the Kruskal–Wallis test. Any P < 0.05 was considered statistically significant. Results: Group LD showed significantly earlier sensory blocks compared to the other group. Postoperative pain scores were comparable between the two groups for the initial 4 h following the surgery. Adjuvant dexmedetomidine was associated with better pain scores for the subsequent 12 h compared to Group L. The duration till the first analgesic request showed a significant increase in the LD group (13.3 vs. 11.09 h in Group L). In addition, the same group showed a significant decline in their opioid consumption after the operation (48.95 μg vs. 72.63 μg in the other group). Postoperative nausea and vomiting were significantly increased in Group L. Conclusion: Adjuvant dexmedetomidine has a significant beneficial impact on postoperative analgesic profile. Its use as an adjuvant to peripheral and neuraxial nerve blocks should be recommended in pain management practice.
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Effect of dexmedetomidine in sub-tenon's block on emergence agitation in pediatric strabismus surgery under sevoflurane anesthesia p. 160
Sameh M El-Sherbiny, Ragab A Kamal, Nashwa Sadik, Ahmed Elshahat
DOI:10.4103/aer.aer_99_22  
Background: Numerous unfavorable complications may occur with strabismus surgery as emergency agitation (EA), oculocardiac reflex (OCR), postoperative pain, and postoperative nausea and vomiting (PONV). Aims: This study was designed to evaluate the dexmedetomidine effect in sub-Tenon's block on EA in strabismus surgery in the pediatric population under sevoflurane anesthesia. Design: This was a prospective randomized double-blind clinical trial. Patients and Methods: Eighty American Society of Anesthesiologists (ASA) Physical Status Class I and II pediatric patients, in an age group ranging from 2 to 8 years of either sex, had strabismus surgery under sevoflurane anesthesia using laryngeal mask airway. Patients were divided randomly into two groups (each = 40). Sub-Tenon's block is performed in the operated eye with 0.5% bupivacaine (0.08 mL.kg−1) alone in Group B (bupivacaine group), and with 0.5% bupivacaine (0.08 mL.kg−1) and dexmedetomidine (0.5 μg.kg−1) in Group D (dexmedetomidine group). Hemodynamics were monitored, and OCR was recorded. Furthermore, postoperative EA (Pediatric Anesthesia Emergence Delirium and Cravero Scales), pain (Face, Legs, Activity, Cry, and Consolability), and incidence of PONV were recorded as well. Statistical Analysis: A prospective analysis of the collected data was performed using the SPSS program for Windows (version 26). Results: The dexmedetomidine group exhibited a lower EA incidence, pain, and PONV as compared to the bupivacaine group. No statistically significant differences regarding hemodynamics, OCR, or emergence time were found between both the groups. Conclusion: The addition of dexmedetomidine to bupivacaine in sub-Tenon's block can alleviate postoperative EA and nausea and vomiting with better pain management and hemodynamic stability in pediatric strabismus surgery under sevoflurane anesthesia.
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Comparison of the effectiveness of two-handed mask ventilation techniques (C-E versus V-E) in obese patients requiring general anesthesia in an Indian population p. 167
Meghana S Bharadwaj, Mamta Sharma, Shobha Purohit, Anie Joseph
DOI:10.4103/aer.aer_59_22  
Background: Two-handed mask ventilation techniques are often used in cases of difficult mask ventilation scenarios. A comparison of two methods of two-handed techniques in terms of tidal volume was undertaken in the context of the obese population. Aims and Objectives: To determine and compare the effectiveness of mask ventilation in obese Indian adult subjects by using either the C-E technique or the V-E technique after induction of general anaesthesia. Material and Methods: This was a randomised interventional study conducted on eighty obese patients. They were randomized into Group A ventilated with C-E technique and Group B with V-E technique. Expired tidal volume (VTe), Peak inspiratory pressure (PIP), SpO2, EtCO2 and vital signs were noted. Results: The BMI and hemodynamic parameters were comparable between the two groups. The expired tidal volume of 702 ± 77 mL with the V-E technique was significantly more than the C-E technique, which was 492 ± 71 mL. The ventilatory failure rate with the C-E technique was 15% and 0% with the V-E technique. There was no significant difference between the peak airway pressures for the two techniques: 20.3 ± 1.5 mm H2O for Group A and 20.5 ± 1.2 mm H2O for Group B. Conclusions: Mask ventilation with the two-handed V-E technique is associated with better tidal volumes and reduced failure rates in the obese population. So the V-E technique should be attempted first as a rescue measure in obese adult patients if the return of spontaneous breathing and tracheal intubation is impossible.
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CASE SERIES Top

Ultrasound-guided serratus anterior plane block for accelerated partial breast irradiation using multi-catheter interstitial brachytherapy technique under anesthesia in breast cancer patients: A case series p. 172
Wasimul Hoda, Sidharth Puri, Rakesh Garg
DOI:10.4103/aer.aer_18_22  
In early stages of breast cancer, breast conservation therapy (BCT) with lumpectomy and adjuvant irradiation is preferred. Accelerated partial breast irradiation (APBI) is considered as an alternative to whole breast irradiation. The reasons are it requires less number of irradiation fractions, shorter treatment time, and decreased size of irradiation. The procedure includes insertion of several brachycatheters, which is associated with significant pain in the postoperative period. We report case series of 8 patients of APBI where perioperative pain management was done using ultrasound (USG)-guided serratus anterior plane (SAP) block with catheter insertion. The catheter was placed between the serratus anterior muscle and external intercostal muscle. The drug used was 0.4 mL.kg−1 of 0.375% Ropivacaine with a maximum value of 30 mL. On the day of the procedure, all patients were given two boluses of ropivacaine 20 mL each at an interval of 6 h. From the next day onward, they received ropivacaine boluses on demand basis when Numerical Rating Scale (NRS) was >4. There were no complications during the procedure. None of the patients required extra fentanyl boluses intraoperatively. One patient did not have an SAP catheter inserted during primary insertion, as she failed to give consent for block. On repositioning of catheters, she experienced severe pain with a NRS of 8/10. After obtaining proper consent, SAP catheter was inserted and she had NRS of 1/10 postoperatively. 2/8 patients received rescue analgesics in the form of diclofenac. 7/8 SAP catheters were removed on day 5. Only one SAP catheter was removed accidentally on day 3. It was concluded that USG-guided SAP catheters are a novel, safe, and effective regional anesthesia technique for perioperative pain management in breast cancer surgeries undergoing APBI.
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Successful management of intraoperative priapism under general anesthesia during transurethral surgery – A case series with review of its management p. 177
Wasimul Hoda, Pratibha Xess, Mukesh Kumar, Srishti Kindo, Ladhu Lakra
DOI:10.4103/aer.aer_61_22  
Penile erection under general anesthesia is a rare occurrence. It may cause delay, complications or can even lead to cancellation of an elective transurethral surgery. In literature, various methods and techniques have been mentioned with variable rates of success and side effects. However, the management becomes challenging and it needs a tailored approach according to the patient's clinical condition with the aim of minimizing complications. Hereby, reporting two cases of successful management of intraoperative priapism in patients undergoing transurethral surgery under general anesthesia.
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