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July-September 2022
Volume 16 | Issue 3
Page Nos. 289-418

Online since Friday, December 9, 2022

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ORIGINAL ARTICLES  

A randomised control study comparing C-MAC D-blade video laryngoscope (hyper angulated blade) and macintosh laryngoscope for insertion of a double-lumen tube in patients undergoing elective thoracotomy Highly accessed article p. 289
Amit Mathew, Roy Rajan Mathai, Bernice Theodore, Jacob Chandy, Bijesh Yadav, Georgene Singh, Raj Sahajanandan
DOI:10.4103/aer.aer_81_22  
Background: The use of a double-lumen endotracheal tube is one of the common anesthetic techniques for operations in the thoracic cavity. However, when compared to a single-lumen tube, placement of a double-lumen tube is technically more difficult as a result of which it takes more time to insert and is associated with more complications such as mucosal injury, hoarseness, and sore throat, even in patients with no anticipated airway difficulty. The CMAC D-blade that is usually used in patients with anticipated airway difficulty, could assist in smooth and quick placement of double-lumen tube (DLT) even in patients with no anticipated airway difficulty. Aim of the Study: This study aimed to evaluate the effectiveness of the C-MAC D-blade in reducing the time taken to visualize the glottis and intubate patients with normal airway with a double-lumen tube. Setting and Design: This was a prospective open-label randomized control trial in a tertiary hospital. Materials and Methods: Seventy-three consenting adult patients with physical status classes I and II, as determined by the American Society of Anesthesiologists, scheduled to undergo elective thoracotomy, were randomly allocated to receive either C-MAC D-blade (Group D) or Macintosh blade (Group M). The primary objective was to compare the time taken for visualization of the glottis and intubation. Statistical Analysis Used: Chi-square/Fisher's exact test and t-test were used for statistical analysis. Results: Seventy-three patients were randomized (Group D = 36; Group M = 37). Time to visualize the glottic structures (4.56 ± 2.396 s vs. 7.27 ± 4.891 s, P = 0.01) was significantly better in Group D; however, the mean intubation time was comparable (55.92 ± 18.749 s vs. 51.08 ± 15.269 s, P = 0.61). Conclusion: C-MAC D-blade videolaryngoscope offers a better glottic view and lesser time to visualize glottis when compared with the Macintosh laryngoscope. However, the time taken to insert the DLT after visualization was longer. We infer that there is no advantage in the routine use of C-MAC D-blade for DLT insertion in patients with no anticipated airway difficulty.
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Reduction in the rate of mortality of moderate to severe COVID 19 infected patients with the use of remdesivir - A Tertiary Care Hospital-based retrospective observational study p. 296
Mahima Lakhanpal, Debpriya Sarkar, Ritesh Kumar, Isha Yadav
DOI:10.4103/aer.aer_55_22  
Background: As the waves of coronavirus disease 2019 (COVID-19) pandemic continues, the current treatment modalities emphasize the use of antiviral agents to save the human lives. Even though remdesivir is one of the current recommended modalities, data on the efficacy of remdesivir in reducing the rate of 28-day mortality are still not concurrent in all the reports. Aim: The present study aimed to determine the effectiveness of remdesivir in reducing the rate of mortality in a tertiary care hospital as retrospective comparative analysis. Setting and Design: The present study is a retrospective, comparative analysis of accurate and well-documented case files. Methods: Data (n = 262) of COVID-19–infected patients admitted and treated with remdesivir (Gp R; n = 160) and without remdesivir (Gp NR: n = 102) between June 1, 2021, and November 30, 2021, were collected and analyzed to obtain the results. Statistical Analysis: The data from individual case files were transferred to excel files (Microsoft office, Redmond, WA, USA) and then analyzed using Statistical Package for the Social Studies (SPSS, IBM, Armonk, NY, USA). The descriptive statistical values were expressed as mean ± standard deviation and number, frequencies/percentages. Student's t-test, Chi-square test, and ANOVA were employed for comparative statistics. P < 0.05 was considered statistically significant. Results: On analysis of the extracted data, the age, Acute Physiology and Chronic Health Evaluation-IV score, and predicted mortality rate between two groups have not shown significant difference (P > 0.05, ANOVA) and were comparable (P > 0.05, ANOVA). Furthermore, the 28-day mortality rate was significantly reduced (P < 0/001) in the Gp R where the rate of mortality was found to be 6.87%, whereas in Gp NR, it was 29.41%. Conclusion: Treatment with remdesivir was able to significantly increase the rate of survival of the patients and reduction in day-28 mortality when compared with the patients who had undergone treatment without remdesivir. Therefore, the results of the current retrospective, observational analysis from a tertiary care hospital could also be a piece of remarkable information to a significant number of existing data globally.
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The effect of caudal anesthesia block on perioperative pain control and reduction of the anesthetic agent in pediatric infraumbilical surgery: A prospective randomized trial study Highly accessed article p. 301
Zeana Amer Gawe, Hasan Mohamed Isa, Muatasem Mohamed Almashaur, Fayza Haider, Khadija Almulla
DOI:10.4103/aer.aer_64_22  
Background: Caudal epidural block (CEB) is a commonly performed neuraxial block to provide effective pain relief and analgesia in pediatric patients undergoing infraumbilical surgery. Aims: This study aimed to compare the effectiveness of adding CEB to general anesthesia (GA) in terms of intra- and postoperative pain management. Design: Prospective, randomized case-controlled trial study. Setting: Operation theater, and postoperative recovery rooms at Salmaniya Medical Complex, Bahrain. Materials and Methods: A total of 74 patients aged 2 months to 6 years with American Society of Anesthesiologists physical status classification I were recruited over a 6-month period between December 2019 and May 2020. Patients were allocated into two groups (Group A, with CEB) or (Group B, without CEB). Both groups were compared based on hemodynamic stability, pain scores, level of sedation, analgesia need, and parental satisfaction. Statistical Analysis: Data were analyzed using SPSS program. Categorical and numerical variables of both the groups were compared. Results: Patients with CEB had better hemodynamic stability during the surgical procedure based on heart rate (P = 0.039). Pain intensity scores were less in patients with CEB than those without (P < 0.001). Fentanyl consumption was lower in Group A compared to Group B at the end of surgery (P = 0.002). They were also ambulated earlier and discharged sooner than those without CEB. Parental satisfaction was 92.1% in Group A compared to 63.9% in Group B (P = 0.012). Conclusions: Adding CEB to GA for intraoperative and perioperative pain control in pediatric patients undergoing infraumbilical surgery makes it more effective, safe, and with better parental satisfaction.
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Levosulpiride and ramosetron for the prevention of postoperative nausea and vomiting in laparoscopic surgery: A prospective randomized double-blind study p. 307
RT Ranjithkumar, Imran Sholapur, Ravi Bhat, C Chandan Kumar
DOI:10.4103/aer.aer_98_22  
Background: Postoperative nausea and vomiting (PONV) continues to be common complication of anesthesia and surgery in spite of availability of so many antiemetic drugs and regimens for prevention. This study compared Ramosetron and Levosulpiride in terms of efficacy for PONV prevention after laparoscopic surgery. Aim: To compare the efficacy of intravenous (i.v.) Levosulpiride 25 mg with i.v. Ramosetron 0.3 mg in preventing PONV. Setting: S. D. M. College of Medical Sciences and Hospital, Sattur, Dharwad from November 2018 to June 2020. Design: It is a prospective randomized double-blind study. Statistical Analysis: All the data were collected, tabulated, and expressed as mean ± standard deviation. Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS 22.0 Evaluation version). Unpaired sample t-test and Chi-square test have been used for the quantitative and qualitative data, respectively. A P value of 0.05 was considered statistically insignificant. Materials and Methods: This prospective randomized, double-blind study was conducted in 200 patients undergoing laparoscopic surgery falling under the inclusion criteria are numbered and every nth patient selected by systemic random sampling procedure and allocated into two groups of 100 each, group Levosulpiride (Group L) and group Ramosetron (group R) study drugs givenwithin 30 min induction of anesthesia. Group L will receive LEVOSULPIRIDE 25 mg i.v. Group R will receive RAMOSETRON 0.3 mg i.v. Results: The incidence of vomiting in the Levosulpiride group and in the Ramosetron groupduring 0-4 h (20% vs. 30%, P = 0.1110), 4-8 h (4% vs. 5%, P = 0.7450), 8-12 h (5% vs. 4% P = 0.7210) and 12-24 h (0% vs. 0%). The incidence of nausea and overall PONV and the use of rescue antiemetic was not significantly different during all time intervals. The severity of nausea was not different between the two groups. Difference in the efficacy of Levosulpiride and Ramosetron was statistically insignificant (P > 0.05) in the prevention of PONV. Conclusion: Levosulpiride 25 mg or Ramosetron 0.3 mg given intravenously to prevent PONV inpatients undergoing elective laparoscopic surgery under general anesthesia are equally effective in controlling PONV.
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The comparison of inflation of cuff with 1% propofol, 4% lignocaine, or 0.9% saline on laryngotracheal morbidity p. 311
Priyamvada Gupta, Sunita Sharma, Anshul Vishnoi, Sakshi Kanoji, Khayyam Moin
DOI:10.4103/aer.aer_91_22  
Background and Aim: While administering general anesthesia requiring endotracheal intubation, it is a common practice to inflate the cuff with air. Continuous pressure exerted by cuff on mucosa may lead to postoperative complaints such as sore throat, cough, and dysphagia, which are very disturbing to the patient. Hence, we hypothesized that inflation of cuff with propofol may reduce the incidence of these complications as a result of cushioning effect as well as non-diffusion of nitrous oxide into it. Our aim was to compare the effects of inflation of endotracheal tube cuff with 0.9% saline, 4% lignocaine, and 1% propofol on the incidence of postoperative morbidity in terms of cough, sore throat, dysphonia, and dysphagia with general anesthesia using nitrous oxide. Methods: Patients scheduled for elective surgery under general anesthesia were randomly allocated into four equal groups of thirty each as per cuff inflation media: air (Group A), 0.9% saline (Group S), 4% lidocaine (Group L), and 1% propofol (Group P). The incidence of cough was noted at 15, 30 and 60 min after extubating. The occurrence and severity of postoperative sore throat (POST) was evaluated at 2, 6, and 24 h after extubating. Results: The incidence of cough was maximum in Group A and minimum in Group P (P < 0.05). The occurrence of POST was highest in Group A, followed by Group S and Group L, and least in Group P. The hemodynamic parameters were comparable with no statistical difference in all the four groups (P < 0.05). Conclusion: The intracuff 1% propofol is superior to 4% xylocaine and normal saline in the prevention of cough and sore throat postoperatively, whereas inflation of cuff with air leads to maximum incidence of these complications.
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Effect of preoperative duloxetine hydrochloride on reducing postoperative morphine requirement after open radical cholecystectomy in cancer patients: A randomized controlled study p. 316
Nida Haider, Aparna Shukla, Manoj Kumar Chaurasia, Reetu Verma, Hemlata , Gyan Prakash Singh
DOI:10.4103/aer.aer_75_22  
Background: Recently, opoids are linked with cancer recurrence. Duloxetine hydrochloride (DH), an anxiolytic may reduce total opoid requirement after cancer surgery. Aims: We assessed the efficacy of a single dose of DH in reducing the total morphine requirement after open radical cholecystectomy. We also calculated the Visual Analog Scale (VAS) score, patient satisfaction score (PSS), and time taken to the use of the first rescue analgesic. Setting and Designes: This is a prospective, randomized, double blind, controlled study conducted in the patients aged 20–70 years (American Society of Anaesthesiologists classes I–III) undergoing open radical cholecystectomy under general anesthesia for carcinoma gall bladder. Materials and Methods: The patients were divided into two groups of 32 patients each by computer-generated randomization. Group A received oral DH (60 mg); Group B received identical placebo capsules 2 h before surgery with a sip of water. Postoperatively, intravenous morphine was given using a patient-controlled analgesia pump. After 24 h, total morphine consumption, the VAS score, time to the first rescue analgesia, and PSS were recorded. Statistical Analysis: Statistical Package for the Social Sciences software (SPSS version 22.0, IBM Corp., Chicago, IL, USA 2013). P value < 0.05 or 0.001 was considered statistically significant. Results: The total morphine consumption and VAS score were significantly lower in Group A. No significant effects was observed on PSS. Conclusion: A single 60 mg dose of DH administered 2 h before open radical cholecystectomy reduced total morphine consumption and improved VAS score postoperatively with no effect on PSS.
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Hyperglycemia risk evaluation of hydrocortisone intermittent boluses versus continuous infusion in septic shock: A prospective randomized trial p. 321
Ganesh Kumar Ram, Saurav Shekhar, Raj Bahadur Singh, Ravi Anand, Ranjeet Rana De, Nitin Kumar
DOI:10.4103/aer.aer_115_22  
Background: Hydrocortisone showed an important role in reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the most common side effects associated with corticosteroid treatment. Aims: This study aimed to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses versus continuous infusion in septic shock patients. Settings and Design: This was a prospective randomized controlled study conducted in a tertiary care teaching hospital. Materials and Methods: One hundred and forty patients with septic shock and who received noradrenaline were enrolled in this randomized study. Group 1 was intermittent bolus hydrocortisone group (n = 70) and Group 2 was continuous infusion group (n = 70). All patients who were admitted with septic shock and who received noradrenaline and hydrocortisone were included in the study. Those patients who had exceeded 200 mg per day of hydrocortisone were excluded from the study. The primary outcome of the study was mean blood glucose. Statistical Analysis Used: Qualitative variables were compared between the two groups with the Chi-square of the Fisher's exact test and continuous variables were compared using the Student's t-test or the Wilcoxon rank-sum test. Results: Out of 112 patients, 54 patients received hydrocortisone as intermittent boluses (48.2%), and 58 patients (51.8%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 154.44 mg.dL−1 (95% confidence interval [CI]: 144.18–166.88) in the bolus group and 160.2 mg.dL−1 (95% CI: 143.82–176.76) in the infusion group with a mean difference of 05.76 mg.dL−1 (95% CI: −13.86–25.38). For the secondary outcomes of the study, no difference was found between the two groups in hyperglycemic or hypoglycemic events, mortality, length of stay in intensive care unit, and reversal of shock. Conclusions: The risk of hyperglycemia is almost equal in both intermittent and continuous infusions of hydrocortisone in septic shock patients.
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Comparative evaluation of C-MAC videolaryngoscope with macintosh direct laryngoscope in patients with normal airway predictors p. 326
Meena Kumari, Aastha , Anju Kumari, Sapna Bathla, Nikki Sabharwal, Akshaya Kumar Das
DOI:10.4103/aer.aer_78_22  
Background: Video laryngoscopes (VL) assist in securing the airway faster and more accurately in difficult airways. However, data regarding its usefulness in patients with normal airways are sparse. Aim: We designed this study to compare the ease and success of endotracheal intubation between C-MAC and Macintosh direct laryngoscope (DL) in adult patients with no anticipated airway difficulty. Settings and Design: The design involves prospective randomized case − control study. Subjects and Methods: One hundred and twenty adult patients with predicted normal airway were randomized into two groups and were intubated using VL (C-MAC VL) and DL (Macintosh DL), respectively. The Cormack-Lehane (CL) grade, time taken for intubation, attempts taken (number), and need for laryngeal maneuvers or stylets were recorded and analyzed for statistical significance. Results: Thirty-eight patients in the DL group and 48 patients in the VL group had CL I view, 20 patients in the DL group and 16 patients in the VL group had CL II, and two patients in the DL group had CL III view. None of the patients in Group VL had CL III view. In seven out of 60 cases in the DL group, difficulty was experienced during insertion of the laryngoscope blade as compared to two cases out of 60 in the VL group. The mean time taken for intubation was lesser in Group DL (28.48 s) as compared to 39.3 s in Group VL. Nine patients in Group DL and 16 patients in Group VL required external laryngeal manipulation. Stylets were used, in seven patients in group DL and in 11 patients in group VL. Conclusions: In patients with a predicted normal airway, C-MAC provides a better glottic view compared to Macintosh DL. Time taken for intubation using the C-MAC video laryngoscope was more. However, success rates on the first attempt at endotracheal intubation and the number of intubation attempts with either laryngoscope were similar.
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Perioperative challenges in the management of rhino-orbital cerebral mucormycosis: An observational study from a tertiary care hospital p. 331
Pradnya Milind Bhalerao, Shital Mahendra Kuttarmare, Shweta Joshi, Sanyogita Vijay Naik
DOI:10.4103/aer.aer_83_22  
Background: Coronavirus disease 2019 (COVID-19) pandemic is the biggest threat of the century. Associated with this disease, are a number of rhino orbital cerebral mucormycosis cases seen as post COVID sequelae. Amphotericin B and surgical debridement are the treatment modalities. Aims: This study aimed to describe the clinical characteristics and perioperative outcomes of patients with ROCM. Settings and Design: This was a prospective, observational study. Materials and Methods: We carried out a study of 238 patients with confirmed ROCM posted for functional endoscopic sinus surgery, craniotomies, maxillofacial surgeries, and orbital exenteration under general anesthesia and the perioperative challenges therein. Statistical Analysis Used: Data were entered in the excel sheet. Descriptive statistics were used to summarize the data. Analysis was done using the Statistical Package for the Social Sciences (SPSS) version 27:0. Categorical variables were expressed as counts and percentages. Results: 78% had diabetes mellitus, 64% had received steroids, 59% had a preoperative oxygen saturation of less than 90%, 86% had a 4–6 zone involvement on chest radiograph, and more than 50% had an anticipated difficult airway. Postsurgery, 13% of patients required intensive care. The 15-day mortality rate was 3% among the operated cases. Conclusion: Post-COVID ROCM is challenging in terms of preoperative poor general condition, difficult airway, intraoperative concerns due to pathophysiology of the disease and its effect on organ systems, and the requirement of postoperative vigilant monitoring.
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A comparative study of dexmedetomidine versus nalbuphine used as an adjuvant to chloroprocaine for daycare surgeries performed under subarachnoid block Highly accessed article p. 336
Priyamvada Gupta, Amit Suthar, Mangilal Deganwa, Vigya Goyal, Sonali Devgan
DOI:10.4103/aer.aer_85_22  
Backgrounds and Aims: Nalbuphine or dexmedetomidine when used as an adjuvant to local anesthetic agents may alter the characteristics of subarachnoid block. The study aimed to compare the effect of adding these drugs as an adjuvant to chloroprocaine for spinal anesthesia. Settings and Design: This prospective, randomized, double-blind study was conducted at a tertiary care center. Materials and Methods: After obtaining permission from the institutional ethical committee and informed patient consent, patients scheduled for surgeries under subarachnoid block were randomized into three groups of 50 each: Group C: Injection 1% chloroprocaine 40 mg (4 mL) with 1 mL normal saline, Group DC: injection 1% chloroprocaine 40 mg (4 mL) with dexmedetomidine 10 μg diluted to 1 mL in normal saline, and Group NC: injection 1% chloroprocaine 40 mg (4 mL) with nalbuphine 0.4 mg diluted to 1 mL in normal saline. Onset, peak, duration, and time to complete regression of sensory and motor blockade were noted. Side effects, if any, were noted and managed appropriately. Statistical Analysis: Qualitative data were analyzed using Chi-square test and quantitative data were analyzed using Student's t-test and two-sided Mann–Whitney U-test. P < 0.05 was considered statistically significant. Results: Group DC had prolonged time to onset, duration, and complete regression of sensory and motor block compared to Group NC and Group C (P < 0.001). Hemodynamic parameters, sedation score, and side effects were comparable in all groups. Conclusion: Thus, nalbuphine is a better adjuvant to chloroprocaine than dexmedetomidine when administered intrathecally for daycare surgeries performed under spinal anesthesia.
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First-pass success rate and number of attempts required for intubation in anticipated difficult airway: Comparison between Macintosh and channeled King Vision video laryngoscopes Highly accessed article p. 340
Rameez Raja, Sunana Gupta, Nandita Mehta, Prerna Attal
DOI:10.4103/aer.aer_68_22  
Background and Aims: Video laryngoscopy has been shown to improvise Cormack–Lehane grading and rate of successful tracheal intubation and is now incorporated in most of the difficult airway guidelines. Since there is scarce literature regarding the use of channeled blade of King Vision video laryngoscope (KVVL) in anticipated difficult intubation, we planned to undertake this randomized control trial to assess the performance of channeled blade of KVVL and Macintosh laryngoscope in patients with anticipated difficult intubation. Design and Setting: This prospective randomized study was conducted in a tertiary care hospital. Materials and Methods: Patients fulfilling the inclusion criteria were randomly assigned equally to the KVVL group or Macintosh group. The primary outcome of the study was intubation success in the first attempt and number of attempts required for intubation, and the secondary outcomes were Cormack–Lehane grading and time required to intubate in both the groups. Results: The first-pass success of intubation was 88.6% in the KVVL group and 76.5% in the Macintosh group (P = 0.035). The second attempt of intubation was required in 11.4% and 20.6% of patients in the KVVL and Macintosh groups, respectively. Cormack Lehane Grade I was achieved in 100% of patients of the KVVL group as compared to 29.4% of patients in the Macintosh group. Moreover, the difference was statistically significant (P = 0.035). The mean duration of intubation was prolonged in the KVVL group as compared to the Macintosh group, and the difference was statistically significant (P = 0.04). Conclusion: The channeled blade of KVVL had a higher first-pass success rate and required fewer attempts to intubate when used in patients with anticipated difficult intubation. Further, the KVVL was found to be significantly better than the Macintosh laryngoscope in terms of Cormack–Lehane grading, but the time taken to intubate the trachea was more in the KVVL group.
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The effectiveness of three regimens of sedation for children undergoing magnetic resonance imaging: A clinical study p. 345
Shwethashri Kondavagilu Ramaprasannakumar, Varadarajan Bhadrinarayan, Sudhir Venkataramaiah
DOI:10.4103/aer.aer_45_22  
Background: Magnetic resonance imaging (MRI) under sedation requires faster recovery for early discharge and feeding resumption in children with neuropsychiatric disorders. The use of dexmedetomidine alone results in delayed recovery. Propofol, when used alone, can cause hypotension and respiratory depression. A new regimen for sedation was evaluated by exploiting the properties of these drugs, to allow faster recovery with minimal adverse events. Materials and Methods: One hundred and fifty children aged 2–12 years requiring MRI were randomly allocated to these three groups. Group P (n = 50) received propofol bolus at 2 mg.kg−1 over 10 min followed by infusion at 100 μg.kg−1.min−1. Group D (n = 50) received dexmedetomidine bolus of 2 μg.kg−1 over 10 min followed by infusion at 1 μg.kg−1.h−1. Group PD (n = 50) received propofol bolus at 2 mg.kg−1 over 10 min followed by dexmedetomidine infusion at 1 μg.kg−1.h−1. Recovery characteristics were noted. Results: Recovery following sedation in Group PD (15 ± 7.0 min) and Group P (17.35 ± 7.4 min) were comparable and significantly (P = 0.03) lesser than Group D (27.58 ± 8.09 min). Emergence delirium scores were significantly less in Group PD (5 ± 1.08) and Group D (5.6 ± 2.4), unlike scores in Group P (9 ± 2.43). About 79.5% (39/49) of children in Group P, 88.2% (45/51) of children in Group D, and 86% (43/50) of children in Group PD completed MRI without any movement. Seven (14.58%) in Group P, 2 (4%) in Group D, and 5 (10.20%) in Group PD required rescue sedation. Conclusion: The regimen with propofol bolus and dexmedetomidine infusion provided adequate sedation and better recovery characteristics in children aged 2–12 years without systemic complications, as compared to the use of either agent alone.
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Comparing efficacy of intravenous dexmedetomidine and lidocaine on perioperative analgesic consumption in patients undergoing laparoscopic surgery p. 353
Vishwadeep Singh, Akhilesh Pahade, Ashita Mowar
DOI:10.4103/aer.aer_121_22  
Background: Perioperative pain management is a major challenge for anaesthesiologists. IV lidocaine and dexmedetomidine have been utilised for peri-operative pain management. Aims and Objectives: To analyse the effects of intraoperative intravenous lignocaine/dexmedetomidine on pain relief, opioid consumption, peri-operative hemodynamic and side-effect profiles/ unique interactions in patients undergoing laparoscopic surgeries. Materials and Methods: Prospective, interventional, single-centric, double-blind, randomised, active-controlled, Helsinki protocol-compliant clinical study was conducted on 90 ASA I/II class patients aged 18-60 yrs. This Patients were block-randomised to Group-L (2% Lignocaine), Group-D (dexmedetomidine) and Group C (Control/Placebo/ 0.9% normal saline). Hemodynamic were noted at pre-defined time frames intra-/post-operatively. Post-operative VAS score and Richmond Agitation Sedation Score monitoring was done. Results: Demographic parameters of were comparable. Mean intra-operative fentanyl consumption amongst the three groups were 20.5 ± 20.05 mcg, 26.5 ± 17.57 mcg and 46.83 + 21.31 mcg (Group-L, Group-D, Group-C; P value Group-L vs Group-D:0.22, Group L/D vs Group C: <0.0001). Group-D exhibited the lower heart rates and MAP (P < 0.05). Extubation- First rescue analgesic phase was comparable for the Group-C and Group-L (59.17 ± 46.224 min vs 61.64 ± 53.819 min) and significantly greater in Group-D (136.07 + 55.350 min; P < 0.0001). Conclusion: Both Dexmedetomidine and lignocaine can be useful intra-operative pain relief adjuncts. Dexmedetomidine delayed First rescue analgesic and total analgesic consumption more than lignocaine. Dexmedetomidine patients exhibited bradycardia intraoperatively more than the other groups. we recommend, Dexmedetomidine in the intra-operative phase and lignocaine in the post-operative phase can be an alternative in patients who are poor candidates for post-operative opioids/sedation/ contraindicated regional anaesthesia regimes.
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Caudal morphine in pediatric patients: A comparison of two different doses in children undergoing infraumbilical surgery – A prospective, randomized, double-blind study p. 360
Sushree Das, Ranjita Acharya, Madhusmita Patro, Nupur Moda, Gunde Mounika
DOI:10.4103/aer.aer_120_22  
Background: One of the most feared symptoms of any disease is PAIN. It is a complex phenomenal experience, especially in children. Various methods and medications have been administered through different routes. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children. Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children. The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Various articles use various doses of morphine as an adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 μg.kg−1 and 30 μg.kg−1 of caudal epidural morphine for infraumblical surgeries with regard to its efficacy and safety and side effect profiles. Materials and Methods: The study is a prospective, randomized, double-blinded study. Sixty patients were divided into two groups. Group A: 20 μg.kg−1 of morphine was added to 0.2% ropivacaine 1 mL.kg−1 and the solution was made. Group B: 30 μg.kg−1 of morphine was added to 1 mL.kg−1 of 0.2% ropivacaine. Heart rate, systolic blood pressure, diastolic blood pressure, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h were recorded. Results: The mean duration of analgesia is similar in both groups (P = 0.011). The mean duration was 20.517 ± 1.9143 h in Group A and 22.233 ± 1.6853 h in Group B. Children with the requirement of one dose of rescue analgesia in Group A was 83.3% which was higher than Group B being 66.7%. Children with no analgesic requirement were 16.7% in Group A and 33.3% in Group B. The incidence of side effects was more in Group B (8 [26.7%] children with nausea and vomiting; 1 [3.3%] children with urinary retention) than in Group A (2 [6.6%] children with nausea and vomiting. Conclusion: From the above observations, it can be concluded that morphine of less dosage (20 μg.kg−1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 μg.kg−1) as the duration of analgesia is similar with decreased incidence of side effects.
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Ultrasonographic changes in transorbital measurement of optic nerve sheath diameter in magnesium sulfate-treated severely preeclamptic patients: A prospective observational study p. 366
Kanchan Rani, Payal Jain, Sushil D Bhogawar, Radhika S Bhogawar, Mukesh Kumar Prasad, Amit Kumar Choudhary
DOI:10.4103/aer.aer_117_22  
Introduction: Severe preeclampsia can lead to various complications including increased intracranial pressure (ICP) which can be catastrophic but difficult to detect because of variable nonspecific symptoms. Ultrasonography has been used as noninvasive measure to monitor optic nerve sheath diameter (ONSD) as a marker of raised ICP. Effect of MgSO4 on ICP can modify the management approach, need for additional monitoring, targeting hemodynamic goals, timing of delivery, and choice of anesthesia. We evaluated the effect of MgSO4 on raised ICP in severely preeclamptic patients using ultrasound-guided ONSD as a surrogate marker of ICP. Methodology: This prospective observational study was conducted after ethical committee approval and written informed consent from patients. Ultrasound-guided ONSD was measured and compared in 47 severe preeclamptic patients before and at 1 h, 4 h, 12 h, and 24 h after starting MgSO4 therapy. The analysis of data was done by one-way analysis of variance using Statistical Package for the Social Science. Results: Mean ONSD was 5.56 ± 0.30 mm in our study group. ONSD above 5.8 mm was seen in 17 (36.17%) patients and was considered as marker of raised ICP. There was a significant decrease in ONSD after 4 h of administration of MgSO4. No significant correlation was observed between mean arterial pressure, serum magnesium level, and ONSD. Conclusion: Ultrasound-guided ONSD measurement can be used as a quick, noninvasive bedside tool in severe preeclamptic patient on MgSO4 treatment as marker of ICP which help us in determining clinical severity, therapeutic response, and to decide further course of management.
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A comparative study of intrathecal hyperbaric bupivacaine 0.5% with morphine and dexmedetomidine in lower limb orthopedic surgeries: A double-blind randomized clinical trial p. 373
Shadab Ashfi, Azizul Haque, Mukesh Kumar, Ladhu Lakra
DOI:10.4103/aer.aer_116_22  
Background: Pain and its alleviation have been a challenge for humans for centuries. Sub arachnoid block is most commonly practiced method for anaesthesia for lower limb surgeries. Adjuvants like opioids and alpha 2 agonists have proven benefits in augmentation of effects of local anaesthetics for spinal anesthesia. The aim of this study was to compare the effects of morphine and dexmedetomidine for sub arachnoid block in lower limb orthopaedic surgeries. Material and Methods: This is a prospective randomised controlled trial done in 120 patients who were posted for lower limb orthopaedic surgery. Along with bupivacaine , Group A received intrathecal dexmedetomidine while group B received intrathecal morphine. Results: the demographic profile was comparable in both the groups. The mean duration of motor block in Group A was 359.33 ± 34.4 and in Group B was 265.71 ± 28.47. The duration of rescue analgesia was almost double in Group A as compared to Group B with P < 0.0001 (CL 95%). Conclusion: Intrathecal dexmedetomidine and morphine both provided good postoperative analgesia. Dexmedetomidine provided a longer duration of analgesia than morphine, thereby increasing the time for first rescue analgesia, but at the cost of greater side effects.
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To compare the effectiveness of granisetron versus ondansetron to control nausea and vomiting during lower segment cesarean section under subarachnoid block p. 378
Milan Vijaykant Mehta, Palak Anilkumar Chudasama, Tushar Baria
DOI:10.4103/aer.aer_86_22  
Background: Nausea and vomiting (NV) seen during and after lower segment cesarean section (LSCS) are due to increased intragastric pressure, hypotension, stretching the peritoneum (exteriorization of the uterus), excessive surgical manipulation and visceral stimulation, using opioids, using uterotonic agents, and the patient's mental status. Ondansetron and granisetron intravenous (i.v.) are useful for avoiding bradycardia and hypotension. Objectives: The objective of this study is to study the effectiveness of granisetron versus ondansetron to control NV during LSCS under subarachnoid block. Materials and Methods: Eighty patients undergoing elective cesarean section under spinal anesthesia by intrathecal bupivacaine were randomly divided into two groups (40 pregnant females of the American Society of Anesthesiologists physical status Classes I and II in each Group). Group 1 received granisetron 40 mg.kg−1 i.v. stat after clamping the cord and Group 2 given i.v. ondansetron 8 mg stat after clamping the cord. NV were observed at the “early postoperative period (0–3 h)” and “late postoperative period (4–24 h).” Statistical Analysis Used: Student's t-test and Chi-square test were used to find out the statistical significance, P < 0.05 was considered statistically significant. Results: The mean age was 29.3 years with 4.15 standard deviation (SD) and 28.3 years with 4.41 SD in Groups 1 and 2, respectively. The mean duration of surgery was 53.1 min with 6.67 min SD and 57.7 min with 10.26 SD in Groups 1 and 2, respectively. In the “early postoperative period,” NV observed in 7.5% and 10.0% participants in Groups 1 and 2, respectively (P > 0.05), and in “late postoperative period,” NV observed in 0.0% and 22.5% participants in Groups 1 and 2, respectively (P < 0.05). Conclusion: Granisetron reduces the severity of spinal-induced hypotension, need for rescue vasopressor, and incidence of nausea.
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Intrathecal nalbuphine and dexmedetomidine as adjuvants to bupivacaine versus plain bupivacaine for orthopedic surgeries under subarachnoid block: A comparative study p. 381
Bindu Nagaraj, BR Vinay, NV Vani, VP Dayananda
DOI:10.4103/aer.aer_127_22  
Background: In long bone surgeries, the severity of pain is more, demanding good intraoperative anesthesia, and prolonged postoperative analgesia. This is achieved in spinal anesthesia with adjuvants to local anesthetics, which act synergistically. Aims: The aim of this study was to compare the efficacy of nalbuphine and dexmedetomidine as adjuvants to bupivacaine versus bupivacaine alone in lower limb orthopedic surgeries under the subarachnoid block (SAB). Settings and Design: This is a prospective, randomized, double-blind control study conducted on 60 patients belonging to the American Society of Anesthesiologists physical status Classes I and II, undergoing lower limb orthopedic surgeries under SAB. Materials and Methods: Sixty patients were divided into three groups by computer-generated randomization. Group A received 2.7 mL of 0.5% hyperbaric bupivacaine with 1.5 mg nalbuphine, Group B received 2.7 mL of 0.5% hyperbaric bupivacaine with 10 μg dexmedetomidine, and Group C received 2.7 mL of 0.5% hyperbaric bupivacaine with 0.5 mL of normal saline (total volume made to 3.2 mL in all groups with normal saline). Time of onset of block, duration of sensory, and motor blocks were noted. Changes in hemodynamic parameters, postoperative first rescue analgesia requirement, and side effects were recorded. Statistical Analysis Used: Data were analyzed using SPSS 22 version software. P < 0.05 was considered statistically significant. Results: There was no significant difference in the onset of sensory or motor blocks in the three groups. However, the time taken for regression of sensory block was longer in Group B that was statistically significant. Conclusion: Intrathecal dexmedetomidine acts as a better adjuvant with bupivacaine in providing quality anesthesia, prolonged sensory and motor block, and good postoperative analgesia with less incidence of adverse effects compared to nalbuphine and bupivacaine alone.
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Comparison of effectiveness of CE technique and jaw thrust technique for mask ventilation on apneic anesthetized adults: A randomized controlled trial p. 386
Akshara Madhav, Leena Harshad Parate, Suresh Govindswamy
DOI:10.4103/aer.aer_110_22  
Background: The two most common techniques for mask ventilation are CE and jaw thrust (JT) technique. However, few studies have validated their efficiency in terms of tidal volume (TV). Aims: This study aimed to compare the effectiveness of the CE technique and JT technique during pressure-controlled ventilation (PCV) by the mean of returned TV on apneic anesthetized adults. Design: This was a prospective, randomized cross over study. Settings: This study was conducted in a tertiary care hospital. Methods: Ethical Committee approval from our institution was taken (ss-1/EC 049/2017) and was registered in Clinical Trials Registry of India (CTRI/2018/04/012958). Sixty-five American Society of Anesthesiologists Physical Status classes I and II adult patients were enrolled in the study. After induction and muscle relaxation, mask ventilation was performed with CE and JT technique on PCV mode (Pinsp 15 cm H2O, respiratory rate 15) for 1 min each. The mean of returned TV of last 12 breaths, gastric insufflation, audible mask leak, and operator comfort in each technique were compared. Statistical Analysis: Statistical software namely IBM SPSS 22.0 and R environment version 3.2.2 (IBM Corp. SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA) were used for data analysis. Microsoft Excel was used to generate graphs and tables. Data were expressed as mean ± standard deviation for continuous variables and number (%) for categorical variables. Student's t-test (two tailed, independent) was used to find the significance of the study parameters on a continuous scale. Chi-square/Fisher's exact test was used to find the significance of the study parameters on a categorical scale between two or more groups. Results: There was a significant increase in mean TV generated by JT technique over CE technique (591.46 ± 140.27 mL vs. 544.59 ± 159.08 mL; P < 0.001). Gastric insufflation (12.9% vs. 14.5%) and mask leak (11.3% vs. 38.7%) were more in CE technique. Operator comfort (79% vs. 19.4%) was more in JT technique. Conclusion: A two-handed JT technique is more effective than a one-handed CE technique for mask ventilation in apneic anesthetized adults.
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The value of routine tests before pediatric eye surgery: A 10-year experience at a tertiary care hospital p. 392
Hideyo Horikawa, Mitsuhiro Matsuo, Mitsuaki Yamazaki
DOI:10.4103/aer.aer_112_22  
Background: Routine tests before ophthalmologic surgery in adult patients are no longer recommended. However, there are limited data on the utility of routine preoperative tests for children. Aims: We aimed to describe the effect of routine preoperative tests on systemic perioperative complications by hospital discharge or by day 30 following eye surgery. Settings and Design: This was a single-center, observational, and descriptive study. Subjects and Methods: We examined all patients ≤ 17 years old for whom ophthalmologists consulted with anesthesiologists before eye surgery under general anesthesia in an academic teaching tertiary care hospital from January 2010 to December 2019. Results: A total of 708 pediatric patients were analyzed. The mean patient age was 8.5 ± 4.6 years. The most frequently performed procedure was strabismus surgery in 433 patients (61.2%). Following anesthetic consultations, 15 patients (2.1%) underwent surgery postponed due to abnormalities at the physical examination. Routine tests identified that the two patients (0.3%) required additional evaluations due to elevated serum creatine kinase and electrocardiographic abnormalities. However, further examinations found that these abnormalities were unremarkable. The remaining 691 patients (97.6%) underwent surgery as scheduled. Substantial intraoperative blood loss was observed only in three patients with malignant tumors or trauma. The incidence of systemic complications was 0 (0%; 95% confidence interval, 0%–0.05%). Conclusions: These data indicated that the development of systemic perioperative complications following pediatric ophthalmic surgery is rare. Preoperative tests should be requested only if they are clinically indicated or before potentially bleeding procedures, such as malignancy or trauma surgery.
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Comparison of pericapsular nerve group block with fascia iliaca compartment block in adult patients undergoing hip surgeries: A double-blinded randomized control study p. 397
Mahindra B Kalashetty, Ranganath Channappagoudar, Vanishree Alwandikar, Dinesh L Naik, SY Hulakund, Aishwarya Guddad
DOI:10.4103/aer.aer_123_22  
Background: Hip fractures are the most common orthopedic condition in elderly patients. In this patient group, efficient preoperative analgesia that reduces the requirement for opioids and their negative side effects is crucial. This study aims for evaluating the efficiency of fascia iliaca compartment block (FICB) and pericapsular nerve group (PENG) in providing the appropriate analgesia before positioning patients for spinal anesthesia (SA). Methods: Ninety participants undergoing hip surgeries under SA were selected randomly to receive PENG block (n = 45) using 20 mL 0.25% bupivacaine or FICB using 30 mL of 0.25% bupivacaine. The blinded observer assessed Visual Analog Scale (VAS) scores at rest, with passive leg raise to 15° before and after 30 min of the block. The blinded observer also recorded hemodynamic parameters including noninvasive blood pressure respiratory rate and heart rate. The data were analyzed using SPSS version 19. Using the appropriate statistical methodology, continuous and categorical data were analyzed, and P ≤ 0.05 was considered statistically significant. Results: At rest and with a passive leg raise to 15°, VAS scores in the PENG and FICB groups decreased significantly (P < 0.0001). After 30 minutes of performing the PENG block, the VAS scores at rest and passive leg raise were 2.16±0.67 and 3.29±0.73 respectively, whereas with the fascia iliaca block the VAS scores at rest and passive leg raise were 4.07±0.69 and 5.11±0.71 with the p = 0.001, which is highly significant. Conclusion: PENG block outperforms fascia iliaca block in providing effective analgesia before positioning patients undergoing hip surgery under SA.
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Effects of the COVID-19 pandemic on the mental health of anesthesiologists: A cross-sectional study p. 402
Neha Singh, Jayanta Kumar Mitra, Bhavna Sriramka, Devi Prasad Mohapatra, Shree Mishra, Sahadeb Panigrahi
DOI:10.4103/aer.aer_132_22  
Introduction: In the COVID-19 pandemic, frontline health-care workers (HCWs) including anesthesiologists have been fatigued due to long working hours in critical care units or operation theaters and necessity to remain available on call at odd hours. In addition, the exposure to numerous diseased and morbid patients throughout the prolonged pandemic period has predisposed them to psychological distress. Materials and Methods: This is a cross-sectional study to evaluate the depression and anxiety among the HCWs during COVID. The demographic and general information of 237 HCWs across India, through an online survey was collected and analyzed. Results: The male: female ratio of the studied population was 53:47. In addition, 50% of the participants were aged <35 years, and 80% of participants were married and living with family and parents. The consultants working in combined (COVID and non-COVID) areas exhibited maximum participation in the survey, with 80% of them involved in aerosol-generating procedures. Of the total, 73.1% of participants exhibited depression, 45.8% of participants exhibited anxiety, 36.2% of participants exhibited stress, and 25.3% of participants exhibited disturbed sleep patterns. Conclusions: Most HCWs on COVID-19 duty exhibited emotional disorders such as anxiety, depression, stress, and insomnia. Addressing risk factors identified in the present study with targeted interventions and psychosocial support will allow health-care workers to cope better.
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A comparative study between local dexmedetomidine and intravenous dexmedetomidine during awake fiberoptic nasotracheal intubation p. 407
Abhay G Sancheti, Sarita S Swami, Shweta Laxmikant Konnur, Nooh Amin
DOI:10.4103/aer.aer_140_22  
Background: Awake fiberoptic intubation (AFOI) is the gold standard for managing a difficult airway. To make the patient comfortable and cooperative during the procedure, many drugs such as benzodiazepines, opioids, or dexmedetomidine are used. Most of these intravenously given drugs may cause respiratory depression and hypoxia. Aim: We compared the efficacy of dexmedetomidine through nebulization and transtracheal route with intravenous routes with the primary aim of comparing patient tolerance score (PTS) and secondary objectives of comparing sedation score, cough score, and total duration required for awake fiberoptic nasotracheal intubation. Settings and Design: This study was a prospective randomized double-blind study. Subjects and Methods: Seventy-six patients, scheduled for elective surgery requiring AFOI between 18 and 75 years, were included in the study. They were randomly divided into two groups of 38 each. Group I patients received intravenous dexmedetomidine 1 μg.kg−1 and Group L patients received local dexmedetomidine through nebulization 0.5 μg.kg−1 and transtracheal injection 0.5 μg.kg−1. Statistical Analysis Used: Statistical Package for the Social Sciences version 22 was used. Results: Patients who received dexmedetomidine through nebulization and transtracheal route have significantly better PTSs and less cough scores as compared to patients who received dexmedetomidine by intravenous route (P < 0.05). Hemodynamic parameters and sedation scores between the two groups were statistically insignificant (P > 0.05). The time required for the procedure was significantly less in Group L compared to Group I (P < 0.05). Conclusion: Dexmedetomidine by nebulization and transtracheal route provides optimal conditions for AFOI with good patient tolerance and less cough score as compared to the intravenous route.
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Evaluation of glottic view and intubation conditions with sniffing position using three different pillow heights during direct laryngoscopy: A prospective analytical study p. 412
Elizabeth Nishi Vijayakumar, Srinivasan Ramachandran, Vishwanath R Hiremath, Sureshkumar Kuppusamy, Balasubramanian Shanmugam, Dinesh Babu Dhamodharan
DOI:10.4103/aer.aer_130_22  
Background: Limited studies are available for assessing the optimal pillow height for sniffing position to obtain the best glottic view during laryngoscopy and intubation in the Indian population. Aims: This study was designed to evaluate laryngoscopic view and intubation conditions in sniffing position using three different pillow heights (without a pillow, 4 cm, and 7 cm) during direct laryngoscopy. Settings and Design: This prospective analytical study was done in a tertiary care teaching institute. Materials and Methods: In 60 patients, direct laryngoscopy was performed in the sniffing position first without a pillow (0 cm), followed by a 4-cm pillow, and then a 7-cm pillow to assess the glottic view after administration of anesthesia. The laryngoscopic views were graded using the percentage of glottic opening (POGO) score and Cormack and Lehane (CL) grade. The pillow with the best laryngoscopic view was subsequently used to intubate the patient. Intubation difficulty was assessed by the Intubation Difficulty Score (IDS). The patient was followed up for 24 h postoperatively to evaluate postoperative complications due to intubation. Statistical Analysis: The categorical data were expressed in frequency and percentages and analyzed using the Chi-square test. Results: With a 4-cm pillow, there are a lower CL grade and a higher POGO score compared to views without a pillow and a 7-cm pillow which was statistically significant. There is a significantly lesser IDS score with a 4-cm pillow. Conclusions: The sniffing position with a 4-cm pillow provides a better laryngoscopic view and improved intubation condition than without a pillow and a 7-cm pillow in the study population.
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CASE REPORT Top

A single-level epidural blood patch for multiple cerebrospinal fluid leaks: How it works p. 416
Amlan Swain, Seelora Sahu, Rashmi Kumari, Manjul Tripathi
DOI:10.4103/aer.aer_131_22  
Spontaneous intracranial hypotension caused by cerebrospinal fluid (CSF) leak is a rarely encountered cause of persistent postural headaches in the absence of trauma or dural puncture. It presents with postural headache and is characterized by radiological findings of spinal CSF leak. The mainstay of management is an epidural patch with the patient's own blood (epidural blood patch [EBP]) and/or a fibrin glue product. We report here a case of spontaneous intracranial hemorrhage presenting with persistent headaches and bilateral subdural hematomas secondary to CSF leaks at multiple levels along the spinal cord, which was successfully managed with a single lumbar EBP.
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