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   Table of Contents - Current issue
July-December 2022
Volume 1 | Issue 2
Page Nos. 53-102

Online since Friday, December 2, 2022

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Revisiting pseudocholinesterase deficiency: The conundrum of succinylcholine use p. 53
Bharti Wadhwa, Kirti N Saxena
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Endotracheal tube cuff pressure changes with pneumoperitoneum and steep head down position in patients undergoing robotic urogynecological surgeries – A prospective observational study p. 56
Nagarapu Divya Meghana, Manoj Kumar Bharadwaj, Nitesh Goel, Seema Shukla
Background: The abdominal insufflation in the laparoscopic surgery has been reported to result in an increase in endotracheal tube (ETT) cuff pressure (Pcuff). However, the effect of Trendelenburg, lithotomy and pneumoperitoneum on the ETT Pcuff in robotic urogynaecology surgeries are not well established. Aim: Analyse the changes in ETT cuff pressure during robotic urognaecological surgery. Primary Objective: 1. The changes in ETT cuff pressure after creation of pneumoperitoneum. 2. The changes in ETT cuff pressure after change in position of the patient. Secondary Objectives: 1. To correlate the changes in ETT cuff pressure with airway pressure. 2. To correlate the changes in ETT cuff pressure with BMI. Methods: Sixty patients undergoing elective robotic urogynaecology surgeries were enrolled in the study. ETT Pcuff during different time points was measured and analysed. Also, the change in ETT Pcuff was correlated with the airway pressure (Paw). Results: The difference in ETT Pcuff, before and after lithotomy, pneumoperitoneum and the Trendelenburg position were 1.1 ± 0.7 cmH2O, 4.6 ± 1.0 cmH2O and 1.8 ± 0.8 cmH2O respectively and were statistically significant (probability: P < 0.05). Results obtained after reversing patient position from Trendelenburg position to supine, abdominal deflation and from lithotomy to supine respectively were -2.2 ± 1.4 cmH2O, -4.1 ± 1.0 cmH2O and -0.4 ± 0.8 cmH2O respectively (P < 0.05). The Karl Pearson coefficient of correlation (r) between Pcuff and Paw after lithotomy, pneumoperitoneum, and Trendelenburg position respectively were 0.606, 0.661 and 0.309. Freidman's nonparametric repeated-measures analysis of variance (ANOVA) was used to analyze differences between related Pcuff values over different time points. Overall P value was significant (P < 0.00001). Conclusion: An increase in ETT cuff pressure is seen in robotic laparoscopic surgeries after abdominal insufflation, Trendelenburg position and lithotomy position.
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Addition of dexamethasone to levobupivacaine in the ultrasound-guided bilateral subcostal transversus abdominis plane block improves the quality of postoperative analgesia after laparoscopic cholecystectomy: A prospective randomized clinical study p. 62
Jaya Choudhary, Anshika Agarwal, Priyanka Bhojwani
Background and Aims: Addition of dexamethasone to levobupivacaine in the peripheral nerve block provides improved pain scores, prolonged pain relief, and reduced postoperative opioid requirement. However, the evidence regarding its efficacy in the transversus abdominis plane (TAP) block is limited. Therefore, we conducted this study to evaluate the potential benefits of combining dexamethasone with levobupivacaine in the subcostal TAP block during the first 24 h after laparoscopic cholecystectomy. Materials and Methods: Seventy-six patients were enrolled in the study and divided into two groups to receive 20 ml of 0.25% levobupivacaine with 1 ml NS bilaterally (Group LS) or 20 ml of 0.25% levobupivacaine with 4 mg dexamethasone bilaterally (Group LD). Each patient received a standard multimodal analgesic regimen. Pain scores were recorded at rest and during coughing at 0, 2, 4, 6, 12, and 24 h postoperatively. Total opioid consumption and associated complications were recorded during the first 24 h. Results: Pain scores were lower in the LD group as compared to the LS group at all time points. Reduction in Numeric Rating Scale values was statistically significant at 4, 6, and 12 h both at rest and during coughing. Estimated P values on coughing at these time points were 0.000, 0.001, and 0.017, respectively. Postoperative opioid requirement was also significantly reduced between 2 and 24 h (P = 0.007). We did not record any complications in our study population. Conclusion: The combination of dexamethasone and levobupivacaine in the subcostal TAP block significantly improves the efficacy of multimodal analgesic regimen during the first 24 h after laparoscopic cholecystectomy.
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Comparison of block characteristics in continuous spinal anesthesia and continuous epidural anesthesia for lower limb orthopedic surgeries: An interventional study p. 68
Pratibha Jain Shah, Ketan Shah, Nikita Vipul, Pratiksha Agrawal
Background: Continuous epidural anesthesia (CEA) is commonly used in routine practice even though it needs a higher dose of local anesthetics (LA) and is sometimes associated with a patchy or unilateral block. Despite advantages, continuous spinal anesthesia (CSA) is underutilized because of concern related to infection and postdural puncture headache. Our aim was to compare the block characteristics and hemodynamic changes following CSA and CEA in lower limb orthopedic surgeries. Materials and Methods: After approval from the Institutional Scientific and Ethics Committee and Registration with (Clinical Trials Registry of India/2021/02/031575), a prospective, double-blind, randomized study was conducted in 144 patients, American Society of Anesthesiologists I-II, aged 18–65 years, scheduled for lower limb orthopedic surgeries. Patients were randomly divided into two groups according to anesthesia technique used (n = 72), i.e., Group CSA and Group CEA. Block characteristics, hemodynamic variables, intraoperative LA requirement, and complications were recorded. Results: Demographic and surgical data, grade of sensory and motor blockade, and incidence of complications were comparable in both the groups. Induction time was significantly shorter in CSA (8.14 ± 0.88 min vs. 15.75 ± 3.29 min, P < 0.0001). Performance time (5.31 ± 0.92 min vs. 4.92 ± 1 min; P = 0.008), duration of blockade (68.3 ± 4.23 min vs. 65.54 ± 4 min; P < 0.0001), and analgesia (230.48 ± 40.76 min vs. 222.86 ± 39.79 min; P = 0.024) were significantly longer in CSA. A significant fall in diastolic blood pressure and mean arterial pressure occurred in CEA. LA requirement was significantly lower in CSA (11.62 ± 2.5 mg vs. 65.35 ± 7.71 mg; P < 0.00001). Conclusions: Considering shorter induction time, prolonged sensory blockade, and analgesia with greater hemodynamic stability, CSA could be preferred over CEA for lower limb orthopedic surgeries.
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Demystifying a hassle in obstetric anaesthesia: A case report p. 74
Prateek Upadhyay, Sahil Garg
We report a case of primigravida posted for emergency lower segment cesarean section (LSCS). She had to be administered general anesthesia due to failure of the spinal blockade. While the intraoperative period remained uneventful, the patient could not be extubated after the procedure due to poor respiratory efforts and motor power. She was shifted to the intensive care unit where, after several hours, she could be extubated. On follow-up and further workup, the pseudocholinesterase enzyme was found to be deficient in the patient's blood reports. This case report aims to highlight the importance of considering the deficiency of pseudocholinesterase while managing obstetric patients while suggesting deliberations and relevant management.
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Intraoperative electrocardiogram monitoring induced bispectral index interference – A misleading heart–mind connection p. 77
Akhilesh Pahade, Ashita Mowar, Vishwadeep Singh, Urvashi Kharayat
Bi-spectral index (BIS) is a common but an important tool in anaesthesiologist's armamentarium across the world which helps to assess the level of sedation and effect of hypnotic drugs. A value between 40-60 in BIS is considered as optimal level of sedation during general anaesthesia. However, numerous factors can interfere with accurate BIS value. Electrocardiogram (ECG), has been mentioned as a factor resulting into fallacious BIS values in the literature, which may have significant implications on appropriate dosage of hypnotic drugs. ECG inferences are usually filtered by proprietary algorithm of BIS, and few cases have been documented wherein ECG interference resulted in fallacious BIS readings. Our case reports a less frequently reported interference in BIS values by ECG, which resulted into lower BIS values.
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Aortoiliac occlusive disease with situs inversus totalis: Anesthetic management of a rare association p. 80
Charu Sharma, Ragi Jain, Ankit Jain, Arindam Roy
Situs inversus totalis (SIT) is a rare, autosomal recessive congenital anomaly, in which the major visceral organs are reversed from their normal position. Their unique anatomy and association with various congenital anomalies may present various challenges during anesthetic management. We report a case of SIT with aortoiliac occlusive diseases who underwent axillobifemoral bypass grafting surgery. We aim to discuss the anesthetic considerations and implications associated with such patients.
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Incessant menace of airway obstruction with flexometallic endotracheal tube p. 83
Sukhyanti Kerai, Upasana Singh, Vineet Manchanda, Kirti N Saxena
Flexometallic endotracheal tubes (ETT) are preferred over standard Polyvinyl Chloride ETTs in cases where intraoperatively there is limited airway access to the anaesthesiologist. As they are comparatively expensive, it is common practice to reuse them after sterilization. Here we describe a case where a flexometallic ETT was used in a case of tonsillectomy after a through visual inspection to rule out any structural deformity. Intraoperatively ETT itself led to airway obstruction mimicking bronchospasm.
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Anesthetic management of carotid artery pseudoaneurysm repair in a healthy weight lifter: A rare case report p. 86
Sahil Garg, Lekshmi V Nair, Jasveer Singh, K Indumathi
We report a 37-year-old healthy male who developed left-sided neck pain following rigorous weight training. The pain was followed by development of a neck lump which was diagnosed as a left carotid bulb pseudoaneurysm with a partial thrombus in the lumen. The patient successfully underwent rent repair of the left common carotid artery wall at the level of its bifurcation and removal of thrombus under general anesthesia with complete recovery.
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Spinal medulloblastoma in pregnancy: A pandora of challenges for the anesthesiologist p. 89
Sharmishtha Pathak, Sanjay Agrawal, Konish Biswas
Tumors of the spinal column, meninges, nerve roots, or the cord parenchyma itself may compress and damage the spinal cord resulting in neural deficits. The presence of spinal cord tumor itself in pregnancy is a rare occurrence. Rapidly progressive neurological involvement due to compression should be considered for immediate decompression. The specific positioning for surgery and inaccessibility to the airway during surgery makes all spinal surgeries technically challenging for the anesthesiologist. The presence of pregnancy along with this disease further complicates patient management. We present the case of a 24-week-old pregnant female who reported to emergency with decreased sensation in her lower limbs and urinary retention. She was operated previously for cranial medulloblastoma and was on regular follow-up. Magnetic resonance imaging spine revealed multiple intradural extramedullary masses at the D3-4, D8-9, and D10-D11 vertebral levels. Considering her pregnancy and increased risk of surgery during this condition, only the mass causing her symptoms was decided to be operated upon (D10-11). The surgery was done in the prone position, during which, fetal well-being was insured by the obstetric team using transabdominal ultrasonography. Careful padding of pressure points was done; frames on the Allen table were placed in a manner to avoid any pressure on the abdomen during the surgery. The surgery was uneventful, and the patient was successfully reversed and extubated. Fetal heart rate was monitored perioperatively at regular intervals, and ultrasonographic assessment was done by the obstetric team once the patient was extubated. This case highlights the requirement of training the professionals for tackling nonobstetric surgery in a pregnant patient. The increased awareness and education in society regarding perioperative care issues will bring forth new challenges and thus we need to be more prepared for handling such cases.
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Yellow-tinged cerebrospinal fluid: Is it safe to proceed with subarachnoid block? p. 92
Evelyn Eliza Minz, Geetanjali Tolia Chilkoti, Nikita Mundael, Anusha De, Janaki Nandnan
Isolated subarachanoid hemorrhage (SAH) could be one of the few causes of xanthochromia or yellow coloured cerebrospinal fluid (CSF). An incidental finding of yellow coloured CSF poses a dilemma to the anaesthesiologist in proceeding with the subarachnoid block (SAB) The present case report discusses the causes and implication of this incidental finding and highlights upon the evidence in literature in this context.
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A challenging case of placenta accreta spectrum with known seizure disorder planned for cesarean hysterectomy p. 94
Rashmi Singh Kuntia, Michell Gulabani, Swati Bharti, Medha Mohta
A 28-year-old female with amenorrhea of 25 weeks G2P1L1, diagnosed case of placenta previa and placenta accreta with previous lower-segment cesarean section and ventriculomegaly in the fetus was planned for hysterotomy ± hysterectomy. Optimization of anticipated bleeding during surgical procedure was done with prior uterine artery embolization and a multidisciplinary care team for the management of the placenta accreta spectrum keeping general anesthesia as the choice. The role of strictly monitoring blood pressure invasively is critical in ensuring hemodynamic stability. In addition, quick access to a blood bank capable of employing massive transfusion protocols is essential. This approach allowed the maintenance of stable hemodynamics with an uneventful surgical course.
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Anesthetic considerations in a child with Rubinstein–Taybi syndrome p. 97
Ruchi Kumari, Arshi Agrawal, Anshul Goyal
Rubinstein − Taybi Syndrome (RTS) is a rare genetic syndrome caused by a mutation in the cAMP response element binding protein gene or EP300 gene or as the result of microdeletion from short (p) arm of chromosome 16. The diagnosis of RTS is made primarily through physical appearance. It may be associated with the disorders of multiple organ systems. Anesthetic management might be challenging in RTS due to various factors. A thorough preoperative evaluation and careful preparation for difficult airways before anesthesia is mandatory for successful case management. Here, we report the case of a 9-year-old child with RTS posted for cystoscopy.
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Anesthetic management of a patient with erythema multiforme for emergency appendectomy p. 100
Mousumi Saha, Ankur Mehra, Kirti N Saxena, Bharti Wadhwa
Erythema multiforme (EM) is an acute, immune-mediated, mucocutaneous disease, caused by several factors such as infections, drugs, malignancy, autoimmune disease, radiation, and immunization. The anesthetic concerns in these patients include possibility of difficult airway, intraoperative steroid supplementation, avoidance of precipitating drugs, intraoperative arrhythmias, perioperative skin, and eye care. A 13-year-old boy, a known case of EM with a history of recurrent ocular herpes and impaired vision along with fibrosis at the bilateral angle of the mouth underwent emergency open appendectomy under spinal anesthesia. Spinal anesthesia with injection hyperbaric bupivacaine (0.5%) is a safe and suitable alternative in a patient with EM with recurrent herpes simplex virus.
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