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   Table of Contents - Current issue
January-June 2023
Volume 2 | Issue 1
Page Nos. 1-66

Online since Thursday, May 25, 2023

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Norepinephrine – Can it replace phenylephrine as the vasopressor of choice in obstetric anesthesia? p. 1
Medha Mohta
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The impact of analgesics and anesthetics on cancer outcomes: Exploring the evidence p. 5
Lalit Gupta, Kirti N Saxena
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Antibiotic challenges and review of appropriate uses in intensive care unit p. 7
Lalit Gupta, Kirti N Saxena, Ruchi Goyal
Antibiotic use in the intensive care unit (ICU) presents unique challenges due to the high acuity and complexity of critically ill patients. Inappropriate use of antibiotics can contribute to the emergence of multidrug-resistant organisms, while underuse can lead to poor outcomes. Antimicrobial stewardship programs can assist in optimizing antibiotic use in the ICU, but implementation can be challenging. One approach to improving appropriate antibiotic use in the ICU is through prolonged infusions, which can be beneficial in populations with altered pharmacokinetics. Other strategies include de-escalation and targeted therapy based on culture results. This review highlights the current literature on antibiotic use in the ICU, including the challenges and opportunities for effective antimicrobial stewardship. Key considerations for appropriate use of antibiotics in the ICU include patient factors, pathogen susceptibility, and local resistance patterns. Ongoing efforts are needed to improve antibiotic prescribing practices in the ICU, with the goal of achieving optimal patient outcomes while minimizing the risk of antibiotic resistance.
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A prospective, randomized, interventional, comparative study between dexmedetomidine and propofol infusion for monitored anesthesia care during internal jugular vein chemoport insertion p. 18
Shahbaz Alam, Nitesh Goel, Nikhil Bhasin, Shikha Modi, Charanjeet Kaur
Background: Chemotherapy through peripheral intravenous cannula causes severe thrombophlebitis. Chemoport is a best and favorable alternative for the same. It is done under local infiltration along with monitored anesthesia care with sedation. However, due to the lack of any fixed regimen, overt to under sedation is more common. To maintain an effective, consistent, and continuous level of sedation, we compared dexmedetomidine and propofol infusion in patients requiring monitored anesthesia care (MAC) for chemoport insertion. Methodology: Fifty patients posted for internal jugular vein chemoport insertion were randomly distributed into two groups: the propofol group and dexmedetomidine group. In Group P-injection, propofol infusion started at 125 μg/kg/min. Once observer's OAAS score 3 was achieved, propofol infusion was reduced to 25–75 μg/kg/min, whereas in Group D-Injection, dexmedetomidine bolus infusion was started at 1 μg/kg for 10 min and followed by 0.3–0.7 μg/kg/h and titrated to an OAAS score of 3. Results: OAAS score 3 was achieved significantly earlier in the propofol group as compared to the dexmedetomidine group (3.12 ± 1.7 vs. 8.04 ± 2.07, respectively). We were also able to maintain the desired sedation level throughout the procedure. Satisfaction scores in both the groups were comparable and patients in both the groups were hemodynamically stable throughout the procedure. Conclusion: In the current study, we found that propofol infusion was better regarding early onset and maintenance of OAAS score 3 with no requirement of rescue sedation during the procedure. The hemodynamic parameters and satisfaction scores were comparable in both groups. Hence, we suggest the use of injection propofol infusion for MAC under sedation in a patient requiring internal jugular vein chemoport insertion when compared to dexmedetomidine.
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Dexamethasone as an adjuvant to local anesthetic mixture in brachial plexus block: A prospective randomized double-blind controlled trial p. 24
Sahil Garg, Hersimran Kaur, Mandeep Kaur, Manvi Garg
Introduction: Peripheral neural blockade is now a well-accepted component of comprehensive anesthetic care. Many adjuvants such as dexmedetomidine, clonidine, opioids, ketamine, and midazolam and corticosteroids have been used; however, still the search for ideal adjuvant is in process. The purpose of this study was to investigate whether addition of 8 mg dexamethasone to local anesthetic solution for brachial plexus block would prolong the period of postoperative analgesia. Materials and Methods: This was a prospective double-blind randomized controlled trial. Forty patients between the age of 20 and 65 years, of either sex of the American Society of Anesthesiologists Grade I-III, who were undergoing upper limb surgery, were selected to study the quality of brachial plexus block and duration of postoperative analgesia produced by addition of dexamethasone to local anesthetic solution versus plain local anesthetic solution in the infraclavicular brachial plexus block. Results: Demographic parameters such as age, weight, height, and body mass index were comparable between two groups with P > 0.05. We also observed that onset of sensory and motor block was earlier in Group I, and duration of motor and sensory block was more in Group I. There was a less requirement of postoperative analgesics. Furthermore, the incidence of postoperative complications was less in Group I compared to Group II. Conclusion: We conclude that addition of dexamethasone to local anesthetic solution for brachial plexus block sets the sensory block early, increases the duration of sensory block without any side effect, provides improved patient comfort, effective pain relief, and decreases the requirement of postoperative supplementary analgesic.
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Preoperative meal practices: An observational study p. 29
Prerana Nirav Shah, Azho Kezo
Background: In this era of enhanced recovery after surgery (ERAS), prolonged fasting has been discouraged. This study is an appraisal on the fasting practice in a tertiary hospital in India. Materials and Methods: Over a period of 1 year, 118 patients were taken into the study. The attending anesthesiologist noted the time of their last meal and the type of meal that was taken on the morning of surgery. Data were analyzed using STATA™ and Microsoft Excel version 2016. Results: Our study found that the fasting period for large and light meals was more and for clear fluids was 10.28 ± 3.63. For light meals and clear fluids, the fasting period was more than recommended. Conclusion: Prolonged preoperative fasting is still practiced despite existing guidelines. Prolonged preoperative fasting is still prevalent in today's era of ERAS. Education on the existing fasting guidelines and its implementation is needed.
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Comparison of intubating conditions and complications of nasotracheal intubation using Macintosh laryngoscope with or without bougie: A randomized controlled trial p. 32
Ritu Singh, Babita Ramdev, Sahil Garg, Hersimran Kaur
Background and Aim: The purpose of this study was to compare the efficiency of nasotracheal intubation (NTI) using a Macintosh laryngoscope with bougie to a Macintosh laryngoscope without bougie on-time of intubation, the incidence of postintubation bleeding, hemodynamic stress response, and postoperative complications. Materials and Methods: The present randomized blind research was carried out on 120 patients undergoing elective surgeries under general anesthesia. The study population was separated into two groups, each with 60 patients. NTI was performed with bougie using a Macintosh laryngoscope in Group 1 (n = 60) and without the use of a bougie in Group 2 (n = 60) using a Macintosh laryngoscope. Results: In Group 1, 47 (78.33%) patients were successfully intubated in the first attempt, and 13 (21.67%) patients were successfully intubated in the second attempt, whereas in Group 2, 38 (63.33%) patients were intubated in the first attempt and 22 (36.67%) patients required second attempt, with a statistically significant difference. In Group 1, the mean time required for intubation was 31.10 ± 2.36 s, and in Group 2, it took 43.08 ± 2.17 s, P value was statistically significant. In Group 1, the number of patients with a sore throat was 5 (8.33%), with dental injury was 4 (6.67%), and with nasal mucosa laceration was 3 (5%). In Group 2, the number of patients with sore throat was 6 (10%), with dental injury was 6 (10%), and with nasal mucosa, laceration were 5 (8.33%). The difference was not significant in both the groups. Hemodynamic variables were comparable among the groups. Conclusion: Bougie-guided NTI resulted in more successful intubation in terms of less number of attempts, less time taken for intubation, and less postintubation bleeding as compared to NTI without bougie.
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Effects of prophylactic bolus of norepinephrine versus phenylephrine on maternal and fetal outcome during caesarean section under subarachnoid block: A randomized study p. 37
Anjeleena Kumar Gupta, Shweta Sinha, Anjali Gera, Ashwin Marwaha, Jayashree Sood
Background: Vasopressors are the mainstay of treatment of subarachnoid block-induced hypotension (SAIH). The literature is ambiguous regarding the choice of vasopressor, the strategy of administration, and their potency ratio for proper comparison. A prophylactic bolus dosing is the preferred mode of administration for obstetric anesthesia. Thus, we undertook a study to assess the efficacy of norepinephrine (NE) and phenylephrine (PE) in preventing SAIH and compare their effects on maternal and fetal outcomes. Materials and Methods: A randomized, double-blind clinical study was conducted on 240 parturients planned for elective cesarean section under subarachnoid block (SAB). They were allocated to receive a prophylactic bolus dose of either NE 4 μg or PE 50 μg immediately after the SAB. The incidence of maternal hypotension (primary outcome); heart rate (HR), reactive hypertension, intraoperative nausea or vomiting, neonatal APGAR score, umbilical umblical cord blood pH, and the need for active neonatal resuscitation (secondary outcomes) was compared between the groups. Results: The incidence of hypotension was comparable between the groups (P = 0.42). The mean HR was significantly higher in the NE group at 2 min (83.9 ± 9.2 vs. 80.6 ± 9.3 bpm, P = 0.005), 3 min (84.4 ± 8.8 vs. 79.3 ± 11.1 bpm, P < 0.001) and 4 min (85.0 ± 9.9 vs. 79.6 ± 12.6 bpm, P < 0.001). Rest of the maternal and fetal outcomes were similar in both the groups. Conclusion: Based on the relative potency ratio of 12.5, the effect of an intermittent prophylactic bolus dose of NE is comparable to that of PE in preventing SAIH.
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Regional anesthesia for a patient with extensive von Recklinghausen's disease p. 44
Hersimran Kaur, Sahil Garg, Ritu Gupta, Tamanna Yadav, Seema Prasad
We report the case of a 60-year-old male posted for surgery on the left inner thigh mass with extensive neurofibromas covering the whole body. The patient was administered a subarachnoid block at L3-L4 level for excision of the mass on the left inner thigh. There were no postoperative anesthetic complications. This case report aims to highlight the importance of regional anesthesia in patients with neurofibromatosis and its anesthetic implications.
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Pressure sore of malar prominence on horseshoe headrest: Prevention of one complication becomes road for another? p. 47
Sharmishtha Pathak, Sanjay Agrawal, Manav Sharma, Roshan Andleeb, Konish Biswas
Pressure sores over bony prominences of heel or sacrum due to positioning are commonly reported, however, the same occurring over malar prominences are rarely seen. We report a case of pressure sore over malar prominence in a patient undergoing surgery in the prone position on horseshoe headrest. These injuries pose a risk of infection, need for surgical intervention, increasing woes, and health cost burden of the patient. Patient care team should aim to prevent such complications by appropriate support device selection, adequate padding, and frequent position changes.
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Ultralow-dose spinal anesthesia in a short stature emergency cesarean section p. 50
Chanchal Nigam, Michell Gulabani, Asha Tyagi, Meghna Choudhary
Anesthesia for parturients with short stature is envoked with unique challenges for the anesthesiologist. Difficulties with airway management, owing to the anatomical and physiological changes in pregnancy, risk of acid aspiration, and difficult regional anesthesia with the possible risk of failure/suboptimal effect, are well-documented. We describe the anesthetic management of a 20-year-old parturient of short stature with a height of 110.5 cm undergoing emergency cesarean section. A single-shot subarachnoid block with 4 mg intrathecal bupivacaine and adjuvant fentanyl 10 μg proved straightforward and reliable with no requirement of vasopressors.
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Anisocoria under anesthesia: Portentous sign or picayune? p. 53
Sukhyanti Kerai, Surbhi Goswami, Prachi Gaba, Garima Bhatt
Anisocoria observed under anaesthesia is an alarming sign for anaesthesiologist and is suggestive of possible of neurological involvement due to raised intracranial pressure, intracranial hemorrhage, or space occupying lesions. We report the occurrence of new onset anisocoria in a patient undergoing video assisted thoracoscopic surgery under anaesthesia. The various etiologies of anisocoria under anaesthesia and their implication have been discussed.
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Anesthetic concerns during rigid bronchoscopy for the management of a friable vegetative foreign body in an infant p. 56
Diksha Gaur, Geetanjali T Chilkoti, Zainab Ahmad, Steffi Dua, Nikhil Gaur, Nandita Kanwar, Ashok Kumar Saxena
Tracheobronchial foreign-body (FB) aspiration is a commonly encountered entity in the pediatric population. FB aspiration (FBA) is an emergency condition requiring early recognition and management, and the primary treatment is the surgical removal of FB under anesthesia. Herein, we report a unique case of an infant developing prolonged severe respiratory distress due to obstruction following a vegetative FBA and shall also discuss the related anesthetic concerns.
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Amitraz poisoning – A rare and uncommon case of poisoning and its management p. 59
Vikash Bansal, Ridhima Sharma, Ripon Choudhary
A 25-year-old male presented to the peripheral hospital with an alleged history of ingestion of amitraz toxin 12.5% (approximately 150 mL), and presented with complaints of nausea, vomiting, abdominal pain, and weakness. On examination, he was conscious but disoriented and agitated, oxygen saturation (SpO2) was 89%–90% on room air, pulse rate was 40/min, blood pressure (BP) was 110/70 mmHg, and bilateral (B/L) crepitations were present on auscultation. Emergency treatment included – intravenous(IV) fluid, atropine 0.6 mg IV, and gastric lavage. Oxygen was given through an oxygen mask with a reservoir bag at 10 L/min. After some time, the patient's Glasgow Coma Scale (GCS) started deteriorating, and arterial blood gas (ABG) analysis revealed severe acidosis with pH of 7.109, pCO2 – 73, and HCO3 – 23.1, and immediately, the patient was transferred to a higher center given falling GCS, decreased saturation, and ABG finding. On presentation in the emergency department in our tertiary care center, the patient was unconscious, SpO2 was 69% on oxygen nonrebreathing mask – NRBM Mask at 15 L, BP was 128/78 mmHg, pulse rate was 104/min, and B/L crepitations were present on auscultation. The patient was immediately intubated in casualty and shifted to the intensive care unit for further management. Amitraz is a triazapentadiene, 1,5 di (2,4 dimethylphenyl) 3 methyl 1,3,5 triaza penta 1,4 diene, a formamidine pesticide, α2 adrenergic agonist in the central nervous system belongs to the amidine chemical family. The systemic effect of amitraz toxin is due to the activation of the pure α2-adrenergic agonist. It is a rare kind of poisoning in humans, and there exists a paucity of literature on the management of the aforementioned poisoning. Only a limited number of case reports of human intoxication have been published and most of them are of accidental ingestion by children. Due to insubstantial data on its management, this case report will be advantageous for practitioners working in emergency and intensive care departments.
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Spinal anesthesia for a neonate with complex congenital heart disease for lower limb surgery p. 62
Sunil Rajan, Niranjan Kumar Sasikumar, Dimple Elina Thomas, Jerry Paul, Lakshmi Kumar
A neonate with complex congenital heart disease was referred for patent ductus arteriosus (PDA) stenting, who had an ulceration of the dorsum of the foot secondary to extravasation injury. Echo showed situs solitus, levocardia, atrioventricular concordance, double-outlet right ventricle, large inlet with conoventricular ventricular septal defect, bidirectional shunt, D-posed aorta, pulmonary atresia, confluent good-sized branch pulmonary arteries, left arch, no coarctation, and tortuous PDA arising from the base of arch supplying the branch pulmonary artery confluence. Three days later, PDA stenting was done. As limb ulceration progressed to cellulitis, he was posted for debridement and VAC application 6 days after PDA stenting. It was performed under subarachnoid block with 0.5% bupivacaine heavy 0.6 ml through L4-L5 interspace using a 24G needle. Intraoperatively, saturation and hemodynamic variables remained stable. Skin grafting was performed 3 days later under spinal anesthesia with an unremarkable intraoperative and postoperative period.
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Submental intubation in a patient with panfacial fracture for bilateral intermaxillary fixation and occlusion p. 65
Sunil Rajan, Jacob Mathew, Sherjin Dev S. Raveendran, Arjun Krishnadas, Syamprasad Padappayil
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