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October-December 2018
Volume 12 | Issue 4
Page Nos. 507-662

Online since Thursday, October 4, 2018

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EDITORIALS  

Welcome Message p. 507
Ahmed Abdulmomen
DOI:10.4103/sja.SJA_516_18  
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Caveat scriptor Highly accessed article p. 508
John A Loadsman
DOI:10.4103/sja.SJA_552_18  
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Video-assisted subpleural block: A description of a novel technique p. 510
Abdullah Aldohayan, Abdelazeem Eldawlatly
DOI:10.4103/sja.SJA_325_18  
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Turning of the tides: Saudi Arabia sits a top in the academic impact factor race in the region p. 512
Sultan Ayoub Meo, Abdelazeem Eldawlatly
DOI:10.4103/sja.SJA_505_18  
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ORIGINAL ARTICLES Top

Using propranolol in traumatic brain injury to reduce sympathetic storm phenomenon: A prospective randomized clinical trial p. 514
Mona Ahmed Ammar, Noha Sayed Hussein
DOI:10.4103/sja.SJA_33_18  
Background: Traumatic brain injury (TBI) correlated with increased sympathetic activity on the expense of parasympathetic system due to loss of cortical control after brain injury. Manifestations of sympathetic storm include tachycardia, hypertension, tachypnea, and hyperthermia. The neuroprotective effects via reducing cerebral metabolism and lowering O2 and glucose consumption are the targets early after trauma. Beta-blockers reduce sympathetic activity. Objectives: We suppose that using propranolol blunts the sympathetic storming phenomenon as it is a nonselective β inhibitor and has a lipophilic property to steadily penetrate blood–brain barrier. Patients and Methods: Sixty patients allocated randomly into two groups, each consisting of 30 patients. Group A started propranolol and Group B received placebo within first 24 h. Primary outcome was catecholamine levels on day 7, and the secondary outcomes were physiological measures (heart rate [HR], respiratory rate [RR], mean arterial blood pressure [MABP], temperature, random blood sugar, and follow-up Glasgow coma score [GCS] and sedation score). Results: Analysis of outcomes demonstrated that Group A tended to have lower catecholamine levels in comparison to Group B in day 7 (norepinephrine 206.87 ± 44.44 vs. 529.33 ± 42.99 pg/ml, P = <0.001), epinephrine level (69.00 ± 8.66 vs. 190.73 ± 16.48 pg/ml, P < 0.001), and dopamine level (32.90 ± 4.57 vs. 78.00 ± 3.48 pg/ml P < 0.001). GCS of the patients in Group A improved and was statistically significant compared to Group B in day 7 (13 vs. 10, P = 0.006), with percent change interquartile range (20.0 vs. 8.33, P = 0.006). Regarding hemodynamic parameters between the two groups MABP, HR, RR, and temperature, there was no statistically significant difference on day 1, while on day 7, there is high statistical significance and significant percent change (P < 0.001). Conclusion: Early usage of propranolol after TBI controls hemodynamics and blood sugar with decreased catecholamine levels correlated with the improvement of GCS.
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Emergency department visits for paroxysmal supraventricular tachycardia in Saudi Arabia p. 521
Saqer M Althunayyan, Anas A Khan, Osama A Samarkandi
DOI:10.4103/sja.SJA_35_18  
Purpose: The present study aimed to compare the demographic, medical history, clinical features, and treatment management of paroxysmal supraventricular tachycardia (PSVT) in the emergency department of a teaching hospital in Riyadh, Saudi Arabia. A secondary purpose was to evaluate Adenosine response among numerous variables that might be used as predictors of the conversion. Methods: All PSVT cases presented to the Department of Emergency Medicine at King Khalid University Hospital, during the period from January 1, 2016, until December 31, 2016, were included in the study. Patients were assigned into two groups: adenosine sensitive (AS-group) and adenosine resistant (AR-group) according to adenosine conversion response. Results: A total of 38 patients were admitted during the study period. Fisher's exact test results showed that there were no signifi cant (P > 0.05) differences among the AS-group and AR-group in the demographics, past medical history and clinical features, and post-ablation condition, except for the previous usage of the other anti-arrhythmic drugs to convert the last PSVT in the AR-group. The first bolus of adenosine had higher sensitivity and specificity, compared to the second bolus. Further, the second bolus of adenosine was not specific for short-term treatment of PSVT. Conclusions: Differences in adenosine sensitivity among PSVT patients were independent of demographic, past medical history, and clinical features of PSVT patients. Thus, the difference in adenosine response among groups may be attributed to the heterozygosity in conducting pathways. The first bolus of adenosine had high sensitivity and specificity, compared to the second bolus, and their optimal levels were predictable by HR deceleration.
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Enteral nutrition with omega-3 fatty acids in critically ill septic patients: A randomized double-blinded study p. 529
Ezzeldin Saleh Ibrahim
DOI:10.4103/sja.SJA_50_18  
Purpose: The present study was done to investigate the effect of the enteral omega-3 fatty acids on critically ill septic patients. Methods: A total of 110 critically ill septic patients were divided into two groups, 55 patients in each. Group A received enteral nutrition with 1000 mg omega-3 three times daily and Group B received enteral nutrition without omega-3. Demographic data, sepsis characteristics, number of patients required invasive ventilation, ventilation days, Intensive Care Unit (ICU) sequential organ failure assessment (SOFA) score, organ failure-free days, hemodynamic failure-free days, ICU stay, ICU, and hospital outcome were recorded. Results: Leukocytic count and C-reactive protein were higher in Group B during ICU stay (P = 0.010 and 0.003, respectively). The number of organ and hemodynamic failure-free days was higher in Group A (P < 0.05). Overall, ICU SOFA score was higher in Group B (P = 0.03). There was no difference in the number of patients requiring mechanical ventilation (P = 0.41). ICU stay was longer in Group B (P = 0.019); however, post-ICU hospital stay was similar in both groups. There were no differences regarding ICU and hospital survivors (P > 0.05). Conclusions: Enteral nutrition with omega-3 can improve organ function and decrease ICU stay in septic patients. Omega-3 fatty acids do not affect ICU mortality or decrease the post-ICU hospital stay.
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Comparison of I-gel for general anesthesia in obese and nonobese patients p. 535
Rati Prabha, Rajesh Raman, Mohammad Parvez Khan, Dinesh Kaushal, Ahsan Khaliq Siddiqui, Haider Abbas
DOI:10.4103/sja.SJA_79_18  
Context: I-gel is a second-generation supraglottic airway device. Despite several studies on i-gel, there are very few studies on the use of i-gel in obese patients. Aims: The aim of the study was to compare the clinical performance of i-gel between obese and nonobese patients. Settings and Design: Prospective, controlled, nonrandomized, hospital-based study. Subjects and Methods: After obtaining informed consent, patients were divided into two groups of 16 patients each: group O consisted of patients with body mass index (BMI) >30 kg/m2 and Group C consisted of patients with BMI 18.5–29.9 kg/m2. I-gel was inserted after induction of anesthesia and muscle relaxation. Oropharyngeal leak pressure (OLP) (primary outcome variable), leak fraction, time taken to insert the device, ease of insertion, fiberoptic view of glottis through i-gel's airway tube, and adverse effects were recorded. Statistical Analysis Used: Data were analyzed using SPSS 20. Continuous, ordinal, and categorical variables were analyzed using students t-test, Mann–Whitney U–test, and Fischer's exact test, respectively. Results: OLP was slightly higher in Group O (25.38 ± 4.79 cm H2O) but was not statistically different than Group C (27.38 ± 4.38 cm H2O). Other parameters except weight and BMI (which were higher in Group O) were statistically similar in both groups. There was no statistical difference in side effects. Conclusions: We concluded that i-gel is as effective in obese patients as in nonobese patients when used for securing the airway for surgical procedures.
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International internship experience for emergency medical service paramedic students p. 540
Daifallah Alrazeeni
DOI:10.4103/sja.SJA_146_18  
Introduction: The purpose of this study is to delineate the training activities in the internship program, describe students' clinical and emergency medical service field hours and skills performance, and compare between internship students groups in their skills performance. Methods: This is a retrospective, descriptive, and analytical study based on an interpretive observational documentary review of internship reports received on internship students. Results: Three groups of internship students participated in various training activities in 3 years. Students in Group A (2015) completed 4610 h and contact 1600 patients. They completed the following clinical skills: 712 medication administrations, 652 intravenous (IV) access, 174 team leads (TLs), 4 live patient endotracheal intubations, and 13 ventilations. Students in Group B (2016) completed 2424 h and contact 797 patients. They completed several clinical skills including 256 medication administrations, 249 IV access, 16 TLs, 1 live patient endotracheal intubation, and 8 ventilations. Students in Group C (2017) completed 5700 h and contact 1200 patients. They completed several skills including 673 medication administrations, 650 IV access, 198 TLs, 11 live patient endotracheal intubations, and 27 ventilations. The study revealed significant differences and superiority in skills performance in Groups A (2015) and C (2017) over Group B (2016). Conclusion: Internship students have exposure opportunities to patients and have more opportunities to perform medication administration, IV activities, and serve as TLs. As expected, internship students have few opportunities to perform live tube insertions and ventilation. There are statistical significant differences in skills performance within the group of students in each year and among the three groups of internship students.
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Comparative evaluation of analgesic sparing efficacy between dexmedetomidine and clonidine used as adjuvant to ropivacaine in thoracic paravertebral block for patients undergoing breast cancer surgery: A prospective, randomized, double-blind study p. 548
Anindya Mukherjee, Anjan Das, Nairita Mayur, Chiranjib Bhattacharyya, Hirak Biswas, Tapobrata Mitra, Sandip Roybasunia, Subrata Kumar Mandal
DOI:10.4103/sja.SJA_81_18  
Introduction: Thoracic paravertebral block (TPVB) is an effective method for intra- and post-operative pain management in thoracic surgeries. For a long time, various adjuvants have been tried for prolonging the duration of TPVB. Objective: In this prospective study, we have compared the analgesic sparing efficacy of dexmedetomidine and clonidine, two α2 adrenergic agonists, administered along with ropivacaine for TPVB for breast cancer surgery patients. Materials and Methods: Forty-four breast cancer surgery patients undergoing general anesthesia (GA) were randomly divided into Group C and Group D (n = 44 each) receiving preoperative TPVB at T3-5 level with 0.5% ropivacaine solution admixture with clonidine and dexmedetomidine, respectively. Cancer surgery was performed under GA. Intraoperative fentanyl and propofol requirement was compared. Visual analogue scale was used for pain assessment. Total dose and mean time to administration of first rescue analgesic diclofenac sodium was noted. Side effects and hemodynamic parameters were also noted. Results: Intraoperative fentanyl and propofol requirement was significantly less in dexmedetomidine group than clonidine. The requirement of diclofenac sodium was also significantly less and later in Group D than Group C. Hemodynamics, and side effects were comparable among two groups. Conclusion: Dexmedetomidine provided better intraoperative as well as postoperative analgesia than clonidine when administered with ropivacaine in TPVB before breast cancer surgery patients without producing remarkable side effects.
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Is body mass index ≥50 kg/m2 a predictor of higher morbidity for patients who have undergone laparoscopic sleeve gastrectomy? p. 555
Fahad Bamehriz, Saad Althuwaini, Omar Alobaid, Yara Alanazi, Rawan Alotaibi, Nawt Alfuweres, Najla Alsaikhan, Waad Almanie, Munira Alghafaily, Abdulla Aldohayan
DOI:10.4103/sja.SJA_140_18  
Background: Super-morbid obese (SMO) patients (body mass index [BMI] >50 kg/m2) carry a higher risk for bariatric surgery. Despite several studies addressing this patient group, the number of patients included tends to be relatively small. Methods: We reviewed 708 patients who underwent laparoscopic sleeve gastrectomy between 2009 and 2015 and compared the outcome of SMO (BMI ≥50 kg/m2) patients with MO (BMI <50 kg/m2) patients. Results: Of 708 patients, 217 were SMO and 491 were MO. Both groups had homogeneous baseline characteristics and comorbidities, except sleep apnea which was higher in SMO group. There was no significant difference for the duration of operation, length of stay, or recovery room time. The mean number of trocars was four for both groups. There were no conversions to open or documented intraoperative complications in either group. Postoperative complications occurred in 13 (6%) SMO patients (3 patients with leakage and 10 with bleeding). Postoperative complications occurred in 21 (4.3%) MO patients (11 patients with leakage and 10 with bleeding). No reoperation was done in both groups. There was no surgical mortality. Conclusion: We detected no significant difference in the duration of operation and intra- or postoperative complication between SMO and MO groups. The possibility of the safety of this procedure in SMO group can be adopted.
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Evaluation of thoracolumbar interfascial plane block for postoperative analgesia after herniated lumbar disc surgery: A randomized clinical trial p. 559
Mona Ahmed Ammar, Mohamed Taeimah
DOI:10.4103/sja.SJA_177_18  
Background: Thoracolumbar interfascial plane (TLIP) block involves injection of local anesthetics between multifidus and longissimus muscles at the 3rd lumbar vertebral level assuming that it can block the dorsal rami of thoracolumbar nerves. Objective: The objective of this study was to evaluate the analgesic effects gained after performing TLIP block (analogous to the transversus abdominis plane [TAP] block, but intended for the back) in patients undergoing lumbar discectomy. Methodology: This was a prospective, randomized, double-blinded, controlled clinical trial. Computer-generated randomization numbers were used to allocate patients into two groups. A total of 102 patients scheduled for lumbar discectomy were considered eligible, of these 70 patients were randomly included in the analysis: 35 patients (control group) received the standard general anesthetic technique and 35 patients (TLIP group) received TLIP block with 20 ml mixture of 0.25% bupivacaine and 1% lidocaine on each side. The primary outcome was to compare the two groups with regard to pain scores, whereas the secondary outcomes included the time to first analgesic (TFA), 24-h morphine consumption, and side effects associated with morphine such as nausea, vomiting, and sedation. Results: TLIP group compared with the control group showed a significant reduction in the postoperative Visual Analog Scale for pain score both on rest and movement, with no statistically significant difference at 24 h during movement. TFA was significantly shorter in the control group compared to the TLIP group (82.00 ± 69.01 vs. 442.7 ± 126.47 min, P < 0.001). TLIP group had lower cumulative morphine consumption than control group of statistically significant difference (9.7 ± 6.38 vs. 25.88 ± 5.17 mg, P < 0.001). TLIP block group compared with the control group showed a significant reduction of nausea and a lower incidence of sedation. Conclusion: TLIP block is an effective and safe method for postoperative analgesia after lumbar discectomy.
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Ultrasound-guided serratus anterior plane block versus thoracic paravertebral block for perioperative analgesia in thoracotomy Highly accessed article p. 565
Fady Samy Saad, Samia Yehia El Baradie, Maha Abdel Wahab Abdel Aliem, Mohamed Metwally Ali, Tamer Ahmed Mahmoud Kotb
DOI:10.4103/sja.SJA_153_18  
Background: Thoracotomy needs adequate powerful postoperative analgesia. This study aims to compare the safety and efficacy of ultrasound (US)-guided serratus anterior plane block (SAPB) and thoracic paravertebral block (TPVB) for perioperative analgesia in cancer patients having lung lobectomy. Patients and Methods: This clinical trial involved 90 patients with lung cancer scheduled for lung lobectomy randomly divided into three groups according to the type of preemptive regional block. Group TPVB received US-guided TPVB. In Group SAPB, US-guided SAPB was performed. The patients of the control Group received general anesthesia alone. The outcome measures were postoperative visual analog scale (VAS) score, intraoperative fentanyl consumption, time of first rescue analgesic, total dose postoperative analgesic, and drug-related adverse effects. Results: Analgesia was adequate in TPVB and SAPB groups up to 24 h. VAS score was comparable in TPVB and SAPB groups and significantly lower compared to control group up to 9 h postoperatively. At 12 and 24 h, TPVB group had significantly lower VAS score relative to SAPB and control groups. Total intraoperative fentanyl consumption was significantly lower in TPVB and SAPB Groups compared to control group. The majority of TPVB Group cases did not need rescue morphine, while the majority of control group needed two doses (P < 0.001). The hemodynamic variables were stable in all patients. Few cases reported trivial adverse effects. Conclusion: Preemptive TPVB and SAPB provide comparable levels of adequate analgesia for the first 24 h after thoracotomy. TPVB provided better analgesia after 12 h. The two procedures reduce intraoperative fentanyl and postoperative morphine consumption.
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2% lidocaine versus 3% prilocaine for oral and maxillofacial surgery p. 571
Ali Alsharif, Esam Omar, Al-Braa Badr Alolayan, Rayan Bahabri, Giath Gazal
DOI:10.4103/sja.SJA_259_18  
Objective: To investigate the speed of action and injection discomfort of 2% lidocaine and 3% prilocaine for upper teeth extractions. Materials and Methods: Forty-six patients were included in the prilocaine 3% group, and 46 in the lidocaine 2% control group. After all injections, soft and hard tissue numbness was objectively gauged by dental probe at intervals of 15 s. Moreover, the pain of the injections was recorded by the patients after each treatment on standard 100 mm visual analog scales, tagged at the endpoints with “no pain ” (0 mm) and “unbearable pain ” (100 mm). Results: There were no significant differences in the meantime of first numbness to associated buccal, palatal mucosa, and tooth of patients in the lidocaine and prilocaine buccal infiltration groups (P = 0.56, 0.37, and 0.33). However, clinically, the patients in prilocaine group recorded earlier buccal, palatal mucosa, and teeth numbness than those in lidocaine group. With regards to the discomfort of the needle injections, there was a significant difference for lidocaine and prilocaine groups when comparing the post buccal scores with the post palatal injection scores (t-test: P < 0.001). Lidocaine and prilocaine buccal injections were significantly more comfortable than palatal injections. Conclusions: Using 2% lidocaine and 3% prilocaine for extractions of upper maxillary teeth produces similarly successful anesthesia. Clinically, prilocaine has slightly rapid onset of action, earlier buccal mucosa, hard palate, and teeth numbness. Prilocaine and lidocaine buccal injection was significantly more comfortable than palatal injection.
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Ultrasonographic assessment of internal jugular vein diameter and its relationship with the carotid artery at the apex, middle, and base of the triangle formed by two heads of sternocleidomastoid muscle: A pilot study in healthy volunteers p. 578
Sohan L Solanki, Jeson R Doctor, Savi J Kapila, Anuja Jain, Malini Joshi, Vijaya P Patil
DOI:10.4103/sja.SJA_309_18  
Background: Anteroposterior (AP) diameter of internal jugular vein (IJV) and its relative position with carotid artery (CA) varies in the triangle formed by two heads of sternocleidomastoid muscle, which is the site of insertion of needle for IJV cannulation. This study assessed the maximum AP diameter of the IJV in supine and Trendelenburg positions and during Valsalva maneuver (supine position) at the apex, middle, and base of the triangle and to study the relationship of the IJV with the CA. Materials and Methods: Twenty-five healthy volunteers were included and ultrasonography of IJV was performed in supine and Trendelenburg positions and during Valsalva maneuver (supine position) at the apex, middle, and base of the triangle bilaterally. The AP diameter of IJV was measured. The relative anatomical position of IJV was assessed as anterior (A), anterolateral (AL), or lateral (L) to CA in neutral head position and 30°, 45°, and 90° head rotation to the contralateral side in supine position. Results: The difference in right IJV diameter was significant (P = 0.001) between supine vs. Trendelenburg position at the base of the triangle. Within one position there was significant difference between apex and base of the triangle. The left IJV diameter was significantly different between supine vs. Trendelenburg position at the apex (P = 0.004), middle (P = 0.003), and base of the triangle (P-value = 0.001). There was significant difference between supine vs. Valsalva maneuver at the middle (P = 0.011) and base (P = 0.014) of the triangle. The right IJV was more L or AL to the CA in apex with head in neutral or 30° rotation. The left IJV was more L or AL to the CA in middle with head in neutral position. Conclusion: Trendelenburg and Valsalva increase diameter of IJV on both right and left side. Diameter of IJV is greater at the base of the triangle. IJV is lateral or anterolateral when the head is either neutral or turned 30° to the contralateral side.
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The utility of limited trans-thoracic echocardiography in the stratification of pulse pressure variation: A feasibility study in major open abdominal surgery p. 584
Tanvir Samra, R Deepak, Aveek Jayant, Vikas Saini
DOI:10.4103/sja.SJA_686_17  
Background and Aim: Limitation in use of pulse pressure variation (PPV) in predicting fluid responsiveness (FR) in hypotensive patients is encountered when values are in the “gray zone ” (8–13%). Dynamic arterial elastance (Eadyn = PPV/SVV) can be used in such situations to predict arterial pressure response to volume expansion (VE). In our study, we used respiratory variation of ascending aorta velocity time integral (AoVTI) calculated from suprasternal window as a surrogate of stroke volume variation (SVV). Fluids/vasopressors were administered to hypotensive patients intraoperatively based on value of Eadyn. Aim was to assess feasibility and utility of suprasternal echocardiography in the above-mentioned subset of patients. Materials and Methods: Hemodynamic data were monitored and respiratory variation in AoVTI was recorded using suprasternal echocardiography at all time points when patients developed hypotension (systolic blood pressure <90 mm Hg/<20% of baseline for 5 min) and at randomly selected time intervals when hemodynamic stability was maintained. VE with 250 ml of Ringer lactate (RL) was done in hypotensive patients with PPV value of 8–13% and Eadyn >0.9. Increase of >15% in AoVTI after VE defined “fluid responsiveness.” Results: Twenty-eight patients were enrolled, but three were excluded in view of left ventricular systolic dysfunction detected during preinduction echocardiography. Hemodynamic and echocardiographic data were recorded at 538 observation points in 25 adults. Hypotension occurred in 247 data sets, and in 168 data sets, value of PPV was 8–13%. VE was carried out in only those 131 data sets in which the value of Eadyn was >0.9. Area under the curve (AUC) for VE as an intervention in the indeterminate (PPV 8–13%) group was 0.574 (0.49–0.68, 95% CI, P < 0.049), and in the observation set with PPV >13, the AUC value was 0.7 (0.59–0.98, 95% CI, P < 0.01). Conclusions: Echocardiography using the suprasternal window in the operating room during abdominal surgery is feasible, but the utility of Eadyn in stratification of patients with PPV 8–13% is inconclusive.
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Surgically-assisted abdominal wall blocks for analgesia after abdominoplasty: A prospective randomized trial p. 593
Maha A Abo-Zeid, Al-Refaey K Al-Refaey, Ahmed M Zeina
DOI:10.4103/sja.SJA_303_18  
Background: Abdominoplasty is a common aesthetic procedure. The transversus abdominis plane block (TAPB) and rectus sheath block (RSB) have proven efficacy as analgesic modality for abdominal surgeries. This study demonstrates post-abdominoplasty analgesic duration consequent to the three surgically infiltrated local anesthetic techniques: bilateral TAPB, bilateral RSB, and subcutaneous infiltration (SCI) of 0.25% bupivacaine. Methods: In this prospective randomized study, 48 adult patients scheduled for abdominoplasty were randomized into three groups: TAPB group (n = 16), RSB group (n = 16), and SCI group (n = 16) utilizing 40 mL of 0.25% bupivacaine for each block. In both TAPB and RSB groups, the block was performed bilaterally after plication of anterior abdominal wall, while in SCI group, the surgical incisional area was infiltrated before skin closure. Main outcome measures included visual analogue scale (VAS), at rest and during movement; the analgesic duration; and the total required doses of morphine in the first postoperative day. Results: A statistically significant longer analgesia was recorded in the TABP group compared with both the RSB and SCI groups. Statistically significant higher VAS scores in the SCI group 4 hours postoperatively was recorded, both at rest and during movement, compared with both TABP and RSB groups. Significant higher morphine consumption in the SCI group was compared with the other two groups. Conclusions: Among the surgically infiltrated anesthetic techniques for abdominoplasty, bilateral TAPB was associated with longer postoperatively analgesic duration with lower morphine consumption in the first 24 hours compared with RSB and SCI.
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A comparative study between interlaminar nerve root targeted epidural versus infraneural transforaminal epidural steroids for treatment of intervertebral disc herniation p. 599
Alaa-Eldin Adel El Maadawy, Alaa Mazy, Mohamed El Mitwalli Mansour El Adrosy, Ashraf Abdel-Moneim El-Mitwalli, Ayman Mohamed Abd El Naby, Mohammad Gomma
DOI:10.4103/sja.SJA_263_18  
Background: Low back pain (LBP) is one of the most common musculoskeletal abnormalities. Epidural corticosteroid injections (ESIs) have been used long time ago for treatment of lumbar radiculopathy or discogenic back pain in case of failed medical and conservative management. Different techniques for ESIs include the interlaminar, the caudal, and the transforaminal approaches. Purpose: The aim of our study is to compare between the efficacy of infraneural transforaminal ESI and lumbar paramedian nerve root targeted interlaminar steroid injection in reduction of unilateral radicular pain secondary to disc prolapse. Patients and Methods: This prospective double-blind randomized study was performed on 40 patients randomized into two equal groups, each of 20: the infraneural transforaminal ESI (IN group) and the interlaminar parasagittal ESI (IL group). Patients with backache without leg radiation, or with focal motor neurological deficit, previous spine surgery, S1 radiculopathy, lumbar ESI in the past month, systemic steroid used recently within 4 weeks before the procedure, allergy to any medication or addiction to opioids, and pregnancy were excluded from the study. The duration and efficacy of pain relief (defined as ≥40% reduction of pain perception) by 0–10 visual analog scale (VAS) is the primary outcome. Functional assessment using Modified Oswestry Disability Questionnaire (MODQ) and possible side effects and complications are the secondary outcomes. Results: The VAS and MODQ scores were significantly lower in both groups in comparison with the basal values. There was also a lower VAS in the infraneural group than the parasagittal (IL) group up to 6 months after injection. Conclusion: The infraneural (IN) epidural steroid is more favorable than the parasagittal (IL) interlaminar epidural steroid owing to its long-term improvement in physical function than the parasagittal technique with no serious side effects.
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Assessment of effectiveness of cricoid pressure in preventing gastric insufflation during bag and mask ventilation: A randomized controlled trial p. 606
Arumugam Vasudevan, Suganya Srinivasan, Stalin Vinayagam, Govindarajalou Ramkumar, Muthapillai Senthilnathan
DOI:10.4103/sja.SJA_240_18  
Background: Rapid sequence induction and intubation (RSII) with application of “Cricoid pressure ” and avoidance of “facemask ventilation ” (FMV) is believed to minimize the risk of pulmonary aspiration of gastric contents during general anesthesia. However, some patients may be at risk of developing hypoxemia and may benefit from FMV during RSII. The purpose of this study was to assess the effectiveness of “cricoid pressure ” in preventing gastric insufflation during FMV using gastric ultrasonography. Materials and Methods: Eighty-four adult patients were randomized to receive cricoid pressure (CP) or no cricoid pressure (NCP), during FMV after induction of general anesthesia. Gastric antral cross-sectional area (CSA) was measured with ultrasonography before and after FMV in supine and right lateral decubitus positions (LDP). Appearance of “comet tail ” artifacts created by acoustic shadows of gas in the gastric antrum was noted. Results: The incidence of insufflation indicated by “comet tail ” artifacts during FMV was lower in group CP (17 vs 71%; P < 0.001). The lowest Paw at which gastric insufflation occurred was higher in group CP (20 vs 14 cmH2O). The change in mean gastric antral CSA was significantly lower in group CP than in group NCP in supine (0.02 vs 0.36 cm2, P = 0.012) and right LDP (0.03 vs 0.67 cm2, P < 0.001). Conclusion: Cricoid pressure is effective in preventing gastric insufflation during FMV at Paw less than 20 cmH2O. Observation of comet tail artifacts in gastric antrum along with measurement of change in antral CSA on ultrasound examination is a feasible and reliable method to detect gastric insufflation.
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REVIEW ARTICLES Top

General versus local anesthesia for carotid endarterectomy: Special considerations p. 612
Nikolaos Patelis, Maria Diakomi, Anastasios Maskanakis, Konstantinos Maltezos, Dimitrios Schizas, Marianna Papaioannou
DOI:10.4103/sja.SJA_10_18  
Anesthesia for carotid endarterectomy (CEA), general or locoregional, has been an issue of debate in literature ever since the first Cochrane review in 1991. The largest available study on the subject, the GALA trial, has not shown any difference in patient's outcome – incidence of stroke and 30-day-mortality postsurgery. However, increasing evidence favors regional anesthesia as an independent factor of reduced morbidity after CEA. The advantages and disadvantages of general versus regional anesthesia for CEA have been well established. Cervical plexus blocks (CPBs) are safe and effective anesthetic techniques, but they may also present adverse effects that we must be aware of. Optimal cerebral function monitoring remains a problem to be solved. Cerebral oximetry may prove to be a reliable tool in predicting neurological impairment. This narrative review intends to highlight the latest implemented anesthetic modalities for CEA, including CPB under ultrasound guidance, and to outline the main limitations of general versus regional anesthesia. Following the appropriate anesthetic, modality necessitates a thorough preoperative consultation among the patient, the surgeon, and the anesthetist. The anesthetic plan should be made on an individual basis, taking into consideration patient's comorbidities and wish.
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Pain relief after ambulatory surgery: Progress over the last decade p. 618
Anudeep Jafra, Sukanya Mitra
DOI:10.4103/sja.SJA_232_18  
The concept of fast-track or ambulatory surgery appeared to facilitate early recovery and discharge from the hospital and early resumption of normal daily activities after elective surgical procedures as well to reduce the health-care costs. Multimodal/balanced analgesia is an increasingly popular approach for this. The use of conventional modalities including central neuraxial blockade and opioids cannot be extended to patients undergoing fast-track surgery. Hence, an aggressive perioperative analgesic regimen/protocol is required for effective pain relief, with minimal side effects and which could be managed easily by the patient or the relatives at home away from the hospital setting. Pharmacological therapy and regional anesthesia techniques have been utilized for postoperative pain management. The use of perineural, incisional, and intra-articular catheters and local anesthetic administration through elastomeric and electronic pumps is promising approach for effective pain management at home. The key to successful pain management of such procedures requires individually tailored education to patients or caregivers including information on treatment options for postoperative pain and use of multimodal analgesia. This review provides an overview of the current armamentarium of drugs and modalities available for effective management of patients undergoing day care surgeries and sheds light on newer modalities available.
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CASE REPORTS Top

Emergent airway management in a patient with in situ tracheal stent: A lesson learned p. 626
Jose R Navas-Blanco, Junior Uduman, Javier Diaz-Mendoza
DOI:10.4103/sja.SJA_106_18  
The prevalence of in situ tracheal stents has increased in the past two decades for the management of malignant and benign central airway diseases for either palliation or definitive therapy. Recent placement of a tracheal stent has been associated with edema of the upper airway; therefore, these patients are at a great risk for airway collapse, especially within the days most recent to the procedure. The authors present the case of a morbidly obese patient with a tracheal stent admitted to the Intensive Care Unit who developed acute respiratory failure and was found to be “unable to ventilate, unable to intubate. ” Surgical airway approach through a cricothyroidotomy failed to provide a patent airway and the patient subsequently developed cardiac arrest and expired. The presence of tracheal stent poses a high challenge during emergent airway interventions; thus, carefully planned airway manipulation in such patients is paramount in order to avoid catastrophic outcomes.
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A case series of different anesthesia approaches for single ventricular physiology patients in various stages of palliation underwent noncardiac procedures p. 629
Abdulaleem Alatassi, Silvia Fernández Mulero, Nancy Massoud, Zainab Alzayer, Ahmed Haroun Mahmoud
DOI:10.4103/sja.SJA_36_18  
Patients with single ventricle physiology (SVP) are a particularly challenging population with congenital heart disease (CHD); they will go for staged, palliation ending in the Fontan circulation. Nowadays, with improvement in surgical procedures for CHD, these patients become growing population, and noncardiac surgeries become not uncommon. The authors report different anesthesia approaches for four pediatric patients with SVP underwent ten noncardiac procedures done under general anesthesia following the different stages of palliation at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia, between 2009 and 2015 and do a brief review of the literature on this topic. The aim of this study is to highlight that anesthesia approach for patients with SVP varies according to the patient physical situation at the time of the procedure, stage of palliation, and type of surgery. Therefore, every anesthesiologist should have thorough knowledge about SVP, different stages of palliative surgery, anesthesia concern in each one and risk factors associated with perioperative morbidity before anesthetizing patients for a noncardiac procedure to keep patient safety as well as avoiding unnecessary cancellation, rescheduling, and admissions to the ward or the Intensive Care Unit.
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Anesthetic considerations and successful management of a patient with permanent pacemaker for cervical spine instrumentation p. 634
Vattipalli Sameera, Mihir P Pandia, Barkha Bindu, Keshav Goyal
DOI:10.4103/sja.SJA_125_18  
Patients with permanent pacemaker posted for cervical spine instrumentation pose special challenges for modern-day anesthesiologist since the field of surgery is in proximity to the pacing apparatus. The important considerations in this regard are pacemaker dependency, prior reprogramming to asynchronous mode, perioperative interference with pacemaker function due to electrolyte, acid-base disturbances, and electromagnetic interference leading to pacemaker failure and hemodynamic compromise. We report successful anesthetic management of a patient of postlaminectomy kyphosis with compressive myelopathy with permanent pacemaker in situ who underwent C5–C6 corpectomy and instrumentation under general anesthesia.
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A novel out plane technique of midpoint transverse process to pleura block in breast surgery: A case report p. 637
Debesh Bhoi, N Ranjitha, Praveen Talawar, Purnima Narasimhan
DOI:10.4103/sja.SJA_116_18  
Regional anesthetic techniques have gradually revolutionized the perioperative analgesia in breast surgeries. Recently, midpoint transverse process to pleura block has been described and found to provide excellent opioid-sparing analgesia. We performed the block in a novel out-of-plane technique to decrease the patient-needle interaction time and at the same time achieving good analgesia. The immediate postoperative Numeric Pain Rating Scale score was 0/10 both at rest and on movement, and patient reported a score of 5/10 after 12 h, which get subsided with single dose of nonopioid analgesic.
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Multidisciplinary team approach for an atypical presentation of postpartum thrombotic thrombocytopenic purpura and severe preeclampsia in the Intensive Care Unit p. 640
Jose R Navas-Blanco, Ileana Lopez-Plaza, Dragos M Galusca
DOI:10.4103/sja.SJA_204_18  
Thrombotic thrombocytopenic purpura (TTP) is a rare hematologic syndrome during pregnancy with overlapping features of severe preeclampsia and is associated with high morbidity and mortality. We present a case of postpartum TTP, associated with severe preeclampsia. Therapeutic approach for this case included corticosteroids, plasma exchange therapy, and immunomodulatory therapy. We describe the pathophysiology of TTP in pregnancy and its similarities with other disorders that constitute the thrombotic microangiopathy syndrome, as well as other clinical factors which made the final diagnosis challenging. In addition, we highlight the value of a multidisciplinary team care approach to assure an optimal outcome for this clinical scenario.
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Endovascular aspiration of clot in a 3-year-old child with embolic infarct of right middle cerebral artery p. 643
Rajashree Uday Gandhe, Chinmaya Pradeep Bhave, Avinash Sahebarav Kakde, Kalyani Anand Sathe
DOI:10.4103/sja.SJA_688_17  
Stroke in children is common and is associated with long-term morbidity. The incidence of stroke is 13/100,000 in children above 1 month, with higher incidences in neonates and premature infants. It has to be differentiated from other diseases which have a similar presentation. We present a case of a 3-year-old female child with embolic stroke of right middle cerebral artery managed with endovascular clot retrieval done under general anesthesia.
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LETTERS TO EDITOR Top

Crack in the epidural catheter filter port p. 646
Neeraj Kumar, Amarjeet Kumar, Prakash Kumar Dubey
DOI:10.4103/sja.SJA_165_18  
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Giant vallecular cyst excision in infant: Should we proceed without a definite airway? p. 647
Nitika Goel, Neerja Bhardwaj, Ankur Gupta, K Gowtham
DOI:10.4103/sja.SJA_149_18  
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An innovative way of monitoring end-tidal carbon dioxide during endoscopic retrograde cholangiopancreatography p. 650
Gaurav Sindwani, Kelika Prakash, Mahesh Kumar Arora
DOI:10.4103/sja.SJA_197_18  
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Prolonged neuromuscular blockade in a middle-eastern female patient homozygous for atypical plasma cholinesterase p. 651
David A Rico-Mora, Leslie Walton, Jose R Navas-Blanco
DOI:10.4103/sja.SJA_181_18  
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Intra-tracheal extension of hilar mass mimicking severe asthma: Anesthesiologist perspective p. 652
Khalid M Siddiqui, Muhammad F Khan, Muhammad A Asghar, Syed S Uddin
DOI:10.4103/sja.SJA_332_18  
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Aortic root abscess and the lost art of the physical exam p. 654
Andres Bacigalupo Landa, Omar Viswanath, Jayanand D'Mello
DOI:10.4103/sja.SJA_330_18  
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Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine on spinal anesthesia-induced hypotension p. 656
Salah Mhamdi, Mohamed Kahloul, Alaeddine Hafsa, Ali Majdoub
DOI:10.4103/sja.SJA_371_18  
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Comments on the article “Intraoperative fluid management: Past and future, where is the evidence?” p. 657
Summit D Bloria, Pallavi Bloria
DOI:10.4103/sja.SJA_385_18  
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Puzzling postoperative toxin-induced acute liver failure after nonhepatobiliary surgery p. 658
Jose R Navas-Blanco, Jennifer Swiderek, Dragos M Galusca
DOI:10.4103/sja.SJA_340_18  
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Anesthetic management of a case of nesidioblastosis p. 660
Ravindra K Pandey, Udismita Baruah, Ripul Oberoi, Neha Pangasa, Nandinie Hamshi
DOI:10.4103/sja.SJA_212_18  
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NOTICE OF RETRACTION Top

Retraction: Evaluation of gabapentin and dexamethasone alone or in combination for pain control after adenotonsillectomy in children p. 662

DOI:10.4103/1658-354X.241421  
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