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   Table of Contents - Current issue
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April-June 2018
Volume 12 | Issue 2
Page Nos. 175-375

Online since Friday, March 9, 2018

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EDITORIAL  

Ultrasound and central neuraxial blocks Highly accessed article p. 175
Atul Gaur, Jatin Dedhia, Kaddour Bouazza-Marouf
DOI:10.4103/sja.SJA_768_17  
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ORIGINAL ARTICLES Top

Assessment of medical practitioners' knowledge of fibromyalgia in Saudi Arabia p. 178
Abdullah Mohammad Kaki, Abdulaziz A Hazazi
DOI:10.4103/sja.SJA_458_17  
Background: Fibromyalgia (FM), a relatively common disease, is difficult to diagnose owing to its subjective symptoms and poor knowledge among medical practitioners. The purpose of this study was to assess the knowledge regarding FM among medical practitioners in Saudi Arabia and the need for educational programs at the undergraduate level. Subjects and Methods: An online survey was administered to physicians, nurses, and technologist/technicians in different regions of the country. Responses were obtained from 104 medical practitioners. Knowledge regarding FM including clinical symptoms, diagnosis, and treatment was assessed. Results: Only 26% of the respondents reported that FM was part of their undergraduate curriculum, and only 8.7% attended educational programs about FM. (Approximately 50% of the medical practitioners either referred FM patients to unrelated specialty or did not know whom to refer these patients to). Only 33.7% of the respondents were familiar with the diagnostic criteria. Physiotherapy (69.4%) and pharmacological treatment (63.9%) were predominantly reported as the appropriate treatment. Conclusions: Knowledge regarding FM among medical practitioners in Saudi Arabia is poor. Further education at the undergraduate level is needed to improve knowledge and avoid delays in diagnosis and treatment.
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Preperitoneal postcesarean section bupivacaine analgesia: Comparison between dexamethasone and dexmedetomidine as adjuvants p. 183
Alaa Mazy, Mona Gad, Mohamed Bedairy
DOI:10.4103/sja.SJA_450_17  
Background: The peritoneal wound is frequently neglected during laparotomy. The preperitoneal local anesthetics and many adjuvants were effective for postcesarean analgesia. Analgesia may involve somatic and autonomic components. The preperitoneal bupivacaine and the promising adjuvants dexamethasone or dexmedetomidine were compared in this study. Patients and Methods: Sixty patients subjected to a cesarean section (CS) under general anesthesia divided into two groups using a bolus of preperitoneal bupivacaine 0.7 mg/kg with either 1ug/kg dexmedetomidine (Group P) or 8 mg dexamethasone (Group D). The time to the first analgesic request was the primary outcome. Results: There was a significantly prolonged time to the first analgesic request in the Group P than the Group D and less required preperitoneal injections in the Group P, also pain assessed by Numerical Rating Scale (NRS) was lower in the Group P than the Group D after 6 h postoperatively up to 24 h. Conclusions: Dexmedetomidine provided better analgesia than dexamethasone as an adjuvant to preperitoneal bupivacaine post-CS.
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Dexmedetomidine vs morphine and midazolam in the prevention and treatment of delirium after adult cardiac surgery; a randomized, double-blinded clinical trial p. 190
Tamer M Abdel Azeem, Nahed E Yosif, Adel M Alansary, Ibrahim Mamdouh Esmat, Ahmed K Mohamed
DOI:10.4103/sja.SJA_303_17  
Background: The aim of this clinical study was to evaluate the efficacy of neurobehavioral, hemodynamics and sedative characteristics of dexmedetomidine compared with morphine and midazolam-based regimen after cardiac surgery at equivalent levels of sedation and analgesia in improving clinically relevant outcomes such as delirium. Methods: Sixty patients were randomly allocated into one of two equal groups: group A = 30 patients received dexmedetomidine infusion (0.4–0.7 μg/kg/h) and Group B = 30 patients received morphine in a dose of 10–50 μg/kg/h as an analgesic with midazolam in a dose of 0.05 mg/kg up to 0.2 mg/kg as a sedative repeated as needed. Titration of the study medication infusions was conducted to maintain light sedation (Richmond agitation-sedation scale) (−2 to +1). Primary outcome was the prevalence of delirium measured daily through confusion assessment method for intensive care. Results: Group A was associated with shorter length of mechanical ventilation, significant shorter duration of intensive care unit (ICU) stay (P = 0.038), and lower risk of delirium following cardiac surgery compared to Group B. Group A showed statistically significant decrease in heart rate values 4 h after ICU admission (P = 0.015) without significant bradycardia. Group A had lower fentanyl consumption following cardiac surgery compared to Group B. Conclusion: Dexmedetomidine significantly reduced the length of stay in ICU in adult cardiac surgery with no significant reduction in the incidence of postoperative delirium compared to morphine and midazolam.
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A prospective randomized study on the impact of low-dose dexamethasone on perioperative blood glucose concentrations in diabetics and nondiabetics p. 198
Athul M Purushothaman, Vinayak Seenappa Pujari, Nalini B Kadirehally, Yatish Bevinaguddaiah, Pratheek R Reddy
DOI:10.4103/sja.SJA_409_17  
Background: Dexamethasone is a potent corticosteroid when administered alone or in combination alone has proven efficacious in preventing nausea and vomiting (PONV) perioperatively. However, the administration of even a single dose has been associated with hyperglycemia. This is the first study that evaluates the effect of two low-doses of dexamethasone (4 and 8 mg) on blood glucose concentrations among diabetics and nondiabetics in patients who have received spinal anesthesia. Materials and Methods: After obtaining ethical clearance and patient consent, 180 American Society of Anesthesiologists 1–3 patients undergoing the elective infraumbilical surgeries under spinal anesthesia aged between 18 and 70 years were included in this study. Ninety diabetic patients were allotted to the diabetic group (DM), and ninety nondiabetic patients were allotted to the nondiabetic group (ND). Group DM was divided into three subgroups DM0, DM4, and DM8. Group ND was divided into three subgroups ND0, ND4, and ND8. The patients in groups DM0 and ND0 served as controls. The patients in groups DM4 and ND4 received 4 mg dexamethasone. The patients in groups DM8 and ND8 received 8 mg dexamethasone. The blood glucose concentrations were monitored at 0 (baseline),1, 2, 3, 4, 5, 6, and 8 h after giving the drug. Results: The baseline blood glucose values were higher in diabetics compared to nondiabetics (128.57 ± 22.26 vs 94.99 ± 12.82 mg/dL). There was a statistically significant increase in blood glucose concentrations in both diabetics and nondiabetics who received dexamethasone. The rise of blood glucose from baseline was similar in both diabetics and nondiabetics. Conclusion: The maximum rise in blood glucose was in the range of 40–45 mg/dl in the patients who received dexamethasone. The clinician should use his clinical judgment before administering dexamethasone for PONV prophylaxis/treatment.
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Pain assessment in the critically ill mechanically ventilated adult patients: Comparison between skin conductance algesimeter index and physiologic indicators p. 204
Puneet Khanna, Chandralekha Chandralekha, Ravinder Kumar Pandey, Ankur Sharma
DOI:10.4103/sja.SJA_489_17  
Background and Objectives: Critically ill patients are unable to communicate effectively, so it is difficult to assess their pain and analgesic requirement. Skin conductance algesimeter (SCA) index is a device that primarily measures changes in skin conductance real time to assess pain. Methods: We planned this quantitative prospective observational study to assess pain in the critically ill mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the Intensive Care Unit (ICU). The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning. Results: There was a significant increase in both hemodynamic variables during painful procedures except for the heart rate during positioning. The correlation between the SCA index and Ramsay scale was negative and significant. Conclusions: This instrument might prove useful to measure pain in uncommunicative critically ill patients and to evaluate the effectiveness of analgesic treatment and adapt it.
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Using dexamethasone as an adjuvant to levobupivacaine in epidural anesthesia to change the pain intensity and duration in painless labor p. 209
Hassan Mohamed Ali, Amr Wahdan
DOI:10.4103/sja.SJA_435_17  
Background and Objective: This is a randomized controlled trial aiming at comparing the effectiveness of levobupivacaine alone versus a levobupivacaine with dexamethasone in the epidural injection for painless labor. Patients and Methods: This is a comparative randomized controlled double-blinded clinical trial with 49 patients were included in this study, all of them were primigravidas and were during vaginal delivery with a cervical dilatation ≥4 cm. Patients were included randomly in one of two groups either Group C (26 cases) with epidural levobupivacaine 0.125% in normal saline or Group D (23 cases) with epidural levobupivacaine 0.125% in normal saline combined with dexamethasone 8 mg. The duration of a second dose request, total dose given, neonatal outcome and adverse effects of epidural were recorded. Results: Group D showed a longer duration of analgesia than Group C (80.5 ± 12.39 min in Group D vs. 61.75 ± 10.74 min in Group C) with a P < 0.05 (0.001). Furthermore, the patients in Group D received smaller dose of levobupivacaine than those in Group C with a statistically significant difference (90.87 ± 33.42 vs. 127.21 ± 40.68 mg with P = 0.002). There were no statistical differences between the two groups regarding hemodynamics, pain score, neonatal outcome, and complications. Conclusion: Dexamethasone in epidural analgesia for painless labor has a prolonged duration of analgesia with no complications for both the mother and the infant.
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Medical students' attitude toward anesthesia as a future career p. 215
Rakan M AlKhilaiwi, Abdulaleem Alatassi, Amjaad H Almohawis, Turki A Alhumaid, Khalid A Almazyad, Rami T Bustami
DOI:10.4103/sja.SJA_367_17  
Objectives: The purpose of this study is to understand the attitude of medical students at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) toward anesthesia as a specialty and to determine common factors influencing their career choice options. Study Design: This was a cross-sectional study. Methods: The study was conducted between March 25, and April 20, 2017, at KSAU-HS. The survey was distributed among 5th and 6th years medical students. Data were collected through a validated hardcopy questionnaire of 16 multiple choice questions. The questionnaire included demographic characteristics, specialty preferences, what factors attract Saudi medical students to choose their preferred specialty and how they view the option of choosing anesthesiology as a career. Results: A total of 236 students completed the questionnaire. The majority of respondents were in their 5th year of medical school representing (62%). The distribution of medical field interest ranged from (38%) surgery to (1%) anesthesiology. approximately, (60%) thought that controllable lifestyle was an important factor to consider in choosing a residency program. Only (45%) of respondents thought that prestige of specialty is a major factor that would influence their choice for a specialty. Conclusion: Based on the outcome of the study, it is recommended that medical undergraduate students exposure to anesthesia specialty should be magnified. Greater efforts have to be made to increase the number of medical students preferring anesthesia through emphasizing on the positive aspects of the specialty.
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Knowledge and attitudes of nurses toward pain management p. 220
Osama Abdulhaleem Samarkandi
DOI:10.4103/sja.SJA_587_17  
Background: Pain control is a vitally important goal because untreated pain has detrimental impacts on the patients as hopelessness, impede their response to treatment, and negatively affect their quality of life. Limited knowledge and negative attitudes toward pain management were reported as one of the major obstacles to implement an effective pain management among nurses. The main purpose for this study was to explore Saudi nurses' knowledge and attitudes toward pain management. Methods: Cross-sectional survey was used. Three hundred knowledge and attitudes survey regarding pain were submitted to nurses who participated in this study. Data were analyzed with the Statistical Package for the Social Sciences software (SPSS; version 17). Results: Two hundred and forty-seven questionnaires were returned response rate 82%. Half of the nurses reported no previous pain education in the last 5 years. The mean of the total correct answers was 18.5 standard deviation (SD 4.7) out of 40 (total score if all items answered correctly) with range of 3–37. A significant difference in the mean was observed in regard to gender (t = 2.55, P = 0.011) females had higher mean score (18.7, SD 5.4) than males (15.8, SD 4.4), but, no significant differences were identified for the exposure to previous pain education (P > 0.05). Conclusions: Saudi nurses showed a lower level of pain knowledge compared with nurses from other regional and worldwide nurses. It is recommended to considered pain management in continuous education and nursing undergraduate curricula.
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Efficacy and safety of pulsed radiofrequency and steroid injection for intercostobrachial neuralgia in postmastectomy pain syndrome - A clinical trial Highly accessed article p. 227
Beshoy Nabil Fam, Ghada Gamal El-Din El-Sayed, Raafat Mahfouz Reyad, Ikramy Mansour
DOI:10.4103/sja.SJA_576_17  
Background: Breast cancer is a common neoplastic tumor in women, and the postmastectomy pain syndrome has been reported frequently after surgical treatment. The injury of the intercostobrachial nerve is considered the major cause of this type of pain. Purpose: Evaluation of efficacy and safety of pulsed radiofrequency (PRF) and steroid injection on the 2nd and 3rd thoracic (T2 and T3) dorsal root ganglions (DRGs) for intercostobrachial neuralgia (ICBN) postmastectomy. Patients and Methods: This study was conducted on 100 patients with ICBN postmastectomy. The PRF waves were applied for 120 s twice on T2 and T3 DRGs then 1 ml of 4 mg dexamethasone and 1 ml of bupivacaine 0.25% were injected at each level then the technique was repeated three times 1 week apart for each patient. Results: After 6 months from the latest intervention, the mean of visual analog scale dropped from 7.48 to 4.7 (P = 0.005712) and the mean of the quality of life scale improved to 6.88 after being 4.66 (P < 0.00001) before the intervention and 64.68% of the patients decided that they would certainly repeat the procedure if they could go back in time and 66.64% would certainly recommend the same procedure to a family member. The analgesics consumption decreased mainly in the 1st month but increased again after 6 months (not significant). No serious complications were recorded. Conclusions: PRF and steroid injection on T2 and T3 DRGs assumed an effective and safe method for ICBN postmastectomy treatment.
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Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study p. 235
Charu Mahajan, Girija Prasad Rath, Gyaninder Pal Singh, Nitasha Mishra, Suman Sokhal, Parmod Kumar Bithal
DOI:10.4103/sja.SJA_608_17  
Background: The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Materials and Methods: Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2–0.7 μg/kg/h (bispectral index target 60–80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). Results: A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. Conclusion: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.
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Comparison of analgesic efficacy and safety of continuous epidural infusion versus local infiltration and systemic opioids in video-assisted thoracoscopic surgery decortication in pediatric empyema patients p. 240
Priyanka Pradeep Karnik, Nandini Malay Dave, Madhu Garasia
DOI:10.4103/sja.SJA_659_17  
Introduction: The stripping of the densely innervated and inflamed parietal pleura in empyema during video-assisted thoracoscopic surgery (VATS) decortication can lead to significant pain and major postoperative respiratory compromise. Hence, we compared the analgesic efficacy of continuous epidural infusion versus local infiltration and systemic opioids in children undergoing VATS decortications. Methodology: Following ethics approval and informed consent, forty patients from 1 to 12 years of age were randomized into two groups, Group E (epidural) and Group L (local infiltration) after induction of anesthesia. In Group E, a thoracic epidural catheter was inserted between T4 and T8. A bolus dose of 0.5 ml/kg of 0.25% injection bupivacaine was given epidurally before incision. Postoperatively, the patients received epidural infusion with bupivacaine and fentanyl up to 48 h using an elastomeric balloon pump. In Group L, patients received local infiltration of bupivacaine (2 mg/kg) and lignocaine (5 mg/kg) at the port sites before incision and at the end of surgery. They also received injection tramadol 1 mg/kg intravenously TDS with thrice daily postoperatively. The pain scores (Face, Legs, Activity, Cry, Consolability/ Wong-Baker FACES scale) were assessed every 4 h on the 1st day and 6 h on the 2nd day. Injection diclofenac 1 mg/kg intravenous was used as a rescue analgesic for pain scores more than 4. Side effects such as nausea, vomiting, constipation, and motor blockade were noted. Quantitative and categorical data were assessed using t-test and Chi-square test, respectively. Results: The pain scores were lower in the epidural group than in the local infiltration group at 0, 4, and 20 h postoperatively (P = 0.001, 0.01, and 0.038, respectively). Seventeen out of nineteen patients required rescue analgesia in the local infiltration group in the postoperative period as compared to five patients in the epidural group with a P value of 0.000081. Conclusion: Epidural analgesia can be considered as an effective modality of reducing pain in patients undergoing VATS decortication for empyema in pediatric patients.
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Analysis of functioning and efficiency of a code blue system in a tertiary care hospital p. 245
Srinivas Monangi, Rangraj Setlur, Ramprasad Ramanathan, Sidharth Bhasin, Mridul Dhar
DOI:10.4103/sja.SJA_613_17  
Background: “Code blue” (CB) is a popular hospital emergency code, which is used by hospitals to alert their emergency response team of any cardiorespiratory arrest. The factors affecting the outcomes of emergencies are related to both the patient and the nature of the event. The primary objective was to analyze the survival rate and factors associated with survival and also practical problems related to functioning of a CB system (CBS). Materials and Methods: After the approval of hospital ethics committee, an analysis and audit was conducted of all patients on whom a CB had been called in our tertiary care hospital over 24 months. Data collected were demographic data, diagnosis, time of cardiac arrest and activation of CBS, time taken by CBS to reach the patient, presenting rhythm on arrival of CB team, details of cardiopulmonary resuscitation (CPR) such as duration and drugs given, and finally, events and outcomes. Chi-square test and logistic regression analysis were used to analyze the data. Results: A total of 720 CB calls were initiated during the period. After excluding 24 patients, 694 calls were studied and analyzed. Six hundred and twenty were true calls and 74 were falls calls. Of the 620, 422 were cardiac arrests and 198 were medical emergencies. Overall survival was 26%. Survival in patients with cardiac arrests was 11.13%. Factors such as age, presenting rhythm, and duration of CPR were found to have a significant effect on survival. Problems encountered were personnel and equipment related. Conclusion: A CBS is effective in improving the resuscitation efforts and survival rates after inhospital cardiac arrests. Age, presenting rhythm at the time of arrest, and duration of CPR have significant effect on survival of the patient after a cardiac arrest. Technical and staff-related problems need to be considered and improved upon.
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Morphine versus fentanyl patient-controlled analgesia for postoperative pain control in major hepatic resection surgeries including living liver donors: A retrospective study p. 250
Eman M Nada, Abdulmajeed Alabdulkareem
DOI:10.4103/sja.SJA_625_17  
Background: Liver resection surgery results in significant postoperative pain. However, it is still not clear which opioids used by patient-controlled analgesia (PCA) provides the best pain control and results in the least side effect in a patient with impaired liver function. Our hypothesis was that fentanyl is a better choice than morphine as it is a potent analgesic that its elimination half-life does not depend on the hepatic uptake and metabolism. The Study Purpose: Is to compare morphine and fentanyl PCA in liver resection patients as regards the degree of pain control, the consumption of opioids, and the side effects. Methods: A retrospective case–control study of hepatic resection patients who received postoperative morphine (Morph) or fentanyl (Fent) PCA. The study compared the pain scores, the morphine equivalent dose (MED), the number of demands requested as recorded by the PCA infusion pump, and the side effects every 12 h for 48 h. Results: This study yielded 40 patients; with the majority were living donor hepatic resection patients. There was no significant difference in the pain scores. However, the MED and the demands were significantly less in the Morph group. The P < 0.000, 0.0001, 0.0005, and 0.003, demands P < 0.002, 0.006, 0.014, and 0.013 at 12, 24, 48, and 36 h, respectively. The overall side effects were not different between the 2 groups at all time intervals measured; however, Morph patients were significantly more sedated in the first 12 h. There was one case of respiratory depression in the Morph group compared to two cases in the in the Fent group that needed treatment with naloxone. Conclusions: Although both groups had adequate pain control. The Morphine group reached faster pain control with less MED and PCA requests in liver resection patients, although it was more sedating in the first 12 h. However, fentanyl patients were less sedated; both drugs need close monitoring in the immediate postoperative period due to reported respiratory depressive effect and the need to use naloxone. The dosage of the PCA settings needs to be studied further to reach to the best dose with a reduced side effect. Further studies are recommended to reduce PCA dosages by introducing a multimodal approach of pain management relying on other methods with no additional sedative effects as regional anterior abdominal blocks.
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Factors affecting reintubations after cardiac and thoracic surgeries in cardiac intensive care unit of a tertiary care hospital p. 256
Khalid Maudood Siddiqui, Khalid Samad, Faisal Jonejo, Muhammad Faisal Khan, Khalid Ahsan
DOI:10.4103/sja.SJA_631_17  
Background: Reintubation and readmission after cardiothoracic surgeries are not uncommon, and its reasons are multifactorial. The study goal was to identify the factors that contribute reintubation after cardiac and thoracic surgery in tertiary care hospital and to compare the outcome with international benchmark. Methodology: A prospective, observational study was planned in Cardiac Intensive Care Unit (CICU). The study included all those patients who required readmission in CICU due to endotracheal intubation following cardiac and thoracic surgeries. The study was conducted from January to December 2016. The primary focus was to identify the reasons for reintubation within 72 h of extubation after CICU discharge and its association with outcome. Results: Out of 750 patients who shifted out from CICU following successful extubation, only 32 were readmitted and among them in 25 patients (3.33%) were reintubated and their reasons reintubation were noted. Patients underwent a coronary artery bypass grafting (CABG) with valve replacement had a higher incidence of reintubation 3/39 (7.69%) when compared with CABG 13/517 (2.51%) and 4/135 (2.96%) valve procedure alone. Single cause of endotracheal reintubation was observed in 7 patients (28%), in which 5 patients (20%) had respiratory and 2 patients had (8%) cardiac reason while 18 patients (72%) were observed with multisystem involvement, in which 7 patients (28%) had both respiratory and cardiovascular causes, and 2 (8%) had both respiratory and neurological causes. More than 70% cause of endotracheal reintubation was both respiratory and cardiovascular. The CICU stay after reintubations was 12.88 ± 16.88 days and the hospital stay prolonged to 23.84 ± 21.61 days. Conclusion: Reasons of reintubation were mainly respiratory and cardiac. The rate of reintubations is high when multisystem involvement is there. CICU, hospital stay, and mortality are increases after reintubation.
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Evaluation of transversus abdominis plane block for renal transplant recipients – A meta-analysis and trial sequential analysis of published studies p. 261
Preet Mohinder Singh, Anuradha Borle, Jeetinder Kaur Makkar, Aanjan Trisha, Aashish Sinha
DOI:10.4103/sja.SJA_598_17  
Background: Patients undergoing renal transplant (RT) have altered drug/opioid pharmacokinetics. Transversus abdominis plane (TAP) block in renal transplant recipients has been recently evaluated for analgesic and opioid-sparing potential by many trials. Methodology: The studies comparing TAP-block to conventional analgesic regimens for RT were searched. Comparisons were made for total opioids consumed (as morphine-equivalents) during the first postoperative 24-h (primary objective), intraoperative, and immediate-postoperative period. Pain scores and postoperative nausea-vomiting (PONV) were also evaluated. Trial sequential analysis (TSA) was used to quantify the strength of analysis. Results: Ten-trials with 258 and 237 patients in control and TAP-block group, respectively, were included. TAP-block decreased the 24-h (reported in 9-trials) opioid consumption by 14.61 ± 4.34 mg (reduction by 42.7%, random-effects, P < 0.001, I2 = 97.82%). Sample size of the present analysis (472) was well past the required “information-size” variable (396) as per the TSA for a power of 85%. Intraoperative opioid consumption also decreased by 2.06 ± 0.63 mg (reduction of 27.8%) (random effects, P < 0.001, I2 = 98.84%). Pain scores with TAP-block were significantly lower in both early and delayed postoperative phase. Odds ratio for PONV without TAP block was 1.99 ± 1.05 (Fixed-effects, P = 0.04, I2 = 0%). Publication bias was likely (Egger's test, X-intercept=7.89, P < 0.05). Conclusions: TAP-block significantly lowers the intraoperative and cumulative postoperative 24-h opioid consumption in RT recipients. Persistent and better pain control is achieved when TAP-Block is used. Benefits of TAP block extend beyond the analgesic actions alone as it also decreases the 24-h incidence of postoperative nausea vomiting as well. The technique of the block needs standardization for RT recipients.
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A prospective randomized controlled study to evaluate and compare GlideScope with Macintosh laryngoscope for ease of endotracheal intubation in adult patients undergoing elective surgery under general anesthesia p. 272
Anudeep Jafra, Satinder Gombar, Dheeraj Kapoor, Harpreet Singh Sandhu, Kamlesh Kumari
DOI:10.4103/sja.SJA_543_17  
Background: The aim of the study was to compare the ease the intubation using GlideScope video laryngoscope and Macintosh laryngoscope in adult patients undergoing elective surgery under general anesthesia. Materials and Methods: A total of 200 American Society of Anesthesiologists I–II patients of either sex, in the age group of 18–60 years were included in the study. Patients were randomly allocated to two groups. We assessed ease of intubation depending on time to tracheal intubation, number of attempts, glottic view (Cormack–Lehane grade [CL grade] and percentage of glottis opening [POGO]) and intubation difficulty score (IDS), hemodynamic variables and any intra- and post-operative adverse events. Results: The rate of successful endotracheal intubation (ETI) in both groups was 100% in the first attempt. The time required for successful ETI was 24.89 ± 5.574 in Group G and 20.68 ± 3.637 in Group M (P < 0.001) found to be statistically significant. There was significant improvement in glottic view with GlideScope (as assessed by POGO score 66.71 ± 29.929 and 94.40 ± 10.476 in group G and 75.85 ± 26.969 and 74.20 ± 29.514 Group M and CL grading [P < 0.001]). A comparison of mean IDS between two groups revealed intubation was easier with the use of GlideScope. The hemodynamic response to intubation was significantly lesser with the use of GlideScope when compared with Macintosh laryngoscope. The incidence of adverse events, though minor like superficial lip or tongue bleed, was similar in two groups. Conclusions: GlideScope offers superiority over Macintosh laryngoscope in terms of laryngeal views and the difficulty encountered at ETI in an unselected population.
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Lumbar epidural depth using transverse ultrasound scan and its correlation with loss of resistance technique: A prospective observational study in Indian population p. 279
Amit Kumar Chauhan, Rohan Bhatia, Sanjay Agrawal
DOI:10.4103/sja.SJA_679_17  
Background and Objectives: The objective of the present study was to evaluate the skin-epidural space distance as assessed by ultrasonography and conventional loss of resistance (LOR) technique and to find the correlation of epidural depth with body mass index (BMI). Methods: Ninety-eight patients of either sex, American Society of Anesthesiology I/II, BMI <30 kg/m2 requiring lumbar epidural for surgery were enrolled. The epidural space was assessed with a curvilinear ultrasound (US) probe, 2–5 MHz, in the transverse plane at L3–L4 intervertebral space. Thereafter, the epidural depth from skin was assessed with conventional LOR method while performing the epidural. The needle depth (ND) was measured using a sterile linear scale, and any change in the needle direction or intervertebral space was noted. Results: The patients were demographically similar. Depth of epidural space measured by US depth (UD) was 3.96 ± 0.44 cm (range 3.18–5.44 cm) and by ND was 4.04 ± 0.52 cm (range 2.7–5.7 cm). The Pearson's correlation coefficient (r) between UD and ND was 0.935 (95% confidence interval: 0.72–0.92, r2 = 0.874, P < 0.001), and Bland–Altman analysis revealed the 95% limits of agreement −0.494–0.652 cm. Conclusion: The present study demonstrates a good correlation between UD and ND and shows that the preprocedural US scan in transverse plane provides accurate needle entry site with a high success rate in single attempt for lumbar epidurals in patients with a BMI <30 kg/m2.
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Appearance of Population, Intervention, Comparison, and Outcome as research question in the title of articles of three different anesthesia journals: A pilot study p. 283
Abdelazeem Eldawlatly, Hussain Alshehri, Abdullah Alqahtani, Abdulaziz Ahmad, Fatma Al-Dammas, Amir Marzouk
DOI:10.4103/sja.SJA_767_17  
Background: It is well known in the evidence-based medicine practice that framing the research question is the most important and crucial part of the research integrity. Population, Intervention, Comparison, and Outcome (PICO) is a specialized framework used by most researchers to formulate a research question and to facilitate literature review. The aim of this study is to investigate the representation of the PICO frame in the title of published articles in three different anesthesia journals. Methods: We performed this double-blind, pilot study on papers published in three anesthesia journals, including Anesthesia and Intensive care (a), Saudi Journal of Anaesthesia (b), and Anesthesia Analgesia (c) from January 2016 to September 2017. We randomly selected 30 randomized controlled trials from each journal to check for the PICO frame in the title of each article. We used Chi-square test to compare the met variables in the three journals with respect to PICO frame. Met variables are those who met the PICO frame and not met are not. We assumed a statistically significant difference when P was <0.05. Results: Ninety randomized controlled trials articles (n = 90) were included in this study (n = 30 each journal A, B, and C). Corresponding estimates of the percent of papers that failed (not met) to adopt PICO elements were as follow for journal A, B, and C, respectively: Population: 30%, 30%, and 20%; Intervention: 50%, 30%, and 26.7%; Comparison: 53.3%, 60%, and 53.3%; and Outcome: 30%, 6.7%, and 0.0% with significant differences between journals A and C (P < 0.05). Conclusion: Researches adopting PICO elements usually receive higher citation percentages. There is a need to further investigate the PICO framework in a larger study to determine whether it can be well represented in the titles of different research designs. That, in turn, will help the precision of searches performed on a PICO-formatted screen to receive relevant citations.
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Correlation of different parity and school education with acceptance of labor analgesia among antenatal women: A questionnaire-based study p. 287
Anita Yadav, Habib Md Reazaul Karim, Avinash Prakash, Pinky Jena, Kumar Aman
DOI:10.4103/sja.SJA_474_17  
Background and Aim: Pain relief is nearly regarded as the right of patients in modern day health care. Women undergo excruciating pain during normal vaginal delivery (NVD). However, the acceptance of labor analgesia (LA) has remained very poor. The present study was aimed to assess the correlation of previous exposure to such pain (parity) and school education with LA acceptance. Methods: The present comparative study was conducted with a total 400 consented participants. A questionnaire was used to collect sociodemographic variables, acceptance/nonacceptance of LA, and the reasons for not opting for LA in upcoming delivery were noted. Participants were divided into primiparous, multiparous, and nulliparous (control). They were also grouped as per school education and compared taking illiterates as controls. Data are presented in absolute number. Fisher's exact test is used for comparison; P < 0.05 was considered statistically significant. Results: Seventy (17.5%) multiparous and 38% primiparous participants were compared with 44.5% nulliparous women. Only 2.75% participants were illiterate. 69.50% were rural inhabitant and 81.50% believed in Hinduism. 87.14% multiparous, 84.21% primiparous, and 88.76% nulliparous women declined LA (P > 0.05). The desire to experience NVD without LA as a reason for nonacceptance was significantly less among primiparous and multiparous as compared to nulliparous (P < 0.0001), but not among literate and illiterate participants (P > 0.295 in all). Conclusion: Previous labor pain significantly reduces the desire to experience NVD without LA, but still more than 80% parturients of any parity do not want LA due to one or more reasons. School education has no impact on LA acceptance.
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Point-of-care ultrasound in the airway assessment: A correlation of ultrasonography-guided parameters to the Cormack–Lehane Classification p. 292
Shelly Rana, Versha Verma, Shyam Bhandari, Shalini Sharma, Vishal Koundal, Sudarshan Kumar Chaudhary
DOI:10.4103/sja.SJA_540_17  
Background and Aim: The sonographic assessment of airway in the preoperative period has encouraging results in predicting difficult laryngoscopy. Materials and Methods: The prospective, observational study was conducted on 120 patients scheduled for elective surgery requiring general anesthesia and tracheal intubation. The depth of the pre-epiglottic space (Pre-E), the distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC) was measured sonographically. Similarly, hyomental distance ratio (HMDR) was sonographically measured with head in neutral and extended positions. The primary outcome was the efficacy of Pre E/E-VC, HMDR for predicting difficult laryngoscopy (Cormack–Lehane [CL] Grade 3, 4). The secondary outcome was to correlate these parameters to CL grading. Results: Difficult intubation was observed in 12.5% of patients. The mean ± standard deviation (SD) of Pre E/E-VC ratio was 1.33±0.335, 1.62±0.264 and 1.87±.243, 2.22±.29 for CL Grade 1, 2, 3, and 4, respectively (P = 0.00). The mean ± SD of HMDR was 1.11±.35, 1.12±.29, and 1.07±.39, 1.04 ± 0.01 for CL Grade 1, 2, 3, and 4, respectively (P = 0.00). Pre E/E-VC ratio of more than 1.77 cm had 82% sensitivity, specificity 80%, whereas HMDR less than1.085 had sensitivity 75% and specificity 85.3%, in predicting difficult laryngoscopy (P = 0.00). Conclusion: The sonographic measurement of the Pre E/E-VC ratio is a better predictor of CL grading as compared to HMDR. The noninvasive prediction of CL grading can be precisely done by Pre-E/E-VC ratio (range: 0–1.425 corresponds to CL Grade 1; 1.425–1.77 ≈ CL Grade 2; 1.77–1.865 ≈ CL Grade 3, more than 1.865 corresponds to CL Grade 4).
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Dexmedetomidine in a surgically inserted catheter for transversus abdominis plane block in donor hepatectomy: A prospective randomized controlled study p. 297
Mohamed Adel Aboelela, Al-Refaey Kandeel, Usama Elsayed, Mohamed Elmorshedi, Waleed Elsarraf, Eman Elsayed, Ahmed Elgawalby, Ahmed Mohamed Sultan, Mohamed Abdel Wahab, Amr Yassen
DOI:10.4103/sja.SJA_577_17  
Background: Transversus abdominis plane (TAP) block is a promising technique for analgesia after abdominal surgery. This prospective, randomized controlled trial assessed the effect of adding dexmedetomidine to bupivacaine in TAP block for donor hepatectomy. We hypothesized that this would improve postoperative morphine consumption and reduce analgesia related complication and inflammation. Methods: A total of 50 donor hepatectomy were enrolled in this study. Patients divided into two equal groups according to drugs used for TAP block. Group (B) received 20 ml of bupivacaine hydrochloride 0.25%, Group (BD) received 20 ml of bupivacaine hydrochloride 0.25% and 0.3 μg/kg dexmedetomidine, on both sides at the end of surgery and every 8 h for 48 h at right side only through inserted catheter. Primary outcome objective was morphine consumption at first 72 h. Secondary outcome objectives were morphine requirement, numbers of intake, time to first intake, pain score numerical analog scale (NAS), postoperative analgesia related complications, recovery of intestinal motility, and inflammatory markers. Results: Data were analyzed, rescue morphine analgesia was significantly lower in (BD) group compared with (B) groups as considering total morphine consumption (B 4 ± 1.9, BD 1.5 ± 0.5, P = 0.03), numbers of morphine intake (P = 0.04), morphine requirement (P = 0.03), and first time of analgesia intake (P = 0.04). NAS was significantly lower in group (BD) compared with group (B) group in the first 12 h (NAS 0 - P = 0.001, NAS 1 - P = 0.03). Adding dexmedetomidine improved gut motility, first oral intake without detectable anti-inflammatory effect. Conclusion: Adding dexmedetomidine to bupivacine in a surgically inserted catheter for TAP block in donor hepatectomy reduced morphine consumption without detectable anti-inflammatory effect.
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Patient satisfaction and experience with anesthesia: A multicenter survey in Saudi population p. 304
Abdulrahman Alsaif, Saleh Alqahtani, Farhan Alanazi, Faris Alrashed, Abdullah Almutairi
DOI:10.4103/sja.SJA_656_17  
Background and Objectives: Patients' satisfaction of anesthesia outcomes is a major part of the overall quality of health care. The aim of this study is to evaluate patient's satisfaction whether pre- or post-operative as well as overall impression using a multicenter prespecified survey tool. Methods: Three hundred and three patients who underwent surgery regardless the type of anesthesia were surveyed. The interview conducted face-to-face before surgery then within the first 24 h of surgery. We recorded all basic demographics of patients, the quality of postoperative symptoms control, and the impression about anesthesia team. Results: The overall satisfaction level was moderate (56.5%) with nearly half of the patients dissatisfied with their anesthetic care due to different reasons. Nausea and vomiting control was the most common postoperative reasons for dissatisfaction followed by pain control with 35.6% and 31.7%, respectively. Conclusion: Type of anesthesia, giving an informative visit to the patient, and the control of postoperative symptoms are the most important predictors of patients' satisfaction.
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REVIEW ARTICLE Top

Intraoperative fluid management: Past and future, where is the evidence? Highly accessed article p. 311
Abdulmohsin A Al-Ghamdi
DOI:10.4103/sja.SJA_689_17  
Currently, there is no consensus about the optimum intraoperative fluid therapy strategy. There is growing body of evidence supports the beneficial effects of adopting “Goal-directed therapy” over either the “liberal” or “restrictive” fluid therapy strategies. In this narrative review, we have presented the evidence to support the optimum strategy for intraoperative therapy. In conclusion, whatever the intravenous fluid replacement strategy used, the anesthesiologist must be prepared to adjust the composition and rate of the fluids administered to provide sufficient intravascular fluid volume for adequate perfusion of vital organs without overwhelming the glycocalyx function with fluid overloads.
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CASE REPORTS Top

Bedside ultrasound assessment of gastric content in children noncompliant with preoperative fasting guidelines: Is it time to include this in our practice? p. 318
Uma R Parekh, Niraja Rajan, Robyn C Iglehart, Patrick M McQuillan
DOI:10.4103/sja.SJA_452_17  
Ultrasound assessment of gastric contents and volume is gaining popularity in adults and children. At present, a preoperative verbal check is used to determine the fasting status. Due to fear of delay or cancellation of surgery, parents may not disclose noncompliance with fasting guidelines. Pulmonary aspiration of gastric contents is a potential cause of morbidity and mortality. Ultrasound assessment of gastric contents is noninvasive and easy to learn. We present a series of three cases to demonstrate how the use of ultrasound to assess gastric contents in children can provide an objective means for decision-making and impact anesthetic management when preoperative fasting status is uncertain.
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Wilm's tumor with intracardiac extension causing dynamic tricuspid valve obstruction: An anesthetic challenge p. 321
Kamal Kajal, Ganesh Kumar Munirathinam, Banashree Mandal, Komal Gandhi, Harkant Singh, Ravi Kanojia
DOI:10.4103/sja.SJA_472_17  
Wilms' tumor (WT) is the most common pediatric renal tumor that often spreads to inferior vena cava and sometimes up to right atrium (RA). We describe successful management of 3-year-old child diagnosed with WT having extension up to RA. He was operated under cardiopulmonary bypass and extubated on postoperative day 2 and discharged. Perioperative anesthesia concerns were shock from dynamic tricuspid valve obstruction, intraoperative massive blood loss, and a higher risk of pulmonary thromboembolism during tumor manipulation.
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Pectoralis blocks for insertion of an implantable cardioverter defibrillator in two patients with Duchenne muscular dystrophy p. 324
Alexander B Froyshteter, Tarun Bhalla, Joseph D Tobias, Gregory S Cambier, Christopher T Mckee
DOI:10.4103/sja.SJA_624_17  
Patients with Duchenne muscular dystrophy (DMD) often have systemic manifestations with comorbid involvement of the cardiac and respiratory systems that increase the risk of anesthetic and perioperative morbidity. These patients frequently develop progressive myocardial involvement with cardiomyopathy, depressed cardiac function, and arrhythmias. The latter may necessitate the placement of an automatic implantable cardioverter defibrillator (AICD) insertion. As a means of avoiding the need for general anesthesia and its inherent potential of morbidity, regional anesthesia may be used in specific cases. We present two cases of successful AICD insertion in patients with DMD using unilateral pectoralis and intercostal nerve blocks supplemented with intravenous sedation. Relevant anatomy for this regional anesthetic technique is reviewed and benefits of this anesthetic technique compared to general anesthesia are discussed.
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Development of postoperative central anticholinergic syndrome due to low-dose intravenous fentanyl p. 328
Hojae Cho, Jiyeon Kim
DOI:10.4103/sja.SJA_478_17  
A 37-year-old female patient, 57 kg and 160 cm, underwent laparoscopic appendectomy. In the recovery room, fentanyl 100 mcg was intravenously administered for pain control. Three minutes after the administration, the patient developed intense and uncontrolled myoclonus, lower limb rigidity, agitation, aphasia, and periocular and neck swelling. The myoclonus and rigidity were suspected to be due to the opioid administration, and thus, naloxone was administered, but the symptoms were not improved. The patient's symptoms continued until the patient received administration of physostigmine. The patient was discharged 3 days later, following resolution of the symptoms. We report a case of central anticholinergic syndrome that developed after general anesthesia owing to the interaction of opioid at an analgesic dose for postoperative pain control with another anesthetic.
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Renal oxalate stones in children with Zellweger spectrum disorders p. 332
Hamdan Hammad Alhazmi
DOI:10.4103/sja.SJA_699_17  
Peroxisomal biogenesis disorders due to PEX gene defects are classified into many subgroups, of which Zellweger spectrum disorders (ZSDs) represent the major subgroup. The ZSDs are clinical and biochemical disorders divided into three phenotypes: neonatal, adolescence, or adult. Clinical presentations vary with severity of the condition. Metabolic abnormalities occur due to functional peroxisomal defects that could be detected in blood and urine. No cure or definitive management exists to date; only supportive and palliative measures are applied to prevent worse sequelae. We experienced a case of oxalate renal stones in a patient with ZSD. This patient had hyperoxaluria and hyperglycolic aciduria with clinically associated clues that correlate with urinary oxalate load. Urinary oxalate and glycolate excretion were assessed. Radiological workup revealed renal involvement with urolithiasis and nephrocalcinosis. Urinalysis and ultrasonography for stones and hyperoxaluria should be used to screen patients with ZSD for early intervention to prevent renal damage.
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Anesthetic and psychiatric implications of accidental awareness under general anesthesia during electroconvulsive therapy p. 335
Hetal Acharya, Atul Gaur, Girish Kunigiri
DOI:10.4103/sja.SJA_675_17  
Accidental awareness under general anesthesia (AAGA) is a well-known phenomenon. However, little literature exists in its relation to the psychiatric field, particularly within the electroconvulsive therapy (ECT) setting. This report explores the case of a 52-year-old woman that describes her own experience of AAGA during ECT. Relevant anesthetic details are also provided along with its possible implications in AAGA. The aim of this case report is to increase awareness among clinicians in regard to AAGA and its occurrence during ECT.
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Crohn's disease-associated silent aspiration in the outpatient setting: Anesthesiologists beware p. 339
Christopher Snell, Scott Coleman, Michele Van Hal, Farshad Rashidian, Gary Okum, Michael Stuart Green
DOI:10.4103/sja.SJA_663_17  
Every anesthesia provider fears aspiration of gastric contents during an anesthetic, and it may occur even in the absence of overt signs such as coughing or choking. Whether the aspiration is frank or silent, catastrophic and deleterious consequences may ensue. Therefore, familiarity with risk factors for silent aspiration is essential. Crohn's disease reportedly delays gastric emptying making these patients more susceptible to silent aspiration during surgery. Anesthesia providers must be cognizant of this risk and vigilant in the recognition to formulate a specific treatment plan preoperatively. We present a case of an ambulatory surgical patient with suspected silent aspiration undiagnosed by the anesthesia care team before induction of anesthesia.
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Magnesium interscalene nerve block for the management of painful shoulder disorders p. 343
Olumuyiwa A Bamgbade
DOI:10.4103/sja.SJA_650_17  
Shoulder pain is a common and distressing disorder. Systemic multimodal analgesia may be ineffective, but interscalene nerve block provides effective therapy. Magnesium may increase the efficacy and duration of systemic or regional analgesia. This case series examines the utility of magnesium interscalene nerve block for the management of painful shoulder disorders. Six elderly patients with shoulder pain and dysfunction received interscalene nerve block with injection of bupivacaine and magnesium. The patients subsequently reported significant improvement in sleep, shoulder pain, and physical function for 16 weeks. This report highlights that magnesium interscalene nerve block provides safe, effective, and prolonged shoulder analgesia.
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COMMENTARY Top

Editorial commentary on: Using dexamethasone as an adjuvant to levobupivacaine in epidural anesthesia to change the pain intensity and duration in painless labor p. 346
Sukanya Mitra
DOI:10.4103/sja.SJA_508_17  
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LETTERS TO EDITOR Top

Subcutaneous emphysema after endotracheal intubation: A case report p. 348
Indranil Ghosh, Prasanta Behera, Bibhukalyani Das, Chistopher John Gerber
DOI:10.4103/sja.SJA_533_17  
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Limited mouth opening: Retrograde intubation revisited p. 349
Reena , Virendra Rastogi
DOI:10.4103/sja.SJA_547_17  
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Evaluation of a new laryngoscope according to preparation time p. 351
Yasuhiko Imashuku, Hirotoshi Kitagawa, Takayoshi Mizuno
DOI:10.4103/sja.SJA_178_17  
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Ultrasound as a guide to reposition a misdirected central venous catheter p. 353
Karthik V Iyer, Sana Yasmin Hussain, Ajeet Kumar
DOI:10.4103/sja.SJA_581_17  
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Pneumomediastinum following iatrogenic pharyngeal perforation during tracheoesophageal fistula repair p. 355
Deepak Dwivedi, Jeetinder Makkar, Ridhima Sharma, Anudeep Jafra
DOI:10.4103/sja.SJA_573_17  
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Asymptomatic congenital subglottic stenosis in a neonate – infant feeding tube as a “Guardian angel!” p. 357
Chetna Shamshery, Ashish Kumar Kannaujia, Rajashree Madabushi, Vansh Priya
DOI:10.4103/sja.SJA_641_17  
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Algorithms for successful repositioning of misplaced left-sided double-lumen tube inserted during lung/thoracic surgery p. 359
Uma Hariharan, Shagun B Shah, Ajay Kumar Bhargava
DOI:10.4103/sja.SJA_629_17  
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Point-of-care lung ultrasound can detect endobronchial intubation during laparoscopic cholecystectomy p. 360
Prakash K Dubey, Pankaj Kumar
DOI:10.4103/sja.SJA_691_17  
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Fixed cervical flexion deformity: Difficult airway p. 362
Kadarapura Nanjundaiah Gopalakrishna, Shetty Prajwal, Kamath Sriganesh, Bhumireddy Suneel Reddy
DOI:10.4103/sja.SJA_676_17  
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Intranasal lignocaine spray for sphenopalatine ganglion block for postdural puncture headache p. 364
Preksha Dubey, Prakash K Dubey
DOI:10.4103/sja.SJA_680_17  
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New technology: Handheld ultrasound-assisted localization of epidural space p. 365
Jitendra Homdas Ramteke, Dinesh Kumar Sahu, Alpa Sonawane, Reena Parampill
DOI:10.4103/sja.SJA_696_17  
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Noncardiac surgery in two severe aortic stenosis patients: General or epidural anesthesia? p. 367
Nitika Goel, M Ganesh Kumar, Parag Barwad, Goverdhan Dutt Puri
DOI:10.4103/sja.SJA_648_17  
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Point-of-care ultrasonography for detection of tracheal tube cuff rupture following nasal intubation? p. 369
Prakash K Dubey, Preksha Dubey
DOI:10.4103/sja.SJA_706_17  
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Palliative surgical gastrostomy under ultrasound-guided bilateral rectus sheath blocks in a head and neck cancer patient p. 371
Saima Rashid, Faisal Shamim, Maha Khan, Robyna Khan
DOI:10.4103/sja.SJA_770_17  
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Intubation over a bougie: Nasal is not novel p. 373
Ron O Abrons, Randy W Loftus
DOI:10.4103/sja.SJA_779_17  
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Saviour in a mess: Spinal needle (Gaurav Technique) p. 374
Gaurav Sindwani, Aditi Suri
DOI:10.4103/sja.SJA_4_18  
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