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   Table of Contents - Current issue
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October-December 2021
Volume 15 | Issue 4
Page Nos. 341-462

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SYSTEMATIC REVIEW  

Heparin-induced thrombocytopenia in COVID-19: A systematic review Highly accessed article p. 341
Sulakshana Sulakshana, Sudhansu Sekhar Nayak, Siva Perumal, Badri Prasad Das
DOI:10.4103/aer.aer_151_21  
Background: It has been more than a year since the whole world is struggling with COVID-19 pandemic and may experience resurgences in the near future. Along with severe pneumonia, this disease is notorious for extensive thromboembolic manifestations. That is why experts advocated aggressive anticoagulation as a part of the therapy since the beginning. However, from May 2020 onwards, cases of heparin-induced thrombocytopenia (HIT) are being reported. HIT in itself is an autoimmune entity leading to life-threatening thrombosis in the setting of thrombocytopenia. Continuation of heparin can have disastrous consequences in case of unrecognized HIT. Hence, timely recognition of HIT is of utmost value to modify the anticoagulation strategy and salvaging lives. We performed a systemic review trying to find all reported cases of HIT in COVID-19. Methods: It involved extensive search of the databases including PubMed, Google Scholar, Scopus, and Embase in an attempt to find all reported literature in the last 1 year (November 1, 2019–December 25, 2020) using keywords in various combinations. Literature search resulted in a total of 27 articles and 12 articles were finally selected based on the study design and their relevance pertaining to the intervention done and the outcome of interest. Results: A total of 35 patients were included (mean age 56.7 ± 12.8 years, male-to-female ratio = 2:1). The most frequent comorbidity was hypertension. Fifty-seven percent of cases were with low-molecular weight heparin and the rest with unfractionated heparin. Confirmatory functional assay was done in 85.7% of cases (67% by serotonin-release assay [SRA] and 33% by heparin-induced platelet aggregation [HIPA]). All cases tested with HIPA were positive, while with SRA, only 30% were positive. The most common alternate anticoagulation used was argatroban infusion. The new arterial thrombotic event was seen in only 5.7% of cases as repeat myocardial infarction, stroke, and splenic infarction, while clinically significant bleeding was seen in 17.1% of cases. Fifty percent of bleeding episodes were seen where conventional doses of argatroban were used, while no mortality was seen with low-dose argatroban infusion. However, only 45.7% of patients were discharged, 31.4% of patients died, while the outcome was pending for 23% of patients. Conclusion: Severe endotheliitis and immune dysregulation giving rise to HIT antibodies and antiphospholipid antibodies have been demonstrated in COVID-19 and modifying our therapy becomes indispensable when it is pathogenic with potentially fatal consequences. In the light of interim results of REMAP-CAP study in severe COVID-19 cases where heparin does not improve the outcome, the present anticoagulation strategy needs re-evaluation. Unrecognized HIT can be catastrophic and close clinical monitoring is required for patients on heparin therapy.
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ORIGINAL ARTICLES Top

Effect of injection speed of heavy bupivacaine in spinal anesthesia on quality of block and hemodynamic changes p. 348
Ann Riya Jacob, Jerry Paul, Sunil Rajan, Greeshma C Ravindran, Lakshmi Kumar
DOI:10.4103/aer.aer_1_22  
Background and Aims: Spinal anesthesia is a technique widely used for gynecological, lower abdominal, pelvic and lower limb procedures. Even though it causes a profound nerve block, it is associated with profound hypotension. Aims of the Study: To assess the effect of the speed of injection of heavy bupivacaine on quality of block and hemodynamic changes in patients undergoing gynecological surgeries under spinal anesthesia. Methods: This was a prospective randomized study conducted on 40 patients. Group F patients were given 3.2 mL of 0.5% heavy bupivacaine intrathecally in 15 s and Group S patients were given the same drug over 60 s. The time to achieve T10 dermatomal block, maximum block height, block height at 5 min were recorded. Heart rate (HR), systolic, diastolic blood pressures, and mean arterial pressures (MAP) were also recorded at different time points. Results: HR, systolic BP, diastolic BP, and MAPs and mean block height at 5 min were comparable between the two groups at all time points. The time to achieve T10 dermatome block was significantly faster in Group F (1.85 ± 1.14 min) as compared to Group S (3.98 ± 1.58 min). Majority of patients in Group F (65%) had a maximum block up to T6 and those in Group S (45%) had a block upto T4. The usage of vasopressors was found to be significantly higher in Group F compared to Group S with P = 0.041. Conclusion: Using faster speed of injection of heavy bupivacaine during spinal anesthesia can lead to faster achievement of blockade but with significantly higher usage of vasopressors.
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Comparison of pericapsular nerve group block versus fascia iliaca compartment block as postoperative pain management in hip fracture surgeries p. 352
KS Senthil, Prem Kumar, Lakshmi Ramakrishnan
DOI:10.4103/aer.aer_119_21  
Background and Objectives: Postoperative pain management and early recovery play an important role in the functional outcome following hip surgeries. Recently, pericapsular nerve group (PENG) block has been used as a good alternative for postoperative pain management following hip fracture surgeries. We compared the efficacy of (PENG) block and fascia iliaca compartment block (FICB) as postoperative pain management in hip surgeries. Methods: Forty patients of the age group of 18 years and older of American Society of Anesthesiologists Physical Status Classes I and II scheduled for hip fracture were selected and the patients were randomly allocated into two groups. Group A comprised of 20 patients who received PENG block and Group B comprised of 20 patients who received FICB. 30 mL 0.25% Levobupivacaine and 4 mg dexamethasone was given for both blocks. The following outcomes were measured: Total fentanyl consumption in 24 h, dynamic pain during 2, 6, 10, 14, 18, and 24 h, Visual Analog Pain score during 2, 6, 10, 14, 18, and 24 h, quadriceps femoris muscle strength. Results: Even though there was no significant difference in the duration of analgesia and dynamic pain grades between these blocks, there was notable difference in Visual Analog Pain score and the motor power of quadriceps femoris which indicates the potency of sensory blockade and decrease in motor sparing was significantly seen in PENG block than FICB. Conclusion: The findings of this study suggest that PENG block was more appropriate analgesic modality than FICB in patients undergoing hip surgeries as postoperative analgesic.
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Prospective randomized study comparing the usefulness of dexmedetomidine versus esmolol in blunting hemodynamic responses to intubation in surgical patients p. 357
Roniya Ann Roy, Rajesh Kesavan, Sunil Rajan, Niveditha Kartha, Lakshmi Kumar
DOI:10.4103/aer.aer_155_21  
Background: Sympathetic response due to laryngoscopy and endotracheal intubation though transient, could be life-threatening in patients with underlying cardiovascular diseases. Aim of the Study: The aim of this study is to assess the effects of dexmedetomidine and esmolol on the hemodynamic response to laryngoscopy and endotracheal intubation in patients undergoing general anesthesia for elective surgery. Settings and Design: Prospective, randomized study conducted in a tertiary care center. Materials and Methods: Sixty patients were recruited and randomly divided into two groups. Group A received 0.5 mcg.kg−1 dexmedetomidine and Group B 0.5 mg.kg−1 esmolol infusions over 10 min. All patients were induced with propofol 2 mg.kg−1 followed by succinylcholine 2 mg.kg−1 and intubated. The heart rate (HR) and mean arterial pressure (MAP) were recorded at different time points. Statistical Analysis Used: Chi-square test, independent sample t-test, and paired t-test. Results: Baseline HR was statistically different in both groups. There was significant decrease in percentage change in baseline HR in Group A compared to Group B at preinduction (20.44% ± 10.82%, 13.63% ± 11.84%), before intubation (23.49 ± 12.62, 13.95 ± 14.86), and 7 min after intubation (14.65 ± 12.62, 6.80 ± 16.11). Percentage change in HR remained comparable in all other time points. Baseline MAP was comparable between the groups. Percentage change from baseline of MAP was significantly higher in Group B before intubation. All other time points MAP were comparable. The incidence of hypotension was comparable in both groups. Conclusions: Both dexmedetomidine and esmolol suppressed the hemodynamic response to laryngoscopy and intubation, but dexmedetomidine was more effective than esmolol in maintaining hemodynamic stability.
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Evaluation of cognitive and psychomotor functional changes in anesthesiology residents after 12 hours of continuous work in operation theater: An observational study p. 362
R Varun Prasad, Suman Lata Gupta, Srinivasan Swaminathan
DOI:10.4103/aer.aer_153_21  
Background: Prolonged working hours in operation theater may impair cognitive and psychomotor function. Aims: This study was done to evaluate the changes in cognitive and psychomotor changes in the anesthesia residents after 6 and 12 h of continuous work in operation theater. Settings and Design: Sixty anesthesia residents whose working hours were expected to be longer than 12 h were recruited for this prospective, observational study. Methods: The study consisted of a set of five tests used for assessing the cognitive and psychomotor functions. The tests were conducted for the participants at 0, 6, and 12 h of work and the total scores at the respective time period were noted. The tests were manual dexterity test using purdue peg board, finger tapping test, visual spatial capacity memory test, digit symbol substitution test (DSST), and frontal assessment battery. Statistical Analysis: The observations of the purdue peg board test, finger tapping test, and digit symbol substitution test at 0, 6, and 12 h were tested using the repeated measures analysis of variance and paired t-test. The observations of visual spatial capacity memory test and frontal assessment battery were tested using the Chi-square test. Results: In the purdue peg board test, there was significant reduction in the mean number of pins assembled by the participants over 12 h of work. There was a significant difference in the number of finger taps by the dominant hand between 0 and 12 h and also between 6 and 12 h. In the visual spatial memory test, there was no significant difference in the performance of the participants with incorrect response at 0 and 12 h of duration. There was a significant decrease in the number of correct response among the participants in the digit symbol substitution test at 0 and 12 h of work. There was no significant difference in the scores obtained in frontal assessment battery test which was used to assess the cognitive function. Conclusion: There was a significant reduction in the psychomotor functions of the anesthesiology residents after 12 continuous hours of work in the operation theater and there was no significant reduction in cognitive function observed during that period.
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Efficacy of dexmedetomidine versus propofol in patients undergoing endoscopic transnasal transsphenoidal pituitary tumor resection p. 368
Maha Younis Youssef Abdallah, Yasser Wafik Khafagy, Mohamed Younes Yousef AbdAllah
DOI:10.4103/aer.aer_154_21  
Background: Dexmedetomidine is associated with good perioperative hemodynamics together with decreased opioid requirements. Furthermore, propofol has been used to achieve hypotensive anesthesia as a part of total intravenous anesthesia. Aims: This study was performed to compare dexmedetomidine and propofol on the adequacy of hypotensive anesthesia during transsphenoidal resection of pituitary tumors. Patients and Methods: A total of 110 cases were included in this prospective randomized study. They were randomized into two equal groups; Group D commenced on Dexmedetomidine, and Group P, which received propofol. Comparing intraoperative hemodynamic parameters and the Boezaart Bleeding Scale was our primary outcome. The secondary outcomes included isoflurane and propranolol consumption, recovery, postoperative analgesic profile. Statistical Analysis: IBM's SPSS Statistics (Statistical Package for the Social Sciences) for Windows (version 25, 2017) was used for the statistical analysis of the collected data. Shapiro–Wilk test was used to check the normality of the data distribution. The quantitative variables were expressed as mean and standard deviation, whereas the categorical variables were expressed as frequency and percentage. Independent sample t and Mann − Whitney tests were used for the comparison of parametric and nonparametric continuous data, respectively. For pair-wise comparison of data (within-subjects), the follow-up values were compared to their corresponding basal value using the paired samples t-test or Wilcoxon matched-pairs signed-ranks test. Fisher exact and Chi-square tests were used for inter-group comparison of nominal data using the crosstabs function. Results: Age, gender, body mass index, and systemic comorbidities did not significantly differ between the two groups. Furthermore, heart rate and blood pressure were comparable at baseline, during operation, and after extubation. Boezaart score, blood loss, isoflurane, and propranolol consumption were also comparable between the two groups. Group D expressed significantly longer emergence and extubation times than Group P. Nevertheless, cases in the same group expressed lower Visual Analog Scale values and postoperative analgesic requirements. Conclusion: Although Dexmedetomidine and propofol are associated with comparable intraoperative hemodynamic changes, the former drug appears to be superior regarding pain control, postoperative analgesic requirement.
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Comparison of trocar site versus trocar site plus intraperitoneal instillation of local anesthetic for shoulder pain following laparoscopic abdominal surgery p. 375
Sheerin Sarah Lysander, G Dilip Kumar, Anusha Balasubramanian, Rajarajeswaran Krishnan, MS Raghuraman, S Vijay Narayanan
DOI:10.4103/aer.aer_156_21  
Background: Laparoscopic surgery in recent times has noteworthy advantages over conventional surgery, yet recovery is prolonged due to debilitating shoulder tip pain (STP) and operated site pain. Various studies have compared the effect of trocar site, intraperitoneal instillation of local anesthetic (LA) for pain relief while only a few studies have tested the combination of these two techniques. Hence, this study was undertaken to compare the combination of these two techniques versus trocar site alone for STP particularly. Subjects and Methods: This prospective, randomized, comparative study was conducted on 52 patients who were undergoing laparoscopic abdominal surgery. The patients were allocated into either of the two groups. Group I (n = 26): trocar site infiltration (20 mL) and intraperitoneal instillation (20 mL) of 0.25% levobupivacaine and Group II (n = 26): trocar site infiltration (20 mL) of 0.25% levobupivacaine and saline (20 mL) intraperitoneally. Postoperative STP was the primary outcome while surgical site pain, nausea, and vomiting were secondary outcomes. Results: There were no statistically significant differences between the groups with regard to shoulder pain, surgical site pain, total rescue analgesics, and incidence of nausea and vomiting (P > 0.05). Conclusion: Trocar site infiltration with intraperitoneal instillation of LA or trocar site infiltration alone was found to be equally effective. However, we suggest that it is better to provide a combination of trocar site infiltration plus intraperitoneal instillation of LA if we have to restrict opioid usage such as in day-care surgeries.
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A comparative study of analgesic efficacy of intrathecal bupivacaine with ketamine versus bupivacaine with magnesium sulphate in parturients undergoing elective caesarian sections p. 379
Jagadish Alur, Vishwajeet V Korikantimath, B Jyoti, KS Sushma, Nataraj V Mallayyagol
DOI:10.4103/aer.aer_125_21  
Background and Aims: Spinal anaesthesia is the most preferred technique of anaesthesia in parturient, undergoing lower segment caesarean sections (LSCS) which provides effective pain relief during intra operative and early postoperative period. However, recent studies demonstrate that about 50%–70% of patients experience moderate to severe pain after LSCS indicating that postoperative pain remains poorly managed. The aim of our study was to compare intrathecal magnesium sulphate (Mgso4) and ketamine as adjuvants to hyperbaric bupivacaine in parturients posted for elective caesarean sections under spinal anaesthesia to determine their effectiveness in extending the duration of analgesia Materials and Methods: After institutional ethical committee approval, 82 parturient undergoing elective LSCS were enrolled into the prospective randomized double blinded study. Group BK (n = 41) received intrathecal ketamine (25 mg) as additive to hyperbaric bupivacaine and group BM (n = 41) received magnesium sulphate (75 mg) as additive to hyperbaric bupivacaine. Time of onset of sensory analgesia, motor blockade, duration of analgesia was noted down. Intraoperative hemodynamics and any adverse effects of study drugs were noted. Results: The mean duration of analgesia in group BK was significantly longer (P < 0.05) than in Group BM. The onset of sensory and motor blockade was significantly early in Group BK compared to Group BM. Hemodynamics was better maintained in Group BK with less requirement of ephedrine compared to Group BM. The visual analog scale scores were significantly lower without side effects in both the groups. Conclusion: The present study demonstrated that the duration, quality of analgesia, hemodynamic stability was better with intra thecal ketamine as an adjuvant to bupivacaine compared to intrathecal MgSo4 without any significant side effects on mother and child.
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Ultrasound block of the medial branch: Learning the technique using CUSUM curves p. 385
Marta Putzu, Maurizio Marchesini
DOI:10.4103/aer.aer_162_21  
Background: Blocking the medial branch of the lumbar facet joints plays a fundamental diagnostic and therapeutic role in the treatment of lumbar pain. Attempts to replace the typical guided X-ray techniques with ultrasound-guided techniques have also involved treating the lumbar medial branches. By applying the cumulative sum control chart (CUSUM method), we sought to evaluate the learning curve associated with ultrasound-guided block of the lumbar medial branches in operators experienced in locoregional anesthesia but without expertise in pain therapy. Aim: This study aimed to use a repeatable method to identify the learning curve of the ultrasound-guided medial branch block. Settings and Design: This study was a prospective application of over forty consecutive procedures of ultrasound lumbar medial branch block. Materials and Methods: The ultrasound medial branch blocks were performed under ultrasound guidance with confirmation of correct positioning using fluoroscopy on a population of patients with low back pain with any body mass index (BMI). Statistical Analysis: The operator's performance was assessed using the learning curve cumulative summation test (LS-CUSUM). Results and Conclusions: The correct target was reached in 29 procedures out of a total of 40 (72.5%) and in 29 out of 36 procedures performed on patients with BMI <30 (80.5%). According to the CUSUM algorithm, 11 further consecutive successes would have been necessary (47 procedures in total) to achieve a proven learning of the technique in the group with only patients with a BMI <30, with a further 22 consecutive successes (62 procedures in total) in the general group. Ultrasound-guided block of the lumbar medial branch appears not to be optimal for training beginner/intermediate operators seeking to replace guided X-ray procedures with guided ultrasound.
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Effects of dexmedetomidine infusion in low dose on dose reduction of propofol, intraoperative hemodynamics, and postoperative analgesia in patients undergoing laparoscopic cholecystectomy p. 391
Vijay Pratap Kalaskar, Dipakkumar Hiralal Ruparel, Rohini Pradip Wakode
DOI:10.4103/aer.aer_123_21  
Background: Dexmedetomidine, alpha 2 agonist, with its anxiolytic, sympatholytic and sedative property can be good adjuvant in anesthesia by modifying stress response to various stimuli during laparoscopic cholecystectomy including laryngoscopy, intubation, pneumoperitoneum, and extubation. We aimed to evaluate low dose dexmedetomidine for reducing hemodynamic perturbations to stressful events with secondary aim of evaluating propofol dose reduction and postoperative analgesia. Methods: Sixty patients of American Society of Anesthesiologists Physical Status (ASA PS) Classes I and II were randomized to two groups of 30 each to receive dexmedetomidine infusion (0.5 mcg.kg−1.h−1) starting 15 min before induction (Group A) and normal saline (Group B). Patient induced and maintained with propofol infusion to keep BIS value 55–60 in both groups and heart rate (HR) and mean arterial pressure (MAP) were recorded. We stopped infusions at surgical closure. VAS score recorded till 24 h of surgery. Total propofol required in both groups were recorded. Data were statistically analyzed using the SPSS software version 15.0. Results: MAP and HR remain elevated following intubation in Group B and remain so throughout procedure and during all stressful events including CO2 insufflation and tracheal extubation and were statistically significant. Significantly lower doses (almost 30%) of Propofol required in Group A to achieve similar BIS values compared to Group B. Visual Analog Scale score remained on the lower side in Group A for 24 h than Group B. Conclusion: Low dose dexmedetomidine (0.5 mcg.kg−1.h−1) can effectively maintain hemodynamics during stressful events, reduces propofol requirement and improves postoperative analgesia in patients undergoing laparoscopic cholecystectomy.
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Central venous access in neonates: Comparison of ultrasound-guided percutaneous access and minimal surgical open methods p. 395
Hosam I El Said Saber, Ahmed M Farid, Tamer A Wafa, Hani I Taman
DOI:10.4103/aer.aer_138_21  
Background: In neonates, percutaneous central venous catheter (CVC) insertion is often a challenging technique. Recent reports have reported the efficacy of ultrasound (US) guidance when performing such an intervention. We conducted this study to compare US-guided and minimal surgical CVC insertion regarding time and ease of insertion, reliability, and complications. Patients and Methods: This prospective randomized study included 92 neonates scheduled for CVC insertion. They were divided into two groups: Group A (46 neonates) underwent the US-guided approach and Group B (46 neonates) underwent the surgical approach. The number of attempts and the duration of the procedure were documented in both groups. In addition, intraoperative and postoperative complications were recorded. Results: Each of patient's age, gender, weight, and the indication of catheter insertion were statistically comparable between the two groups. The number of trials showed a significant increase in Group A (1.52 vs. 1.07 in Group Bp <0.001). Nevertheless, the time of the procedure was significantly decreased in the same group (3.68 vs. 10.21 in Group Bp <0.001). [Table 2] summarizes the previous findings. Failure was encountered only in one case in Group A (2.2%), which was converted to the open surgical technique. In general, the incidence of complications showed no significant difference between the two approaches. Conclusion: Although US-guided CVC insertion is associated with an increased number of trials, the duration of the procedure is significantly diminished with its use. Furthermore, it has a high success rate in addition to a comparable complication profile with the traditional surgical method.
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An inquiry on airway management by mccoy blade with elevated tip and miller straight blade with paraglossal technique: Relevance for difficult airway management in current infectious times p. 401
Sri Vidhya, Neel Prakash, Amlan Swain, Sharad Kumar, Rajiv Shukla
DOI:10.4103/aer.aer_163_21  
Background: Modifications of curved and straight laryngoscope blades have been used for airway management since a long time. While McCoy blade with an elevated tip is commonly used to intubate patients with anticipated difficult airway, the Miller's straight blade is used for intubations in children and less commonly adults. In this study, we revisit the paraglossal technique of Miller's straight blade as a method to improve laryngeal view especially in difficult intubations. Aim: This study aimed to compare laryngoscopic view and ease of intubation (EOI) using McCoy blade elevated tip and Miller's straight blade paraglossal technique. Materials and Methods: A prospective single-blind study was conducted on 170 patients undergoing elective surgery under general anesthesia. They were randomly allotted to two groups. In Group A, laryngoscopy was performed by Miller's blade paraglossal approach, whereas in Group B, laryngoscopy was performed by McCoy blade with an elevated tip. Laryngeal view was graded using the modified Cormack–Lehane grading, and EOI was graded using EOI score. These were compared with preoperative intubation prediction score. Statistical analysis was done using "Medcalc" version 19.0.3. Numerical and categorical data were analyzed by Student's t-test and Chi-square test, respectively. A P < 0.05 was considered statistically significant. Results: The paraglossal approach with Miller's blade offered better laryngoscopic view as compared with McCoy blade with an elevated tip in normal (54.1% vs. 25.9%) and difficult airway (44.7% vs. 11.8%). Tracheal intubation was easier with McCoy blade with an elevated tip although the success rate of intubation improved with the assistance of a bougie with Miller's straight blade paraglossal approach. Conclusion: The laryngeal view was significantly better with the paraglossal approach of Miller's straight blade even in difficult airway. McCoy blade with an elevated tip was also found to be a useful tool to have in difficult airway, as EOI is significantly higher. The study also highlights the usefulness of adjuncts such as a gum elastic bougie while intubating.
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Apnoeic oxygenation during simulated difficult intubation in obese patients: comparison of buccal ring, adair and elwyn tube versus nasal cannula: A prospective randomized controlled trial p. 408
Rakesh Mohanty, Leah Raju George, Sajan Philip George, Malavika Babu
DOI:10.4103/aer.aer_114_21  
Background: Apnoeic oxygenation is an established method of increasing safe apnoea times during intubation and this is of more importance in obese patients. The usefulness of buccal Ring, Adair and Elwyn (RAE) oxygenation has been established in previous studies, however a head-to-head comparison with nasal cannula (NC) is lacking. Aim: The aim of this study was to compare apnoea time with buccal RAE (BR) versus NC in obese patients. Setting and Design: This was a prospective, nonblinded randomized controlled trial conducted in a tertiary hospital where fifty American Society of Anaesthesiologists Physical Status Class I and II, obese patients with body mass index ≥30, posted for elective surgery were included. Materials and Methods: Following adequate preoxygenation and standard induction of anaesthesia, a prolonged simulated difficult laryngoscopy was performed during which oxygen was provided via either BR or NC. The primary outcome was time to desaturation to <95% or 10 min, which ever occurred first. Other outcomes recorded were lowest saturation, time to resaturation and highest end tidal carbon di oxide. Statistical Analysis: Mean with standard deviation (SD) or median with inter quartile range were used for continuous variables and absolute number with percentage were used for categorical variables. The primary outcome was analyzed using Kaplan-Meier survival curves, and log-rank tests were applied. Results: Patient characteristics were similar in both arms. The mean apnoea time in seconds (SD) in the BR group, 375.3 (116.6) was higher than the NC group 316.1 (94.1), P = 0.054. From the Kapan Meier curves the probability of desaturating to <95% was earlier in the NC group than the BR group (P = 0.092). The other outcomes were similar in both groups. Conclusion: This is the first study that demonstrates that oxygenation via a BR is better than NC in providing apnoeic oxygenation in obese patients and can safely be used when NC are contraindicated.
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Perioperative satisfaction and health economic questionnaires in patients undergoing an elective hip and knee arthroplasty: A prospective observational cohort study p. 413
Mahesh Nagappa, Jill Querney, Janet Martin, Ava John-Baptiste, Yamini Subramani, Brent Lanting, Christopher Schlachta, Julie Ann Von Koughnett, Kathy Speechley, Jeff Correa, Maoz Bin Yunus Chohan, Nita Rrafshi, Mariska Batohi, Ashraf Fayad, Homer Yang
DOI:10.4103/aer.aer_5_22  
Background: Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated. Methods: We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care. Results: Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04). Conclusion: Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients' concerns.
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Comparison of postoperative pulmonary outcomes in patients undergoing cesarean section under general and spinal anesthesia: A single-center audit p. 439
Andrew Louis, Manish Kumar Tiwary, Praveen Sharma, Abhijit Sukumaran Nair
DOI:10.4103/aer.aer_6_22  
Introduction: Regional anesthesia (RA), i.e., spinal or epidural anesthesia when performed for lower segment cesarean section (LSCS) provides excellent surgical conditions, avoiding manipulation of the maternal airway, maternal satisfaction, and good postoperative analgesia. However, in situations like fetal distress (fetal heart rate abnormalities), obstetric indications (abruption of placenta, antenatal placental bleeding, cord prolapse), maternal refusal for RA, contraindications to neuraxial anesthesia (anticoagulation, coagulopathy), and at times failed RA general anesthesia (GA) is administered. Several studies have demonstrated greater mortality and morbidity when LSCS is done under GA when compared to neuraxial block. Methods: After necessary approval, we retrospectively reviewed data over a period of 1 year (January 1, 2020–December 31, 2020) of LSCS under GA versus RA. The aim was to compare immediate postoperative complications, postoperative pulmonary complications up to 4 weeks from the time of elective and emergency LSCS under either RA or GA. Results: Of the 753 patients who underwent LSCS in one calendar year, there were 272 (36.12%) elective and 481 (63.87%) emergency LSCS. The number of elective LSCS under neuraxial block was 219 (29.09%) and under GA were 53 (7.03%). Emergency LSCS done under neuraxial block were 268 (35.59%) and under GA were 213 (28.28%). There were no adverse pulmonary complications at the end of 4 weeks in either group. Conclusion: RA provides maternal satisfaction and excellent perioperative analgesia in LSCS. Safe GA can be achieved with proper airway planning, if case is attended by at least two anesthesiologist with adequate preoperative fasting, and postoperative monitoring.
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A comparative study of effect of 0.25% levobupivacaine with dexmedetomidine versus 0.25% levobupivacaine in ultrasound-guided supraclavicular brachial plexus block p. 443
Lakshmi S Iyer, Shreyas S Bhat, HN Nethra, HN Vijayakumar, K Sudheesh, Ramachandriah
DOI:10.4103/aer.aer_145_21  
Context: Dexmedetomidine, an α2-agonist, has been studied widely as an adjuvant to local anesthetics in regional anesthesia techniques to enhance the quality and duration of analgesia (DOA). It was hypothesized that addition of dexmedetomidine 0.5 ug.kg‒1 to levobupivacaine would prolong the DOA. Aims: We aimed to evaluate the efficacy of dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block with respect to onset and duration of sensory and motor blockade, and duration of analgesia. Settings and Design: This was a prospective randomized double-blind study carried out at a tertiary hospital attached to medical college. Subjects and Methods: Sixty American Society of Anesthesiologists PS Class I and II patients aged between 18 and 60 years of either sex, undergoing elective upper-limb surgery lasting more than 30 min, were included in the study. They were randomly divided into two groups of thirty each to receive ultrasound-guided supraclavicular brachial plexus block. Group L was given nerve block with 20 mL of 0.25% levobupivacaine and 1 mL saline, and Group D received 20 mL of 0.25% levobupivacaine with 0.5 ug.kg‒1 of dexmedetomidine (diluted to volume of 1 mL). Onset time and duration of sensory and motor blockade, time to first rescue analgesia, and hemodynamic parameters were recorded. Statistical Analysis Used: Chi-square test for qualitative variables and Student's unpaired "t" test for continuous variables were used for statistical analysis. Results: The onset of sensory and motor blockade was 6.51 ± 0.77 min and 10.71 ± 0.34 min in Group D and 9.9 ± 0.45 and 15.93 ± 1.92 min in Group L, respectively (P < 0.005). DOA was 9.53 ± 0.29 h in Group D and 3.89 ± 0.30 h in Group L (P < 0.001). The duration of sensory and motor block was 9.14 ± 0.19 h and 8.55 ± 0.31 h in Group D and 6.15 ± 3.02 and 5.61 ± 2.98 h in Group L, respectively (P < 0.005). No adverse effects were observed in either of the groups. Conclusions: Addition of 0.5 ug.kg‒1 of dexmedetomidine to 20 mL 0.25% levobupivacaine in ultrasound guided (USG)-guided supraclavicular brachial plexus block shortens the onset time of sensory and motor blockade and prolongs duration of sensory and motor block and DOA.
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Comparison of postoperative pain and analgesia requirement among diabetic and nondiabetic patients undergoing lower limb fracture surgery – A prospective observational study p. 448
KB Sravani, Sapna Annaji Nikhar, Narmada Padhy, Padmaja Durga, Gopinath Ramachandran
DOI:10.4103/aer.aer_157_21  
Background: Diabetic patients usually experience neuropathic pain and have a decreased response to opioids. Fractures are acute conditions and as such, they are very painful. No data is available related to fracture and postoperative pain in diabetics. Aim: This study was conducted to evaluate postoperative pain and analgesics requirement among diabetic and nondiabetic patients undergoing lower limb fracture surgery and the effect of glycosylated hemoglobin (HbA1c) on the postoperative pain. Setting and Design: This was a prospective observational study, conducted on 80 patients comprising of nondiabetic and diabetic, scheduled for elective lower limb fracture surgery under spinal anesthesia. Materials and Methods: HbA1c was done in all the patients who were included in the study. Postoperative Visual Analog Scale (VAS) and analgesic consumption were assessed by an anesthesiologist blinded to the diabetic or nondiabetic status of the patients. VAS was assessed every 2nd hourly, for 24 h and rescue analgesia was given if the VAS was ≥4 and record was maintained. Sedation scores and adverse effects were also recorded postoperatively. Statistical Analysis: The Chi-square test was used for the analysis of categorical variables and Student's t-test was used for continuous variables. Results: Diabetic group of patients had a significantly high VAS score with P ≤ 0.05. Rescue analgesics requirement was significantly different in two groups with diabetic patients requiring more supplementation of analgesia with a P = 0.025. The overall patient satisfaction was lesser in diabetic group (P = 0.004). There was statistically significant correlation between glycosylated hemoglobin and VAS at 2nd, 16th, 18th, 20th, 22nd, and 24th h. Conclusion: Postoperative pain and analgesic requirement was significantly higher in diabetic patients with lower limb fracture. Glycosylated hemoglobin had good correlation with higher VAS.
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CASE REPORTS Top

Anesthetic management in a case of MURCS syndrome p. 454
JR Rekha, Poonam Arora, Rajnish Kumar Arora, Monica Arora
DOI:10.4103/aer.aer_137_21  
MURCS syndrome is a more severe form of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, an acronym meaning aplasia/hypoplasia of Müllerian ducts (MU), congenital renal agenesis/ectopia (R), and cervical somite dysplasia (CS). A common presentation is primary amenorrhea in adolescent females. An anesthetist must consider the benefits and limitations of both regional and general anesthesia for these patients based on site of surgery and severity of malformations. We report successful anesthetic management of a 21-year-old female with MURCS syndrome scheduled for a creation of neovagina under spinal anesthesia using ultrasound guidance.
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Myasthenia gravis and COVID-19 – A clinical checkmate p. 457
Vijayalakshmi Sivapurapu, Pratheeba Natarajan, Ravindra Raghuveera Bhat, R Remadevi
DOI:10.4103/aer.aer_129_21  
Myasthenia gravis (MG) patients with coronavirus disease (COVID-19) pose a unique challenge for intensive care management. Higher risk of infection is observed in patients with MG due to the immunosuppressant medications they are prescribed. The underlying component of respiratory muscle weakness predisposes these patients to experience a more severe form of illness. In the case of diagnosis of COVID-19 in MG patients, judicious continuation of immunosuppressants, avoiding drugs that worsen MG along with the continuation of cholinesterase inhibitors is prudent. Early diagnosis in cases with high-index of suspicion, extra precautions, COVID-appropriate behavior, and early immunization is paramount for the health of MG patients during this pandemic.
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Emergency thoracotomy for congenital lobar emphysema – Anesthesiology concerns p. 460
Muthukumar Rajagopalan
DOI:10.4103/aer.aer_14_22  
Congenital lobar emphysema (CLE) is a rare malformation of lungs, which presents usually in neonatal period or infancy as acute hypoxia and respiratory distress. It is characterized by the lobar over aeration of the normal lung followed by respiratory distress due to partial obstruction of bronchus by ball-valve effect. We would like to present the case of a 3-month-old female preterm (31 weeks) baby who presented to our neonatal intensive care unit with respiratory distress for 1 day. The baby was diagnosed with left-sided CLE having severe mediastinal shift to the right side and a dextroposition heart. Her venous blood gas showed PaCO2 of 70 mmHg and SpO2 of 70% with 15 L high-flow nasal oxygen. We would like to highlight the anesthesia techniques of airway management and ventilation during the critical period of induction till thoracotomy and exteriorizing the emphysematous lobe.
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