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   Table of Contents - Current issue
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October-December 2017
Volume 11 | Issue 4
Page Nos. 381-521

Online since Friday, September 22, 2017

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EDITORIAL  

Has goal directed fluid therapy and glycocalyx a role in enhanced recovery after anesthesia? p. 381
Abdelazeem Eldawlatly
DOI:10.4103/sja.SJA_456_17  
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ORIGINAL ARTICLES Top

Transdermal fentanyl as an adjuvant to paravertebral block for pain control after breast cancer surgery: A randomized, double-blind controlled trial Highly accessed article p. 384
Ahmed H Bakeer, Nasr M Abdallah
DOI:10.4103/sja.SJA_84_17  
Objective: The aim of this study is to investigate the effect of transdermal fentanyl (TDF) as an adjuvant to paravertebral block (PVB) for pain control after breast cancer surgery. Patients and Methods: This randomized, double-blind trial included fifty females with breast cancer scheduled for surgery. They were randomly allocated into one of two equal groups. The TDF group used transdermal fentanyl patches (TFPs) 25 μg/h applied 10 h preoperative then PVB with 20 mL of bupivacaine 0.25% was done before induction of general anesthesia. The PVB group used placebo patches in addition to PVB the same way as TDF group. Postoperative pain was assessed with a visual analog scale (VAS) score up to 48 h. Intravenous morphine 0.1 mg/kg was given when the VAS is ≥ 3 or on patient request. The primary outcome measures were the time to first request for analgesia and the total analgesic consumption in the first 48 h. Results: Relative to the VAS score reading was 30 min. After the end of surgery, VAS score decreased significantly in the two groups up to 48 postoperative hours and was significantly lower in TDF group up to 24 h. The time to first request of additional analgesia was significantly longer, and total dose of morphine consumption was significantly lower in TDF group (P < 0.001, and P = 0.039, respectively). Conclusion: TFPs releasing 25 μg/h is a safe and effective adjuvant to PVB after breast cancer surgery. It provides adequate analgesia with reduction of opioid consumption and minimal adverse effects.
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Comparison of oropharyngeal leak pressure of air-Q™,i-gel™, and laryngeal mask airway supreme™ in adult patients during general anesthesia: A randomized controlled trial p. 390
Srinath Damodaran, Sameer Sethi, Surender Kumar Malhotra, Tanvir Samra, Souvik Maitra, Vikas Saini
DOI:10.4103/sja.SJA_149_17  
Study Objective: Various randomized controlled trials and a meta-analysis have compared i-gel™ and laryngeal mask airway Supreme™ (LMA-S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air-Q™ with i-gel™ and LMA-S™ in adult patient. Hence, we designed this study to compare air-Q™ with LMA-S™ and i-gel™ in adult patients. Materials and Methods: A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer-generated random number sequence: group air-Q™ (n = 25), group i-gel™ (n = 25), and group LMA-S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications. Results: The mean ± standard deviation OLP of air-Q™, i-gel™, and LMA-S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H2O (P = 0.279). The first insertion success rate for air-Q™, i-gel™, and LMA-S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air-Q™, i-gel™, and LMA-S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air-Q™ insertion was significantly higher than time taken for i-gel™ (mean difference 5.8 s, P < 0.0001) and LMA-S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices. Conclusions: We concluded that air-Q™, i-gel™, and LMA-S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy.
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A randomized comparative study assessing efficacy of pain versus comfort scores p. 396
Richa Jain, Anju Grewal
DOI:10.4103/sja.SJA_256_17  
Context: Use of language with negative emotional content is likely to increase patient's pain and anxiety. Aims: We designed a single-blinded randomized study to compare pain scores with comfort scores and to determine whether the technique of pain assessment affects patient's perceptions and experience. Subjects and Methods: After cesarean section, 180 women were randomized before postanaesthesia interview into two groups. Group P women were asked to rate their pain on a 0–10-point verbal numerical rating scale (VNRS) for pain while Group C women were asked to rate their comfort on a 0–10-point VNRS for comfort. All women were asked whether the surgical wound was associated with injury or healing. The primary outcomes were to compare the incidence of reported pain and to assess pain severity as measured by a 0–10-point VNRS for pain compared with an equivalent inverted VNRS for comfort. The secondary outcomes were whether the wound was associated with injury or healing. Statistical Analysis Used: Data were analyzed using Student's t-test and nonparametric Mann–Whitney U-test, performed at a significance level of α =0.05. Results: In Group P, 62 women (68.9%) reported pain compared with only 49 women (54.4%) in Group C (P < 0.05). There were no significant differences between groups for VNRS at rest and on movement. In Group P, thirty women (33.33%) reported sensations as injury compared with only 11 women (12.22%) in Group C (P < 0.001). Conclusions: Assessment of pain using positive word like comfort decreases its incidence with no effect on its severity when measured by comfort score and also affects patient's postsurgical perceptions.
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Epidemiology and characteristics of nosocomial infections in critically ill patients in a tertiary care intensive care unit of Northern India p. 402
Anirban Hom Choudhuri, Mitali Chakravarty, Rajeev Uppal
DOI:10.4103/sja.SJA_230_17  
Background and Aims: The prevalence of nosocomial infection is higher in the Intensive Care Unit (ICU) than other areas of the hospital. The present observational study was undertaken to describe the epidemiology and characteristics of nosocomial infections acquired in a tertiary care ICU and the impact of the various risk factors in their causation. Materials and Methods: A retrospective study was conducted on the prospectively collected data of 153 consecutive patients admitted in a tertiary care ICU between July 2014 and December 2015. The primary objective was to assess the epidemiology of ICU-acquired bacterial infections in terms of the incidence of new infections, causative organism, and site. The secondary end point was to assess the risk factors for developing ICU-acquired infections. Results: Out of the 153 patients enrolled in the study, 87 had an ICU-acquired nosocomial infection (58.86%). The most common organism responsible for infection was Klebsiella pneumoniae (37%), and the most common infection was pneumonia (33%). The duration of mechanical ventilation and length of ICU stay were significantly prolonged in patients developing nosocomial infections. There was no difference in mortality between the groups. The multivariate analyses identified intubation longer than 7 days, urinary catheterization >7 days, duration of mechanical ventilation more than 7 days, and ICU length of stay longer than 7 days as independent risk factors for nosocomial infections. Conclusion: The study demonstrated a high incidence of nosocomial infection in the ICU and identified the risk factors for acquisition of nosocomial infections in the ICU.
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Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine - a double-blind, randomized, placebo controlled trial p. 408
Jose Ramon Ortiz-Gomez, Francisco Javier Palacio-Abizanda, Francisco Morillas-Ramirez, Inocencia Fornet-Ruiz, Ana Lorenzo-Jiménez, Maria Lourdes Bermejo-Albares
DOI:10.4103/sja.SJA_237_17  
Background: Prophylactic administrations of ondansetron or phenylephrine have been reported to provide a protective effect against hypotension in women undergoing cesarean delivery under spinal anesthesia (SA). The main hypothesis is that ondansetron improves the hemodynamic response, especially combined with phenylephrine infusion. Methods: This prospective, double-blind, randomized, placebo-controlled study included 265 healthy pregnant women scheduled for elective cesarean delivery under SA. Women were randomly allocated into four groups to receive either placebo (control), ondansetron (O) 8 mg intravenously before induction of SA, phenylephrine infusion (50 mcg/min) (P) or ondansetron plus phenylephrine (OP). Demographic, obstetric, intraoperative timing, and anesthetic variables were assessed at 16 time points. Anesthetic variables assessed included blood pressure, heart rate, oxygen saturation, nausea, vomiting, electrocardiographic changes, skin flushing, discomfort or pruritus, and vasopressor requirements. Results: There were differences (P = 0.0001) in the number of patients with hypotension (50.8% control, 44.6% O, 20.9% P, 25.0% OP), the percentage of time points (P = 0.0001) with systolic hypotension per patient (17.4% control, 8.7% O, 2.1% P, 6.7% OP) and the number of patients requiring supplementary boluses of ephedrine (P = 0.003), phenylephrine (P = 0.017) or atropine (P = 0.0001). Conclusions: A 50 μg/min phenylephrine infusion reduces by 50%, the incidence of maternal hypotension compared with placebo, but infusions of phenylephrine are still not routine in our environment. Prophylactic ondansetron 8 mg might be considered in this situation, because it does not reduce the incidence of maternal hypotension but diminishes its severity, reducing the number of hypotensive events per patient by 50%.
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An audit of in-hospital cardiopulmonary resuscitation in a teaching hospital in Saudi Arabia: A retrospective study p. 415
Abdullah Mohammed Kaki, Kamal Waheeb Alghalayini, Mohamed Nabil Alama, Adnan Abdullah Almazroaa, Norah Abdullah A Khathlan, Hassan Sembawa, Beena M Ouseph
DOI:10.4103/sja.SJA_255_17  
Objectives: Data reflecting cardiopulmonary resuscitation (CPR) efforts in Saudi Arabia are limited. In this study, we analyzed the characteristics, and estimated the outcome, of in-hospital CPR in a teaching hospital in Saudi Arabia over 4 years. Methods: A retrospective, observational study was conducted between January 2009 and December 2012 and included 4361 patients with sudden cardiopulmonary arrest. Resuscitation forms were reviewed. Demographic data, resuscitation characteristics, and survival outcomes were recorded. Results: The mean ± standard deviation age of arrested patient was 40 ± 31 years. The immediate survival rate was 64%, 43% at 24 h, and 30% at discharge. The death rate was 70%. Respiratory type of arrest, time and place of arrest, short duration of arrest, witnessed arrest, the use of epinephrine and atropine boluses, and shockable arrhythmias were associated with higher 24-h survival rates. A low survival rate was found among patients with cardiac types of arrest, and those with a longer duration of arrest, pulseless electrical activity, and asystole. Comorbidities were present in 3786 patients with cardiac arrest and contributed to a poor survival rate (P < 0.001). Conclusions: The study confirms the findings of previously published studies in highly developed countries and provides some reflection on the practice of resuscitation in Saudi Arabia.
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Effect of intravenous phenylephrine infusion on dose requirement of intrathecal plain levobupivacaine for cesarean section: A placebo-controlled preliminary study p. 421
Asha Tyagi, Aanchal Kakkar, Namrata Niwal, Medha Mohta, Ashok Kumar Sethi
DOI:10.4103/sja.SJA_269_17  
Background: Phenylephrine infusion has been shown to decrease rostral spread of plain and hyperbaric local anesthetic (LA) when compared to ephedrine infusion. However, it does not result in higher dose requirement of hyperbaric LA for cesarean section. There is no trial evaluating the effect of phenylephrine infusion on ED50 of a plain intrathecal LA. Methods: Pregnant patients with term uncomplicated singleton pregnancy undergoing elective cesarean section were given combined spinal-epidural anesthesia. They received intrathecal plain levobupivacaine 0.5% in a dose decided by up-and-down sequential allocation method along with 25 μg fentanyl. Intravenous infusion of phenylephrine (100 μg/ml) or normal saline was initiated immediately after intrathecal injection. Systolic arterial pressure ≤0.8 times baseline was treated using rescue boluses of phenylephrine 50 μg. Results: Demographic, other patient and surgical characteristics were similar in the two groups. ED50 of intrathecal plain levobupivacaine was significantly greater in phenylephrine group (5.5 mg [95% confidence interval (CI): 5.1–5.9 mg]) compared to saline group (4.2 mg [95% CI: 3.4–5.1 mg]) (P = 0.01). Maximum sensory level, time to achieve adequate block, Apgar scores, and umbilical artery pH were similar in both groups. Total phenylephrine dose and patients having significant bradycardia were lesser in the saline group. Conclusions: Intrathecal dose requirement of plain levobupivacaine is greater using phenylephrine infusion as compared to saline infusion with rescue phenylephrine boluses. When using phenylephrine as a variable dose regimen titrated to maintain blood pressure within 20% of baseline, the ED50 of plain levobupivacaine is 5.5 mg (95% CI: 5.1–5.9 mg).
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Postoperative pain management in patients undergoing thoracoscopic repair of pectus excavatum: A retrospective analysis of opioid consumption and adverse effects in adolescents p. 427
Ralph Beltran, Giorgio Veneziano, Tarun Bhalla, Brian Kenney, Dmitry Tumin, Bruno Bissonnette, Joseph D Tobias
DOI:10.4103/sja.SJA_339_17  
Introduction: Although the Nuss procedure provides excellent cosmetic results for the correction of pectus excavatum, the provision of analgesia following such procedures can be challenging. Methods: The current study retrospectively reviews our experience over a 2.5 year period with thoracic epidural analgesia (TE), paravertebral blockade (PVB), and intravenous opioids delivered via patient-controlled analgesia (PCA) to provide postoperative analgesia. Results: The study cohort included 30 patients (mean age = 15.6 ± 1.5 years), 15 of whom were treated with PCA, 8 with TE, and 7 with PVB. There were no significant differences in pain scores between the 3 groups at any time point during the first 3 postoperative days. Compared to PCA, the PVB group had lower opioid consumption over the first 24 hours of hospitalization by 1.7 mg/kg morphine equivalents (95% CI of difference: 0.1, 3.3; p=0.035); but had higher opioid consumption by 2.0 mg/kg morphine equivalents than the TE group (95% CI of difference: 0.3, 3.7; p=0.024). There were no differences in opioid consumption between PVB and PCA or between PVB and TE at 48 or 72 hours. The number of intraoperative hypotension episodes was significantly lower in the PCA group when compared to the PVB group (p=0.001), with no difference between the PVB and TE groups. Conclusions: The use of regional anesthesia should be considered a viable option for the relief of postoperative pain in pediatric patients following the Nuss procedure albeit with a higher incidence of intraoperative hemodynamic effects. A randomized, prospective, study powered to compare all 3 techniques against one another would be necessary to confirm the significance of these findings.
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Comparison of laryngeal tube suction II and proseal LMA™ in pediatric patients, undergoing elective surgery p. 432
Saurabh Chandrakar, Deepak Kumar Sreevastava, Sidharth Bhasin, Mridul Dhar
DOI:10.4103/sja.SJA_418_17  
Background: Supraglottic airway devices now have an established place in pediatric anesthesia practice. The laryngeal tube suction (LTS) II, a recent revision of the LTS, has very few studies evaluating its use in pediatric patients. The aim of this study was to compare insertion and ventilation profiles of the LTS-II size 2 and the ProSeal™ Laryngeal Mask Airway (PLMA) size 2 in pediatric patients undergoing elective surgeries. Materials and Methods: A randomized prospective study was conducted in 100 children aged 2–5 years between 12 and 25 kg weight, of the American Society of Anesthesiologists physical status I and II scheduled for routine elective surgeries of <90 min duration. They were randomly divided into two groups of 50 each, depending on the device inserted, and a standard protocol for anesthesia was followed. Outcome measures were studied in terms of ease and time of insertion, oxygen saturation (SpO2), oropharyngeal seal pressure (OSP), and ventilation failures. Results: Both groups were well matched in terms of age, weight, and type of surgery. The success rate for the first attempt was 90% for both the LTS-II group and PLMA group. Insertion was found to be easy in the majority of cases in both groups, and there was no statistical difference in blood pressure, heart rate, or SpO2on insertion. However, the OSP was significantly more in LTS-II and PLMA (P < 0.001). There were no clinically important complications in the postoperative period. Conclusions: Pediatric size 2 LTS-II is easy to insert and provides higher OSP compared with same size PLMA in anesthetized and paralyzed children undergoing elective surgery. It is a safe alternative to PLMA in short duration elective surgeries and may be a better device as it provides for higher OSPs.
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Assessment of patient-controlled analgesia versus intermittent opioid therapy to manage sickle-cell disease vaso-occlusive crisis in adult patients p. 437
Alaa Al-Anazi, Lowloa Al-Swaidan, Maha Al-Ammari, Tariq Al-Debasi, Abdulmalik M Alkatheri, Shmeylan Al-Harbi, Aiman A Obaidat, Abdulkareem M Al-Bekairy
DOI:10.4103/sja.SJA_228_17  
Background: Vaso-occlusive crisis (VOC) is one of the acute complications of sickle-cell disease (SCD). Treatment mainly relies on hydration and pain control by analgesics. The specific aim of this study was to assess potential health outcomes within the first 72 h of admission between intermittent and patient-controlled analgesia (PCA) by opioids among VOC patients. Methods: A retrospective chart review study was conducted to determine SCD patients with VOC. Using the hospital electronic system, the following data were collected: patient's age, gender, blood pressure, heart rate, respiratory rate, oxygen saturation, and pain score on admission and daily for 3 days as well as the cumulative opioid analgesic dose for 72 h which is reported as morphine equivalent. Results: One hundred and seventeen patients were screened over a period of 5 years. Of those, 99 (84.6%) met the study inclusion criteria, and 18 patients (15.4%) were excluded from the study. During the first 72 h of admission, a significant reduction in pain score was observed in patients on intermittent intravenous (IV) administration compared to those in the PCA group (P < 0.0004) where the mean pain scores were 3 and 5, respectively. The total amount of morphine administered over 72 h of admission was significantly higher in PCA group (777 ± 175 mg) as compared to the intermittent IV administration group (149 ± 74 mg) (P < 0.000003). Clinically significant hypotension or respiratory depression was not observed in both groups over the 72 h of admission. Conclusion: During the first 72 h of admission, intermittent IV administration of morphine was more effective than PCA infusion in pain control.
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Ultrasound-guided multilevel paravertebral block versus local anesthesia for medical thoracoscopy p. 442
Maha A Abo-Zeid, Mohammad M Elgamal, Asem A Hewidy, Amro A Moawad, Alaa Eldin Adel Elmaddawy
DOI:10.4103/sja.SJA_292_17  
Background: Local anesthetic infiltration for medical thoracoscopy has an analgesic properties for short duration. Single injection thoracic paravertebral block (PVB) provides limited analgesia. Purpose: Comparison between thoracic PVB performed at two or three levels with local infiltration for anesthetic adequacy in adult medical thoracoscopy as a primary outcome and postthoracoscopic analgesia and pulmonary function as secondary outcomes for adult medical thoracoscopy. Patients and Methods: Prospective randomized control study included 63 adult patients with exudative pleural effusion randomly divided into three groups of 21 patients: 3-level PVB, 2-level PVB group, and local infiltration group. Patients with contraindications to regional anesthesia or uncontrolled comorbidities were excluded from the study. Pain visual analog scale and spirometry were used for comparison as anesthetic adequacy in adult medical thoracoscopy as a primary outcome besides prolonged analgesia and improved pulmonary function as secondary outcomes. Results: The anesthetic adequacy was 95.3% in 3-level PVB group, 81% in 2-level PVB group, and 71.5% in local infiltration group. The mean sensory level was 1 ± 0.8 and 1 ± 0.6 segment above and 0.8 ± 0.6 and 0.7 ± 0.7 segment below the injected level in 3-level PVB group and 2-level PVB, respectively. VAS was statistically significant higher in local infiltration compared to the other two groups immediately postthoracoscopic and 1 h after. Two-hour postthoracoscopy, significant increase in forced vital capacity values in the three groups compared to their basal values whereas forced expiratory volume at 1 s (FEV1) only in both PVB groups. Conclusion: Unilateral 3-level TPVB was superior to 2-level TPVB and LA infiltration for anesthetic adequacy for patients undergoing medical thoracoscopy. Moreover, US-guided TPVB was followed by higher FEV1 values and lower pain scores during the next 12 h postthoracoscopy in comparison to local infiltration, so 3-level TPVB is an effective and relatively safe anesthetic technique for adult patients undergoing medical thoracoscopy which may replace local anesthesia.
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Ultrasound assessment of cranial spread during caudal blockade in children: Effect of different volumes of local anesthetic p. 449
Chandni Sinha, Amarjeet Kumar, Shalini Sharma, Akhilesh Kumar Singh, Somak Majumdar, Ajeet Kumar, Nishant Sahay, Bindey Kumar, UK Bhadani
DOI:10.4103/sja.SJA_284_17  
Background: Ultrasound-guided caudal block injection is a simple, safe, and effective method of anesthesia/analgesia in pediatric patients. The volume of caudal drug required has always been a matter of debate. Materials and Methods: This present prospective, randomized, double-blinded study aimed to measure extent of the cranial spread of caudally administered levobupivacaine in Indian children by means of real-time ultrasonography. Ninety American Society of Anesthesiologists I/II children scheduled for urogenital surgeries were enrolled in this trial. Anesthesia and caudal analgesia were administered in a standardized manner in the patients. The patients received 0.5 ml/kg or 1 ml/kg or 1.25 ml/kg of 0.125% levobupivacaine according to the group allocated. Cranial spread of local anesthetic was noted using ultrasound. Results: There was no difference in the spread when related to age, sex, weight, or body mass index. A significant difference of ultrasound-assessed cranial spread of the local anesthetic was found between Group 1 (0.5 ml/kg) with both Group 2 (1 ml/kg) (P = 0.001) and with Group 3 (1.125 ml/kg) (P < 0.001) but there is no significant difference between Group 2 and Group 3 (P = 0.451) revealing that spinal level spread is only different between 0.5 ml/kg and 1 ml/kg of local anesthetic. Conclusion: In conclusion, the ultrasound assessment of local anesthetic spread after a caudal block showed that cranial spread of the block is dependent on the volume injected into the caudal space. Since there was no difference between 1 ml/kg and 1.25 ml/kg, to achieve a dermatomal blockade up to thoracic level, we might have to increase the dose beyond 1.25 ml/kg, keeping the toxic dose in mind.
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REVIEW ARTICLE Top

Anesthesia in pregnancy with heart disease p. 454
Ankur Luthra, Ritika Bajaj, Anudeep Jafra, Kiran Jangra, VK Arya
DOI:10.4103/sja.SJA_277_17  
Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence – for better or for worse – on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.
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CASE REPORTS Top

Use of rocuronium and sugammadex under neuromuscular transmission monitoring in a patient with multiple sclerosis p. 472
Chryssoula Staikou, Martina Rekatsina
DOI:10.4103/sja.SJA_625_16  
Multiple sclerosis (MS) is a potentially disabling disease characterized by demyelinating lesions in the central nervous system. One of the anesthetic challenges encountered in surgical patients with MS is the management of neuromuscular blockade (NMB) and its reversal. We report a case of a 31-year-old female patient suffering from MS, who underwent gynecological surgery under general anesthesia with sevoflurane, fentanyl, and rocuronium which was successfully reversed with sugammadex. Neuromuscular transmission (NMT) monitoring was used to guide the intraoperative doses of rocuronium and also the reversal of NMB by the use of sugammadex to ensure a safe tracheal extubation. In addition, delivered volatile was titrated according to anesthetic depth monitoring (Bispectral Index) while esophageal temperature was also monitored for the maintenance of normothermia. Postoperatively, a multimodal analgesic scheme offered a high-quality analgesia and sleep, minimization of anxiety, and increased patient satisfaction. At 1-month follow-up, the patient's course was uncomplicated without any MS exacerbation. We consider that the use of rocuronium and sugammadex under NMT monitoring may represent a useful and safe choice in patients with MS.
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Intentional intra-arterial injection of midazolam in a patient with status epilepticus in the intensive care unit p. 476
Muhammad Asghar Ali, Muhammad Yahya
DOI:10.4103/sja.SJA_93_17  
Fundamental medical care includes intravenous (IV) access which provides prompt resuscitation and reliable delivery of analgesics, antibiotics, and vasoactive medication. Difficult access populations, especially in critical area, continue to challenge providers to consider and utilize alternative means to provide IV access. Potential options under such circumstances include intramuscular, intraosseous, and intratracheal drug administration, but in extreme cases where no other options are available, intra-arterial route might be considered. We present a case where midazolam was intentionally injected intra-arterially to abort seizure activity in a patient with status epilepticus in the Intensive Care Unit.
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Ultrasound-guided continuous spinal anesthesia for cesarean section in a parturient with scoliosis corrected with harrington's rod surgery p. 479
Amer Majeed, Iftikhar Ahmed, Ghadah Jamaan Alkahtani, Nasser Abdullah Altahtam
DOI:10.4103/sja.SJA_112_17  
With rapid improvement in healthcare in Saudi Arabia, increasing number of women with surgically corrected kyphoscoliosis are likely to present for cesarean section (CS) or vaginal delivery requiring anesthesia or analgesia. Despite the surgical correction, these patients have poor cardiopulmonary reserves which increase the risks associated with general anesthesia. Whereas altered vertebral anatomy from previous surgery and the presence of metal work in spine make performing of regional anesthesia (RA) difficult and unpredictable, we report anesthetic management of such a patient who underwent CS using continuous spinal anesthesia technique. Challenges of placement of a spinal catheter in such a patient are discussed, and use of ultrasonography to circumnavigate these challenges is described. We propose that ultrasound can prove extremely valuable in performing of RA in patients with surgically corrected kyphoscoliosis. We could not find a similar case report from Saudi Arabia in the published literature.
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Double aortic arch presenting with respiratory distress: A case report and review of the literature p. 483
Abdelhafid Houba, Mustapha Bensghir, Redouane Ahtil, Badr Slioui, Hicham Balkhi, Salim Jaafar Lalaoui
DOI:10.4103/sja.SJA_249_17  
Tracheal compression by vascular structures in infants is uncommon and may be masked by nonspecific respiratory symptoms. Double aortic arch (DAA) is the most common vascular ring. We describe a case of a 9-month-old male infant presented with respiratory distress and found to have a DAA. In this report, the authors emphasize the consideration of this pathology-induced respiratory distress and discuss its anesthetic management.
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Anesthesia management for a case of laryngeal keel placement p. 486
Kundan Gosavi, Paulomi Dey, Sachin Swami, Akshay Salunke
DOI:10.4103/sja.SJA_236_17  
Congenital laryngeal web is a rare anomaly with incidence of 1 in 10,000 births. Its clinical presentation may range from an asymptomatic patient or mild hoarseness of voice to severe respiratory stridor. The primary goals of surgical intervention for congenital laryngeal web are to establish a patent airway and to achieve a good voice quality. As recurrence rate after plain excision of laryngeal web is very high, its removal may be coupled by placement of a silastic keel in between vocal cords. Endolaryngeal placement of a keel is definitely less invasive than laryngofissure, but little is known about its anesthesia management. Frequent ventilatory adjustment and endotracheal tube (ETT) manipulations are needed along with vigilant monitoring. Risk of perforation or accidental dislodgment of the ETT and laryngeal edema are other concerns in management. We report a case.
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Microlaryngeal endotracheal tube for lung isolation in pediatric patient with significant tracheal narrowing p. 490
Renu Sinha, Anjan Trikha, Rajkumar Subramanian
DOI:10.4103/1658-354X.215427  
A 15-year-old boy, weighing 45 kg, 160 cm height with large anterior mediastinal mass and significant tracheal narrowing was scheduled for thoracotomy and excision of the mass. He had a history of progressive dyspnea, inability to lie supine, and a right upper hemithorax mass 13 cm × 13 cm × 11 cm as evident on a computerized tomography with significant compression of the trachea and right main stem bronchus. Inhalational induction was carried out using sevoflurane with 100% oxygen. After achieving adequate depth of anesthesia with the maintenance of spontaneous respiration with oxygen and sevoflurane (minimum alveolar concentration 1.7), left principal bronchus was intubated under fiber-optic bronchoscopy, with 5 mm cuffed microlaryngeal surgery tube. Excellent lung isolation was achieved. Selection of endotracheal tube for lung isolation and endobronchial intubation in the presence of significant tracheal narrowing are discussed.
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Intramyometrial vasopressin: A fear for anesthetist? p. 494
Savitri D Kabade, Roopa Sachidananda, Elizabeth Wilson, Shobha B Divater
DOI:10.4103/sja.SJA_102_17  
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Avoiding failed spinal anesthesia: “Advik technique” Highly accessed article p. 495
Bhavna Kakkar, Lalit Gupta, Anish Gupta, Kamna Kakkar
DOI:10.4103/sja.SJA_98_17  
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A very rare unusual site of ventilator breathing circuit leakage: Beware!! p. 496
Akshaya Narayan Shetti
DOI:10.4103/sja.SJA_114_17  
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Magill forceps: A savior in bronchoscopy p. 498
Teena Bansal, Shilpa Popli, Nidhi Bangarwa, Sudhir Kumar, Pushpa Yadav
DOI:10.4103/sja.SJA_100_17  
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Intravenous burn following accidental warm saline infusion p. 498
Vandna Bharti, Raghavendra Vagyannavar, Mohammad Hashim
DOI:10.4103/sja.SJA_109_17  
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Child with Edward's syndrome for radiological procedure: An anesthetic challenge p. 500
Gaurav Singh Tomar, Shailendra Kumar, Keshav Goyal, Arvind Chaturvedi
DOI:10.4103/sja.SJA_157_17  
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Ventricular laryngeal cyst: A threat to airway! p. 501
Ankur Luthra, Rashmi Singh, Anudeep Jafra, Sameer Sethi, B Naveen Naik, Rajeev Chauhan
DOI:10.4103/sja.SJA_208_17  
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Gum elastic bougie as a guide in nasotracheal intubation: A novel technique p. 503
Rohini Varadraj Bhat Pai, Shaila Kamat, Deependra Kambli
DOI:10.4103/sja.SJA_214_17  
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Splanchnic nerve radiofrequency ablation for treating resistant abdominal pain p. 504
Sherif Zaky, Alaa Abd-Elsayed
DOI:10.4103/sja.SJA_206_17  
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Pulsed radiofrequency of the supraorbital nerve for the treatment of supraorbital neuralgia p. 505
Harsh Sachdeva, Lance Hoffman, Alaa Abd-Elsyed
DOI:10.4103/sja.SJA_159_17  
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Using angle connector? Be careful: A hazard note p. 506
Akshaya Narayan Shetti
DOI:10.4103/sja.SJA_226_17  
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Concealed kinking of pediatric flexometallic tube at fixation point p. 507
Uma Hariharan, Priyanka Shrivastava, Alka Gupta, Nihar Nalini Senapati
DOI:10.4103/sja.SJA_219_17  
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Craniopagus twins for magnetic resonance imaging p. 509
Raghavendra Vagyannavar, Amrita Bhattacharyya, Gaurav Misra, Mohammad Hashim, Asmita
DOI:10.4103/sja.SJA_89_17  
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Arm position-dependent kinking of intravenous cannula p. 511
Yassar Alamri
DOI:10.4103/sja.SJA_260_17  
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“Two-hand-manoeuver” during nasotracheal intubation p. 512
Sohan Lal Solanki, Jasmeen Kaur
DOI:10.4103/sja.SJA_229_17  
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Bilateral quadratus lumborum block for postoperative analgesia in a Von Hippel-Lindau syndrome patient undergoing laparoscopic radical nephrectomy p. 513
Gaurav Sindwani, Sandeep Sahu, Aditi Suri, Zakia Saeed
DOI:10.4103/sja.SJA_263_17  
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“Curare crest” can detect breakthrough breathing p. 514
Om Prakash Sanjeev, Deepak Malviya, Prakash Kumar Dubey
DOI:10.4103/sja.SJA_238_17  
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Anesthetic management of craniopagus conjoined twins in a remote location p. 516
Monu Yadav, Ramakrishnaprasad Chikkala, Dilip Kulkarni, R Gopinath
DOI:10.4103/sja.SJA_288_17  
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Use the natural curve of the nasogastric tube: A simple technique of insertion p. 518
Monish S Raut
DOI:10.4103/sja.SJA_389_17  
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Retroclavicular approach of brachial plexus block: Here to stay!!! p. 519
Chandni Sinha, Amarjeet Kumar, Akhilesh Kumar Singh, Umesh Kumar Bhadani
DOI:10.4103/sja.SJA_355_17  
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A rare case of submitral left ventricular aneurysms p. 520
Zara Wani, Meenaxi Sharma
DOI:10.4103/sja.SJA_483_17  
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