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   Table of Contents - Current issue
July-September 2020
Volume 14 | Issue 3
Page Nos. 295-422

Online since Saturday, May 30, 2020

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Saudi Anesthesia Society and COVID-19 outbreak Highly accessed article p. 295
Abdelazeem Eldawlatly, Ahmed Abdulmomen
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Does articaine, rather than prilocaine, increase the success rate of anaesthesia for extraction of maxillary teeth Highly accessed article p. 297
Giath Gazal
Objective: To compare the anesthetic performances of 3% prilocaine and 4% articaine when used for the extraction of the maxillary teeth. Materials and Methods: Ninety-five patients, aged between 16 and 70 years, were included in this study. Patients were divided into two groups. Group one received articaine 4% with 1:00.000 adrenaline. Group two received prilocaine with 3% felypressin (0.03 I.U. per ml). Onset time of anesthesia was objectively evaluated by using electronic pulp testing. Results: Eighty-five patients in this study had a successful local anesthetic followed by extraction within the study duration time (10 minutes). However, there were six patients with failure anesthesia (5 in prilocaine group and 1 in articaine group). By applying Person's Chi-square test (x2), there were no significant differences in the number of episodes of the anesthetic success between articaine and prilocaine groups at time intervals (P = 0.5). T-test showed that there have been no important variations within the mean onset time of anesthesia for articaine and prilocaine buccal infiltrations (P = 0.1). Conclusions: 3% Prilocaine with felypressin is as effective as 4% articaine with adrenaline when used for the extraction of maxillary teeth. Recommendations would be given to the dental practitioners to use prilocaine more frequently than articaine because of its low toxicity. Trial registration number: NCT04236115.
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Occlusion of multi-holed catheters used in continuous wound infusion in open gynecologic surgery: A pathological study p. 302
Keisuke Shimizu, Takuo Hoshi, Tatsuo Iijima
Background: Continuous wound infusion (CWI) with local anesthetics is useful as a method of pain management after abdominal surgery. However, there have been no studies regarding the obstruction of multi-holed catheters in this application. Methods: We conducted from July to November 2015. In the first portion of the study, we obtained 34 catheters used postoperatively with open gynecologic surgery, and evaluated the status of each hole in vitro. Each catheter had eight holes, and we investigated the number of open holes after the removal of the catheter. In the second portion of the study, we reviewed pathological specimens from four occluded catheters. Statistical analysis was performed using the statistical software MedCalc™ (MedCalc, Ostend, Belgium), and intergroup comparisons were made with independent sample t-test. Data are expressed by mean and standard deviation. Results: In each catheter, the number of remaining open holes was 0–7, and there were no catheters with all eight holes still open. Although the occlusion may be occurred after the end of infusion, 38.2% (n = 12) did not have any open holes remaining in our investigation. The composition of the emboli in the catheters was clotted blood and plasma, with a mass of fibrin and possibly some inflammation around the embolus. Conclusions: Occlusion of these catheters occurs at a very high rate, and the catheter embolus might be composed of clotted blood, plasma, and/or fibrin.
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Beyond selective spinal anesthesia: A flow pattern analysis of a hyperbaric dye solution injected in a lower-density fluid p. 307
Romualdo Del Buono, Giuseppe Pascarella, Fabio Costa, Felice E Agró
Introduction: Spinal anesthesia is a technique performed since more than a century and the introduction of hyperbaric anesthetics allowed the anesthesiologists to be more selective when using this technique. The aim of this study is to show the in vitro flow patterns of a hyperbaric dye solution through 27 G Quincke and Sprotte spinal needles, injected at different speeds, in a lower-density fluid. Methods: A simulator was made using a gummy-like sponge and a disposable plastic urine glass, filled with saline solution, which has a similar density to cerebrospinal fluid (CSF). A hyperbaric dye solution was composed by mixing 3 ml of plain methylene blue with 1 ml of glucose 33%. We used both 27 G Quincke and Sprotte spinal needles to perform a bevel up and a bevel down injection with both slow (15 s) and fast (4 s) injection speed of 0.5 mL hyperbaric dye solution. All the injections were performed using a preset syringe pump and recorded by a camera. Results: The least selectivity was observed after a bevel up-fast injection through the 27 G Sprotte needle, followed by both bevel up and down fast injections through the 27 G Quincke needle. On the contrary, the best selectivity was observed after a bevel down-slow injection through the 27 G Sprotte needle, followed by both bevel up and down slow injections through the 27 G Quincke needle. Conclusion: When a 27 G Sprotte needle is used to inject a hyperbaric solution in a lower-density fluid-like CSF, the spread depends on both the bevel direction and the injection speed.
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Timeliness of care and adverse event profile in children undergoing general anesthesia or sedation for MRI: An observational prospective cohort study p. 311
Suma Mary Thampi, Riya Jose, Poornima Kothandan, Meghna Jiwanmall, Ekta Rai
Background and Aims: Anaesthesia for children undergoing magnetic resonance imaging (MRI) ranges from moderate to deep sedation in order to facilitate uninterrupted completion of the scan. While various intravenous and inhalational techniques of anaesthesia have their own merits and demerits, there is a paucity of comparative literature between the two in children undergoing diagnostic MRI. Materials and Methods: This prospective observational cohort study was conducted at the Radiology suite of a 2800-bedded tertiary care hospital, wherein 107 unpremedicated children between the ages of 6 months to 15 years received either sedation with propofol infusion (Group GSP, n = 57) or inhalational anaesthesia with a laryngeal mask airway (Group GAL, n = 50). Primary outcome measures included time to induction and time to recovery. Secondary outcomes comprised the incidence of respiratory and non-respiratory adverse events in the two groups. Results: The median time to induction was significantly shorter in GSP than GAL [7.00 (IQR 5.0, 10.0) versus 10.00 minutes (IQR 8.8, 13.0), P < 0.001]; the incidence of desaturation [8 (16.0%) in GAL, 1 (1.8%) in GSP, P = 0.012], laryngospasm [11 (22.4%) in GAL, 1 (1.8%) in GSP, P = 0.001] and emergence delirium (5 (10%) in GAL, 0 in GSP, P = 0.047) were significantly greater in the GAL group. There was no difference in the time to emergence, nausea and vomiting or bradycardia between the two groups. Conclusion: Sedation with propofol infusion during paediatric MRI scan offers a short turnover time and favourable adverse event profile when compared to inhalational anaesthesia with an LMA.
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The VL3 videolaryngoscope for tracheal intubation in adults: A prospective pilot study p. 318
Giuseppe Pascarella, Stefano Caruso, Vincenzo Antinolfi, Fabio Costa, Domenico Sarubbi, Felice E Agrò
Background: Videolaryngoscopy (VLS) is recommended by international guidelines for the management of difficult airways. We conducted an observational prospective pilot study to assess the efficacy of the new VL3 videolaryngoscope for routine tracheal intubation (TI) in adults; in terms of success rate, the number of attempts, and maneuver duration, including both normal and difficult airways. Methods: This prospective observational pilot study comprised a sample of 56 adult patients undergoing elective general anesthesia. For each patient, we performed VLS by VL3 recording the following data: successful TI rate, number of attempts, time of intubation, time to glottis visualization, Cormack-Lehane grade (CL), need for external laryngeal pressure, and presence of post-laryngoscopy side effects. Results: TI was successfully carried out in the totality of patients. In only 4 out of 56 cases, the VL3 offered a CL II. The first attempt intubation was achieved in 48 patients (85.7%). In one case, external laryngeal pressure was needed. No CL III or CL IV were observed. We did not find any significant difference between the predicted difficult airways sample and the rest of the population. Conclusion: VL3 videolaryngoscope showed to be an effective and safe device for routine TI, even in those patients with predicted difficult airway. More studies are needed to confirm our findings and verify its efficacy even in other settings.
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Effect of pneumoperitoneum on dynamic variables of fluid responsiveness (Delta PP and PVI) during Trendelenburg position p. 323
Djamal Ghoundiwal, Amelie Delaporte, Javad Bidgoli, Patrice Forget, Jean-François Fils, Philippe Van der Linden
Background and Aims: Pulse pressure variation (ΔPP) is considered as one of the best predictors of fluid responsiveness in patients under mechanical ventilation. Pleth Variability Index (PVI) has been proposed as a noninvasive alternative. However, pneumoperitoneum has been recently suggested as a limitation to their interpretation. The aim of this study was to compare changes in ΔPP and PVI related to autotransfusion associated with a Trendelenburg maneuver before and during pneumoperitoneum. Methods: 50 patients undergoing elective abdominal laparoscopic surgery were enrolled in this prospective observational study. All patients were equipped with an invasive radial artery catheter and a PVI probe. After obtaining a stable signal with both ΔPP and PVI, baseline values were recorded, before and after head-down tilts of 10°, with or without abdominal insufflation (10-12 mmHg). All measurements were made before any fluid challenge under standardized anaesthesia, while patients were paralyzed and mechanically ventilated with 8 mL/kg tidal volume. Results: Changes in ΔPP and PVI associated with the Trendelenburg maneuver before and after insufflation of the pneumoperitoneum were significantly different (P < 0.001). In baseline conditions, the Trendelenburg maneuver was associated with a significant decrease in heart rate while mean arterial pressure remained unchanged. Both ΔPP and PVI decreased. After insufflation of the pneumoperitoneum, the Trendelenburg maneuver was associated with a significant decrease in heart rate and ΔPP and an increase in mean arterial pressure while PVI remained unchanged. Conclusion: Pneumoperitoneum did not alter the response of ΔPP to autotransfusion associated with the Trendelenburg maneuver, which was not the case for the PVI. This latter decreased during Trendelenburg maneuver performed alone and remained unchanged during Trendelenburg maneuver performed after insufflation of the pneumoperitoneum.
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Awareness of brain death, organ donation, and transplantation among medical students at single academic institute p. 329
Hani A Alnajjar, Maan Alzahrani, Muath Alzahrani, Mazen Banweer, Essam Alsolami, Azzam Alsulami
Objective: To assess the knowledge of the concept of brain death, attitude, and level of awareness towards organ donation and transplantation, among medical students and interns at the University of Jeddah, Kingdom of Saudi Arabia. Methods: A cross-sectional study via electronic questionnaire over period of 3 weeks to 2nd through 6th year medical students and interns at university of Jeddah. Results: A response rate of 113 out of 151 (74.83%) was achieved. Among participants, 36% expressed uncertainty when questioned about the concept of brain death. 8.8% of the participants were against the idea of organ donation. 60% of those who refused to contemplate organ donation were unfamiliar with the brain death concept. No significant difference was seen regarding fears about cosmetic disfiguration between those familiar and unfamiliar with the concept of brain death. 60.2% of the study cohort would consider donating their organs to family members but only 29.2% of them had discussed the matter of organ donation and transplantation with them, while 44.2% had discussed the matter with their friends. Majority of medical students (71.7%) were interested in being organ donors. Conclusion: Knowledge of organ donation and transplantation were adequate. Matter accepting brain death and its implication still not clear for most of participants. We believe there is still room to improve. This could be achieved by integrating more education about different aspects of brain death and its implications through medical school years.
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Local infiltration analgesia for total knee arthroplasty: Does a mixture of ropivacaine and epinephrine have an impact on hemodynamics? An observational cohort study p. 335
Andrea Calvo, José M Gómez Tarradas, Xavier Sala, Misericordia Basora, Luis Lozano, Gabor Erdoes
Purpose: High doses of local anesthetic administered intra-articularly and peri-articularly during local infiltration analgesia (LIA) for total knee arthroplasty (TKA) may have potential effects on patient hemodynamics. The aim of this study was to know if hemodynamic changes are associated with LIA in patients undergoing TKA. Methods: In a prospective observational design, elective patients undergoing orthopedic surgery for TKA and treated with LIA consisting of a mixture of ropivacaine (300 mg) and epinephrine (1 mg) were investigated for changes in selected hemodynamic parameters: heart rate (HR), non-invasively registered mean arterial blood pressure (MAP), and incidence of arrhythmias during the perioperative course, consisting of the following periods: period 1. from establishment of spinal anesthesia to prior to LIA administration, period 2. from administration of LIA to before release of ischemia tourniquet, period 3. from release ischemia tourniquet to end of surgery, and period 4. from transfer to the post anesthesia care unit to the ward. Statistical analysis was done with ANOVA-RM for the difference in means in repeated measurements, and with the Tukey Test between pairs. Data are presented as mean ± standard deviation. A P value <0.05 was considered significant. Results: Ninety-nine patients (mean age 77 ± 8 years) were included. HR increased from period 2 to period 3 up to 16% (67 ± 14 to 77 ± 13 bpm, P < 0.001), and from period 2 to period 4 up to 21% (67 ± 14 to 81 ± 12 bpm, P < 0.001). MAP showed no significant changes from period 2 to period 3 (89 ± 13 to 87 ± 13 mmHg, P > 0.50), and from period 2 to period 4 (89 ± 13 to 91 ± 11 mmHg, P > 0.50). No arrhythmias were detected during follow-up. Conclusions: A mixture of ropivacaine and epinephrine for LIA, despite the high doses administered, does not have a negative impact on hemodynamics.
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Pain perception assessment using the short-form McGill pain questionnaire after cardiac surgery p. 343
Hussam A Alharbi, Monirah A Albabtain, Nourah Alobiad, Jomanah Aba Alhasan, Maram Alruhaimi, Muzun Alnefisah, Samar Alateeq, Haneen Alghosoon, Sumaiah J Alarfaj, Amr A Arafat, Khaled D Algarni
Background: Pain management remains an integral part of patient care after cardiac surgery, and it required proper pain assessment. The aim of the study was to assess pain perception using validated Arabic version of the short-form McGill Pain Questionnaire (SF-MPQ) and to identify analgesics prescribing patterns post cardiac surgery. Methods: This is a prospective study conducted in an adult cardiac critical care unit of a tertiary cardiac center from September 2018 to March 2019. The study enrolled 74 patients who underwent cardiac surgical procedures through a median sternotomy. Results: The mean age of our patients was 57 ± 11 years and 47 (63.5%) were males. Patients described post-cardiac surgery pain as heavy (n = 37; 50%) and tiring-exhausting (n = 49; 66%), mainly at the site of incision (n = 20; 27%). Pain intensity at day 1 according to pain rating index (PRI) and numerical rating scale (NRS) was 7 (25th, 75th percentiles: 2.8–15) and 6 (3–8), respectively. There was a significant change in pain intensity score between 2 days of assessment (PRI: 7 [2.8–15] vs 5 [2–11] P = 0.010; NRS: 6 (3–8) vs 5 (2–8), P = 0.021]). The most common analgesics prescribed were paracetamol (39%) and a combination of tramadol and paracetamol (33.8%). Conclusion: Pain decreased the second day after cardiac surgery compared to day 1. Paracetamol was the most prescribed analgesic; however, there was an underutilization which might be affected by insufficient pain reporting. Future improvement could focus on multimodal pain management and proper communication of pain experience.
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Oliceridine and its potential to revolutionize GI endoscopy sedation p. 349
Basavana Goudra, Preet Mohinder Singh
Providing sedation to patients undergoing gastrointestinal (GI) endoscopy is a controversial and emotive issue. The mainstay of sedation is propofol, whose administration is within the sole jurisdiction of anesthesia providers, at least in the USA. Attempts have been made to seize the authority by the GI community. One of the first attempts was the use of the prodrug of propofol –fospropofol. However, as the drug has a similar adverse effect profile as propofol in terms of respiratory depression, the FDA did not approve its use by providers other than those trained in airway management. Sedasys® was the next attempt, which was a computer-assisted personalized sedation system. As a result of insufficient sedation that could be provided with the device, although very successful in research settings, it was not a commercial success. It seems that remimazolam is the next effort in this direction. It is likely to fail in this regard unless its respiratory depressant properties and failure rates could be addressed. G protein-biased μ-receptor agonists are a new class of opioids exhibiting analgesic properties similar to morphine without equivalent respiratory depressant properties. Oliceridine is the prototype. As a result, the drug can be additive to midazolam or remimazolam and allow screening colonoscopy to be comfortably completed without the need for propofol. For an anesthesia provider, the administration of oliceridine can eliminate the need for drugs such as fentanyl that add to the respiratory depressant properties of propofol. As a result, oliceridine has the potential to render the sedation for GI endoscopy procedures both safe and cost-effective.
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Anesthesia management of ophthalmic surgery for patient with suspected/confirmed COVID-19 -Saudi Anesthesia Society guidelines- p. 355
Nauman Ahmad, Abdul Zahoor, Abdulaziz E Ahmad, Abdelazeem El Dawlatly
The outbreak of the novel coronavirus (COVID-19) has been declared a global pandemic. With a mortality rate reaching up to 5%, healthcare professionals treating patients with COVID-19 are at a significantly higher risk for exposure themselves. Given the rapidly progressing rate of COVID-19, there is an urgent need for developing guidelines within each specialty. This article discusses guidelines specifically for anesthesiologists dealing with ophthalmic surgeries with suspected or confirmed COVID-19 patients. Anesthesiologists always work in the proximity of the patient's face while performing either ocular regional anesthesia or while managing the airway in the process of intubation/extubation. Within these guidelines, the emphasis is provided on thorough preoperative screening to identify COVID-19 patients and to prevent the exposure of healthcare staff by following standard personal protective equipment (PPE) precautions.
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Considerations and recommendations for obstetric anesthesia care during COVID-19 pandemic - Saudi anesthesia society guidelines p. 359
Omar Alyamani, Ibrahim Abushoshah, Nasser A Tawfeeq, Fatma Al Dammas, Fahd A Algurashi
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) emerged in Wuhan, China late 2019 and became a pandemic causing coronavirus disease 2019 (COVID-19). Despite its lower mortality rate compared to the other coronaviruses, it has a higher human-to-human transmission rate. Anesthesiologists may benefit from a review of the current evidence related to the obstetric patient with COVID-19. Methods: We reviewed the literature for relevant articles as well as experts' opinions from related medical societies' websites. Conclusion: There are several anesthetic considerations in the care of pregnant women with COVID-19 due to their unique physiological changes. We provide considerations and recommendations for departmental and institutional leadership as well as the obstetric anesthesia providers. These recommendations may apply and can be edited, for future droplet or airborne based pandemics. The rapidly evolving literature makes it important to get updates directly from the relevant medical societies' websites.
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Saudi heart association, national heart center and national cardiopulmonary resuscitation committee taskforce statement on cpr and resuscitation during COVID-19 pandemic p. 365
AbdulMajeed S Khan, Abdullah M Kaki, Abdulrahman R Bakhsh, Ahmed S A. Hersi, Jameel T AbuAlenain, Jubara S Alallah, Fayez A Bokhari, Nasser AlQahtani, Bandar M AlKabli, Abdulrahman Al Qahtani, Nawfal AlJerian, Rashid AlOtaibi
Corona virus disease 2019 is a global pandemic, which affects around 2million individuals with a high death rate that exceeds 90,000 death cases across the globe. The Saudi Heart Association and the national cardiopulmonary resuscitation committee developed a taskforce to discuss the magnitude of clinical situation and CPR management on COVID-19 patients in a prehospital and in-hospital settings. Meanwhile, the taskforce aims to develop a nation-wide clinical guidance to be used by health care workers and untrained laypersons to resuscitate COVID-19 suspected and diagnosed patients.
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Perioperative care of pediatric anesthesia for children with suspected or confirmed COVID-19 p. 370
Talal Al Juhani, Nezar Al Zughaibi, Ahmad Haroun, Ahmed Al Saad
COVID-19 is a pandemic disease that recently been spreading all over the globe. Health-care bodies recognize that organized and written protocols are essential tools to help in fighting this highly contagious virus. In this review, we published our protocol and recommendations in the pediatric anesthesia department in our hospital in preparation for the management of children who are confirmed or suspected in perioperative periods.
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Electroconvulsive therapy during a highly contagious respiratory pandemic—A framework during COVID-19 p. 378
Roman Schumann, Edward K Silberman, Heidi M Hotin, Sadeq A Quraishi
Necessary procedures during the COVID-19 pandemic include electroconvulsive therapy (ECT). Providing ECT has been considered an essential service during COVID-19 in the Singapore healthcare system, not least to contribute to disease control within a society in part due to the nature of the ECT patient population. There is limited evidence-based scientific information available regarding a procedural framework for ECT during a respiratory pandemic, when much attention in the healthcare system is focused on different areas of clinical care. This article attempts to describe such a framework for ECT procedures acknowledging limited solid scientific evidence at this time and being mindful of future changes to these suggestions as testing, immunization, and treatment options develop. This approach can be adopted in whole or in part to assist practitioners to protect the patient and themselves during the procedure.
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Anesthesia management of thoracic surgery in a patient with suspected/confirmed COVID-19: Interim Saudi Anesthesia Society guidelines p. 383
Abdelazeem Eldawlatly, Mohamed R El Tahan, Ahmed Abdulmomen, Maan Kattan, Abdulaziz E Ahmad
The Saudi Anesthesia Society (SAS) has developed interim guidelines on perioperative care of COVID-19 patients who undergo surgery and anesthesia.[1] Patients with “ suspected/confirmed” COVID-19 might be scheduled for emergency thoracic procedures either during the acute or convalescence phases of the disease. There is a demanding need to develop the SAS recommendations on the perioperative care of thoracic surgery patients during the COVID-19 outbreak. There are no relevant publications on perioperative care of thoracic surgery in COVID-19 patients. These recommendations were developed from the previous experience of management of patients during the MERS-CoV outbreak in 2012-2013 and literature available on the general airway and anesthesia care for patients with COVID-19, SARS, MERS-CoV.
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Airway management and COVID-19 patient -Saudi Anesthesia Society guidelines- p. 387
Mohammed K Al Harbi, Ahmed Abdulmomen, Fahad Al Qurashi, Maan Kattan, Abdulaziz E Ahmad, Abdelazeem Eldawlatly
The Saudi Anesthesia Society (SAS) in line with the Mission and Vision of the Kingdom of Saudi Arabia to contain the new coronavirus disease (COVID-19) is pleased to develop a statement regarding airway management of suspected/confirmed patients with this virus, to ensure the safe practice in dealing with the patient as well as protecting the medical staff from getting the infection. In this report, we have summarized the guidelines necessary for airway management of suspected/confirmed COVID-19 patient. Since the COVID-19 outbreak is up to date existed, therefore this report is considered as interim guidelines for airway management of the suspected/confirmed patients. The guidelines will be revisited and modified in the future, if necessary.
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C-arm fluoroscopy for tracheal intubation in a patient with severe cervical spine pathology p. 390
Yukihide Koyama, Koichi Tsuzaki, Kazuo Ohmori, Koichiro Ono, Takeshi Suzuki
Tracheal intubation is challenging in patients with severe cervical spine pathology. In such cases, awake fiberoptic intubation is the gold standard and safest option for tracheal intubation. However, this technique requires the patient's understanding and cooperation, and therefore, may be contraindicated in patients with refusal or poor tolerance. Herein, we report successful orotracheal intubation in a patient with limited mouth opening and severe cervical spine rigidity under general anesthesia using an extraglottic airway device and a gum-elastic bougie under C-arm fluoroscopic guidance.
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Management of postdural puncture headache in pediatric using an epidural catheter for an epidural blood patch p. 394
Adnan Al Wosaibai, Ahmed Alfaraj, Abduladem K Alshabeb
We report the case of an 8-year-old child suspected to have postdural puncture headache after multiple lumbar punctures for collection of cerebrospinal fluid for analysis. His symptoms included headache, nonprojectile vomiting, and lethargy. When conservative management failed, an epidural blood patch was applied and the depth of the epidural space was determined using MRI. Epidural blood patch treatment was successful, and an epidural catheter was left in situ, in case a second patch was required.
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Altered airway anatomy but challenges remains same p. 397
Leena P Harshad, Vinayak Pujari, T Balaji, K Navdeep
The altered pediatric airway is a nightmare for an anesthesiologist. Managing such cases with limited resources makes it more challenging. Here, we report a case of pediatric patient with altered airway anatomy posted for gastrotomy and feeding tube insertion. This case highlights the management of pediatric difficult airway and discusses the various choices of anesthesia technique.
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Floppy epiglottis together with extra-laryngeal mass causing an inducible laryngeal obstruction and hypoxemic event in an adult: A case report p. 400
Manish Keshwani, Habib M R. Karim, Govind Gourh
Floppy epiglottis in an adult is rare and often pathological. Airway obstruction caused by floppy epiglottis in an adult is rarely reported. Neck mass, however, can affect the airway in many ways; however, inducible upper airway obstruction by extra-laryngeal neck mass is hardly been reported. In most of the instances of inducible laryngeal obstruction, the tumor is found in and around the laryngeal inlet. Herein, we report such an unusual incident happened to a 40-year-old gentleman, a case of oral carcinoma for 3 months and a rapidly increasing swelling (6 × 5 cm) over the right side of the neck for 8 days. He presented to us for emergency tracheostomy with the feature of acute upper airway obstruction, unable to lie down; and having difficulty in breathing, desaturation, and chocking even in propped up position. The case highlights the importance of clinical findings and difficulties faced for airway management in such patients.
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Keyhole anesthesia—Perioperative management of subglottic stenosis: A case report p. 403
Anudeep Jafra, Ramandeep Virk, Gourav Mittal, Kanika Arora, Suman Arora
Any narrowing in the airway presents as obstruction and with features of noisy breathing. The presence of subglottic stenosis poses a great challenge to the anesthesiologist. Diagnostic and corrective procedures by Otolaryngologist require rigid endoscopy which demands apneic ventilation. Hence, the goal of general anesthesia in the presence of subglottic stenosis requires a patent airway to maintain oxygenation and ventilation and avoid hypoxia. We present an interesting case of a preterm neonate with subglottic stenosis who was managed successfully with endoscopic release.
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Bilateral continuous posterior quadratus lumborum block for analgesia after open abdominal surgery: A prospective case series p. 406
Wael Ali Sakr Esa, Hassan Hamadnalla, Barak Cohen, Loran M Soliman, Marta Kelava, Dilara Khoshknabi, Syed Raza, Hesham Elsharkawy
The quadratus lumborum (QL) block provides analgesia to the abdominal wall while sparing the side effects of neuraxial blocks. We describe a case series of eight patients treated with a continuous infusion of local anesthetic via bilateral posterior QL catheters infusion block for analgesia after abdominal surgeries. We found that the median duration of the procedure was 26 min and the median opioid consumption over the first postoperative 72 h was 110 mg of morphine equivalents. The bilateral continuous posterior QL block is a feasible analgesic intervention and can be considered as a component of multimodal analgesic pathways.
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A comment on – “Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway – pediatric double-lumen tube and pediatric ureteroscope as rescue devices” p. 409
Swapnil Y Parab
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Comment on the published article: Accidental injection of succinylcholine into epidural space as a test dose p. 410
Sohan L Solanki, Raghu S Thota
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Anesthetic management of a COVID 19 suspected patient for mastectomy p. 411
Karthik C Babu, Sunil Rajan, Jerry Paul, Lakshmi Kumar
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Anesthetic management of a patient with right endobronchial vascular tumor for total thyroidectomy p. 413
Jacob Mathew, Sunil Rajan
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Regarding the paper published “Serratus anterior plane block: Anatomical landmark-guided technique” p. 414
Deepti Ahuja, Swagata Biswas, Sachidanand J Bharati
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The ventilator solution for COVID -19 patient at rural tertiary care hospital p. 415
Akshaya N Shetti
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Anesthetic management of an insulinoma patient with recurrent hypoglycemic seizures p. 417
Manbir Kaur, N Balakrishnan, Rakesh Kumar, Pradeep Bhatia
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HTX-011: Another game changer multimodal analgesic or an ephemeral, experimental drug! p. 419
Abhijit Nair, Srinivasa S P. Mantha, Praneeth Suvvari, Poornachand Anne
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Be careful to avoid hemodynamic disturbances in craniosynostosis surgery! p. 420
Chandrakant Prasad, Surya K Dube, Arvind Chaturvedi
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Retraction Highly accessed article p. 422

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