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   Table of Contents - Current issue
July-September 2019
Volume 13 | Issue 3
Page Nos. 177-283

Online since Wednesday, June 26, 2019

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Erector spinae plane block: Safety in altered anatomy Highly accessed article p. 177
Can Aksu, Yavuz Gürkan
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Management of traumatic flail chest in intensive care unit: An experience from trauma center ICU Highly accessed article p. 179
Shashi P Mishra, Manjaree Mishra, Noor Bano, Mohammad Z Hakim
Background/Aim: The thoracic injury and related complications are responsible for upto 25% of blunt trauma mortality. This study is designed to compare these two popular ventilation modes in traumatic flail chest. Materials and Method: A total of 30 patients with thoracic trauma, aged 18–60 years, were enrolled in this study for a period of 1 year. The Thoracic Trauma Severity Score (TTSS) was used for assessing the severity of chest injury. Patients were divided into two treatment groups: one recieved endotracheal intubation with mechanical ventilation (ET group, n = 15) and another recieved noninvasive ventilation (NIV group, n = 15). All patients were observed for the duration of ventilatory days, complications such as pneumonia and sepsis, length of the stay in ICU, and mortality. Statistical analysis was done using statistical software SPSS for windows (Version 16.0). Results: There were no significant differences in age, sex, weight, and length of the stay in ICU in between the two groups. Rate of complications was significantly higher in ET group. Oxygenation was significantly improved in NIV group within 24 hr, later it become equivalent to the ET group patients while the pCO2level was significantly lower in ET group compared with NIV group. Analgesia in both the groups is maintained to keep the visual analog scale (VAS) score below 2 and was comparable in both the groups. Conclusions: The endotracheal intubation is also associated with serious complications as compared to NIV. The use of NIV in appropriate patients decreases complications, mortality, length of the stay in ICU, the use of resources, and cost.
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Preoperative fasting: Assessment of the practices of Lebanese Anesthesiologists p. 184
Christine Dagher, Joanna Tohme, Rita Bou Chebl, Viviane Chalhoub, Freda Richa, Hicham Abou Zeid, Samia Madi-Jebara
Background: Although new guidelines developed by the American Society of Anesthesiologists (ASA) recommend a liberalized preoperative nutrition, authorized clinical practice guidelines or recommendations have not yet been proposed by the Lebanese Society of Anesthesia (LSA). Objective: The purpose of this study was to examine Lebanese anesthesiologists' preoperative fasting routines and determine their knowledge and acceptance of the ASA recommendations, their attitude toward liberalized fasting, and the factors favoring their nonadherence to the new recommendations. Materials and Methods: This study was conducted in university hospitals, affiliated hospitals, and nonuniversity hospitals located in different regions of Lebanon. The survey was approved by the local ethics committee. A written questionnaire was emailed to all anesthesiologist members of the LSA which was completed anonymously. Results: Out of the 294 anesthesiologists registered in the LSA and who read the email, 118 (40.1%) completed the questionnaire. Of respondents, 90% are aware of the latest ASA practice guidelines for preoperative fasting, and 78.7% claim to apply them in their practices; however, 75% of respondents still require adult patients to stop eating after midnight, and only 45% allow them to drink clear fluids up to 2 h preoperatively. One of the main reasons for not complying with the ASA guidelines was “to allow flexibility for changes in the operating schedule.” Conclusion: A long preoperative fasting period is still the common practice for Lebanese anesthesiologists. National guideline for preoperative fasting as liberal as that recommended by the ASA should be considered.
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Preference of cognitive approaches for decision making among anesthesiologists' in Saudi Arabia p. 191
Anas Alshaalan Alshaalan, Mohammed K Alharbi, Khaled A Alattas
Aims: The aim of this study was to analyze the thinking processes of anesthesia physicians at in Riyadh, Jeddah, and Dammam cities in Saudi Arabia. Subjects and Methods: This cross-sectional study was undertaken in the cities of Riyadh, Jeddah, and Dammam in Saudi Arabia. Using a previously published psychometric tool (the Rational and Experiential Inventory, REI-40), the survey was sent through email and social networks to anesthesia physicians working in the targeted hospitals. An initial survey was sent out, followed by a reminder and a second survey to nonrespondents. Analysis included descriptive statistics and Student's t-tests. Results: Most of the participants (69.2%) were males. At the time of the study, 35% of participants were consultants; 9.6% were associate consultants; 19.2% were registrars, fellows, or staff physicians; and 35.8% were senior residents. Anesthesia physicians' mean “rational” score was 3.22 [standard deviation (SD) =0.49)] and their mean “experiential” score was 3.01 (SD = 0.31). According to Pearson's correlation, the difference of 0.21 between these two scores was not statistically significant (P = 0.35). Male anesthesia physicians tended more toward faster, logical thinking. Consultant anesthesia physicians had faster rational thinking than nonconsultant physicians (P = 0.01). Anesthesia physicians with more than 10 years in practice had faster rational thinking than physicians who had worked for fewer than 10 years (P = 0.001). Conclusions: This study evaluated anesthesia physicians' general decision-making approaches. Despite the fact that both rational and experiential techniques are used in clinical decision-making, male consultants and physicians with more than 10 years' experience and certified non-Saudi board anesthesiologists prefer rational decision-making style.
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Factors affecting blood glucose and serum sodium level with intraoperative infusion of 1% dextrose in ringer's lactate in neonates undergoing surgery p. 197
Sushama R Tandale, Kalpana V Kelkar, Sunita M Khedkar, Jayesh R Desale
Context: Under anesthesia, blood glucose level in term neonates varies widely due to stress induced glucose mobilisation due to various factors. Postoperative hyponatremia occurs with intraoperative infusion of large volume of hypotonic fluid. There is a growing consensus on the intraoperative use of 1–4% glucose containing isotonic fluid in them. Aims: To know the relation of duration of surgery, infusion rate, fluid bolus, blood transfusion with blood glucose level and effect on serum sodium level with intraoperative 1% dextrose ringer's lactate (1% DRL) in neonates undergoing surgery. Settings and Design: Prospective single-center study in tertiary institute. Subjects and Methods: A total of 100 neonates undergoing various surgeries under general anesthesia with or without caudal anaesthesia were included. 1% DRL was used as maintenance and replacement fluid intraoperatively. Blood glucose level at hourly interval throughout surgery and serum sodium concentration before and after infusion was documented. Statistical Analysis Used: Student's t test (two tailed, independent) has been used for statistical analysis. Results: After the infusion of 1% DRL during surgery, mean blood sugar levels were increased above the base line in all neonates at successive hourly interval. Serum sodium levels remained within physiological range in all neonates. Conclusion: Intraoperative hyperglycemia is more obvious with higher intravenous fluid infusion rate, prolonged duration of surgery, and requirement of fluid bolus as well as blood transfusion intraoperatively. Use of 1% DRL in neonates undergoing surgery is effective in preventing dysnatremia.
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Cost drain of anesthesia emergency drugs in a quaternary care hospital p. 203
Amer Majeed, Attyia Firdous, Hesham AlBabtain, Tahir Iqbal
Background: Anesthesiologists draw up a selection of drugs for emergency use at the start of their list; unused drugs are discarded at the end of the list, to prevent contamination and spread of infections. We audited the practice in our department to evaluate the scale and cost impact of anesthesia emergency drugs wastage. Subjects and Methods: A questionnaire was randomly given to anesthesiologists in our department, working in some of the operating rooms in our main floor, every morning over 7 working days. Completed forms were collected at the end of respective lists. Results: A total of 93 completed forms were returned. Ephedrine (96%) and phenyepherine (95%) were the most frequently drawn drugs; atropine (96%) and suxamthonium (92%) were the most frequently discarded drugs. Phenylepherine was the single most expensive item wasted, representing 160% of the cost of all other drugs wasted together, and the price of discarded ephedrine and phenylephrine together represented 3/4th of the total wastage. Some practices carried room for rationalization, such as drawing up of atropine and glycopyrolate simultaneously, of both the vasopressors in patients unsuspected for developing significant hypotension, or of suxamethonium in a patient planned to be intubated and postoperative ventilation. Conclusion: Significant savings may be realized through switching to prefilled syringes, making protocols available for rational use of emergency drugs, and safe pooling of expensive drugs between adjacent operating rooms, in an anesthesia department.
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Hemodynamic effects of low-dose bupivacaine spinal anesthesia for cesarean section: A randomized controlled trial p. 208
Marta J Cenkowski, Doug Maguire, Stephen Kowalski, Fahd A Al Gurashi, Duane Funk
Background: Spinal anesthesia is the most common technique for cesarean section. The conventional local anesthetic dose has been decreasing over time to 8–12.5 mg of bupivacaine. Lower doses of bupivacaine may be associated with reduced incidence of hypotension and other complications. This low dose also may be associated with improved maternal cardiac index (CI). We hypothesized that low dose spinal anesthesia using 4.5 mg bupivacaine would result in improved maternal CI when compared with conventional dose (9 mg) intrathecal bupivacaine. Methods: This randomized controlled trial included all healthy parturients presenting for elective cesarean section. In addition to standard monitors, an arterial line was placed for pulse contour cardiac output measurement. Due to limited data on maternal cardiac output during cesarean section, we had to power our study on recovery room length of stay. Secondary outcomes included the change in maternal CI, fluid administration, vasopressor usage, maternal satisfaction, and adequacy of surgical blockade and recovery time from motor and sensory blockade. Results: The low dose group had significantly faster motor recovery times (132 [122–144] versus. 54 [48–66] min conventional versus. low-dose, respectively, P < 0.01), and a shorter recovery room stay (92 ± 21 vs 70 ± 11 min, conventional vs. low-dose, respectively, P < 0.01, 95% CI -35 to -10 min). There was no difference in CI between the conventional dose and low dose spinal groups. Both groups had a drop in CI with spinal anesthesia. The low-dose group demonstrated equivalent surgical anesthesia and block onset times compared to the conventional group. Conclusions: Low-dose spinal anesthesia provides adequate surgical anesthesia, improved recovery time, but no difference in maternal cardiac index when compared to conventional dose spinal anesthesia. NCT02046697
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Does prewarming of i-gel improve insertion and ventilation in anaesthetised and paralysed patients? A prospective, randomised, control trial p. 215
Aamuktha Malyadha Reddy, Nita Varghese, Basavaraj Herekar, Udupi Kailashnath Shenoy
Context: I-gel are supraglottic airway devices with non-inflatable gel-like cuff that is believed to mould to body temperature, to seal the airway. Hence a pre-warmed i-gel may seal faster, provide better ventilation and superior leak pressure. Aims: To determine if pre-warming i-gel to 40°C improves insertion and efficacy of ventilation. Methods and Materials: A prospective, randomised, controlled trial was done on 64 patients requiring anaesthesia with muscle relaxation for short duration. For those in group W, i-gel warmed to 40°C for 15 minutes before insertion was used, whereas for those in group C, i-gel kept at room temperature (approximately 23°C) was used. The airway sealing pressure over time, number of attempts and time taken for a successful insertion were noted. Statistical Analysis: Mean sealing pressure between two groups was compared using independent sample t-test. Repeated Measures ANOVA was used to analyse mean sealing pressure at 0, 15 and 30 min. P value ≤0.05 was considered statistically significant. Results: Sealing pressure improves over time in both the groups but the mean sealing pressure was higher in group C when compared to group W at all points of time, however this was clinically and statistically insignificant. Ease of insertion, time for successful insertion, insertion attempts, intra-operative manoeuvres were all comparable between the groups with no adverse effects. Conclusions: Pre-warming of i-gel to 40°C does not improve the success rate of insertion or provide a higher sealing pressure in anaesthetised and paralysed patients when compared to i-gel at room temperature.
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Sufentanil sublingual tablet system (Zalviso®) as an effective analgesic option after thoracic surgery: An observational study Highly accessed article p. 222
Costa Fabio, Pascarella Giuseppe, Piliego Chiara, Valenzano Antongiulio, Di Sabatino Enrico, Riccone Filippo, Bruno Federica, Agro' F. Eugenio
Introduction: Sufentanil sublingual tablet system (SSTS) (Zalviso®) is a sublingual system for patient controlled analgesia, demonstrated to be an effective strategy for pain control after major abdominal and orthopedic surgery. We present a prospective observational study on the use of SSTS for the management of postoperative pain after thoracic surgery. The aim of this study was to assess the efficacy of Zalviso® in reducing pain scores and increasing respiratory ability during postoperative period. Materials and Methods: There were about 40 patients underwent video assisted thoracoscopy were included in the study. All the enrolled patients signed the informed consent were educated to the use of the device. Pain numeric rating scale values (NRS) were recorded at awakening from anesthesia (T0) and during the next hours, both at rest and with cough. We evaluate the time to obtain a mean NRS value ≤3 and difference in pain scores between first and subsequent measurements as the primary outcomes. The ability to use incentive spirometer and eventual drug adverse effect were evaluated as secondary outcomes. Results: All patients in recovery room experienced moderate to severe pain. Pain score at rest and coughing decreased to a mean NRS value ≤3 (mild pain) respectively after 2 and 6 hours and the pain score difference continued to increase significantly after repeated measurements. 67.5% of patients resumed the original spirometric ability in pod 1; 9.5% in pod 2; 12% in pod 3. Only three patients out of forty (7,5%) experienced nausea; one patient (2,5%) had a vomiting episode. Conclusion: Our study showed SSTS as an effective option for postoperative pain management in thoracic surgery, improving pain scores and respiratory ability.
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Insertion depth of left-sided double-lumen endobroncheal tube: A new predictive formula p. 227
Abdelazeem Eldawlatly, Ahmed Alqatari, Naveed Kanchi, Amir Marzouk
Background: In the field of thoracic anesthesia, it is well-established practice that the insertion depth of left-sided double-lumen tube (LDLT) is achieved after checking its position via fiberoptic bronchoscopy (FOB). Several studies have shown positive correlation between body height (BH) and the optimal insertion depth of a LDLT. Each of these studies has developed a formula for proper insertion depth of the LDLT. In this study, we prospectively studied our patients whose tracheas were intubated correctly with LDLT using FOB confirmation and examined the optimal insertion depth of LDLT aiming at finding a formula suitable for our patients. Methods: After obtaining the institutional review board approval of College of Medicine Research Centre, King Saud University, we recruited 41 adult patients who underwent thoracic surgery with one-lung ventilation (OLV). The study included patients whose procedure required placement of a LDLT. The optimal insertion depth of the LDLT was confirmed using FOB. The following variables were recorded, the patient's sex, age, BH, and the final correct insertion depth of the LDLT (cm) measured from the corner of the mouth. The results of LDLT insertion depth in our study were compared to another published five studies. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22 software (SPSS Inc., Chicago, IL, USA). Results: Positive correlation was found between BH (cm) and insertion depth of LDLT (cm) since r = 0.744 (P < 0.05). Also, positive correlation was found between the LDLT size (Fr) and insertion depth of LDLT (cm) since r = 0.792 (P < 0.05) where r is Pearson's correlation coefficient. By fit curve (Curve Estimation), we were able to get the predicted equation for our cases as follow: the insertion depth of LDLT (cm) =0.249 × (BH)0.916 with significant correlation to the other five formulae (P < 0.05). Conclusion: In the present study we have obtained a novel formula to predict the insertion depth of LDLT. Currently we are conducting a verification study on a larger sample size to attest its validity. However at this stage and till the results are released we cannot judge on it. We believe time will tell about the validity of our formula for our patients.
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Extended release granisetron: Review of pharmacologic considerations and clinical role in the perioperative setting p. 231
Anh L Ngo, Vwaire Orhurhu, Ivan Urits, Edwin O Delfin, Medha Sharma, Mark R Jones, Omar Viswanath, Richard D Urman
In this review, we evaluate recent literature on use of ER granisetron in clinical practice as compared with current antiemetics and describe its potential uses for perioperative PONV prophylaxis and treatment. Recent literature was evaluated on ER granisetron use compared with currently used antiemetic agents ondansetron, droperidol, metoclopramide, promethazine, and dexamethasone with a focus on procedural anti-emesis. Though promising great effect, application of extended release granisetron to clinical use may be limited by it's increased relative cost.
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Anesthetic challenges in a pregnant patient with post mitral valve replacement, complete heart block, and coagulopathy coming for emergency cesarean section: A case report Highly accessed article p. 237
Vinodhadevi Vijayakumar, Thiruvarul Santhoshini, Dhanabagyam Govindarajulu, Shaik Mushahida
A 24-year-old primigravida with a history of rheumatic heart disease and prosthetic mitral valve on oral anticoagulation who was lost follow-up during the third trimester presented with premature rupture of membranes. On evaluation, she had new-onset complete heart block. She was temporarily paced but developed cardiac failure. Anesthetic challenges and management of this parturient with post mitral valve replacement, complete heart block, and warfarin-induced coagulopathy for emergency cesarean delivery are discussed in this case report. Ours is the first case report of a pregnant patient with new onset of complete heart block during pregnancy several years after mitral valve replacement.
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Calcium salt administration for circulatory shock due to severe hyperkalemia p. 240
Zohair Al Aseri
Patients with severe hyperkalemia may present hemodynamic instability. The use of intravenous (IV) calcium for the treatment of hyperkalemia is based on sparse evidence. We hypothesized that the administration of calcium salts would decrease mortality in patients with severe hyperkalemia and circulatory shock. We report a case of a 56-year-old female who presented to an academic emergency department with acute confusion, lethargic mental status, and circulatory shock. Venous blood gas showed a potassium concentration of 7.9 mmol/L. The patient was given 2 g of IV calcium gluconate. The patient started to regain consciousness, and her blood pressure began to normalize. This emergency management led to an almost immediate resolution of the circulatory shock without the need for cardiac pacing. We conclude that hyperkalemia should be suspected in any patient presenting with acute onset of hypotension and bradycardia. IV calcium salts should be used for hemodynamic instability due to hyperkalemia.
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Point-of-care lung ultrasound to evaluate lung isolation during one-lung ventilation in children: A case report p. 243
Yoshikazu Yamaguchi, Alok Moharir, Candice Burrier, Joseph D Tobias
Minimally invasive thoracic surgical techniques require effective lung separation using one-lung ventilation (OLV). Verification of lung isolation may be confirmed by auscultation, visual confirmation using fiberoptic bronchoscopy, or more recently, point-of-care ultrasound (POCUS). We describe anecdotal experience with POCUS to guide OLV during robotic-assisted thoracic surgery in a child. Techniques to confirm thoracic separation are reviewed and potential advantages of POCUS discussed.
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Comprehensive perioperative management of an infant with huge mediastinal mass p. 246
Sandeep Diwan, Sunil Patil, Sudhakar Jadhav, Abhijit S Nair
Anaesthesia induction and meticulous airway management is important in a patient with anterior mediastinal mass. It is all the more challenging if this is encountered in infants. We report a comrehensive successful management of an infant with huge anterior mediastinal mass who was anaesthesized for diagnosis initially followed by surgical resection of the tumor.
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Cardiac arrhythmia from epinephrine overdose in epidural test dose p. 249
Shelly B Borden, Molly K Groose, Mark J Robitaille, Kristopher M Schroeder
Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading to an unstable cardiac arrhythmia and our subsequent development of a visual cue system to prevent future errors. A 56-year-old man with a history of rectal adenocarcinoma presented for low anterior resection and creation of diverting loop ileostomy. Epidural placement was requested by the surgical team, and following administration of a second test dose (created by the physician), the patient experienced supraventricular tachycardia with heart rates of 200-210 BPM for approximately 2 minutes. This rhythm then converted to atrial fibrillation with rapid ventricular response with heart rate of 150-170 BPM. The patient was stabilized after cardioversion. Later evaluation of medication administration revealed that the second epidural test dose inadvertently contained 100 mcg epinephrine instead of the intended 10 mcg dose. The test dose had to be created because the original ampule with the kit had been utilized. Since this time, our kits have no test dose, and this shortage is concerning for increased provider error. We suggest a novel visual cue system that may prevent unintentional epinephrine overdoses in the setting of regional anesthesia.
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Erector spinae plane block unbound: Limits to safety in a patient with laminectomy p. 253
Victor Tseng, Arjun Tara, Jian Hou, Jeff L Xu
The erector spinae plane (ESP) block has been used to provide analgesia for multiple surgeries involving the abdomen and thorax. Like other plane blocks, the ESP block relies upon normal anatomical boundaries for predictable and safe distribution of local anesthetic. Surgical intervention can alter the anatomy and present new considerations for performing plane blocks. We present a case in which an ESP block was performed for multiple rib fractures in a patient with a recent laminectomy. Laminectomy patients present unique considerations regarding the safety of the ESP block.
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Is it the time to standardize the procedure of ultrasound guided optic nerve sheath diameter measurement? p. 255
Summit D Bloria, Pallavi Bloria, Ankur Luthra
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Ultrasound guided subclavian perivascular block: The modified parasagittal approach p. 256
Chelliah Sekar, Tuhin Mistry, Balasubramanian Senthilkumar, Kuppusamy Elayavendhan
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Modified E-C technique for edentulous geriatric patients p. 257
Rakhi Bansal, Narender Kaloria, Pradeep Bhatia, Ankur Sharma
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Unusual path taken by peripherally inserted central catheter guidewire p. 259
Srinivasa S P Mantha, Sai Kaushik, Abhijit S Nair, Basanth K Rayani
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Novel technique of using laryngoscope in HIV, hepatitis B, and hepatitis C infected patients p. 260
Kirti Kamal, Savita Saini, Teena Bansal, Geeta Ahlawat
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Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: Decreased bronchial tube angulation is a cause? p. 262
Amarjeet Kumar, Chandni Sinha, Poonam Kumari, Neha Nupoor, Sanjeev Kumar
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Scope of chronotherapy in managing acute perioperative pain p. 263
Abhijit S Nair, Sandeep Diwan
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Allopregnanolone: A neurosteroid for managing acute and chronic pain conditions p. 264
Abhijit S Nair, Sandeep Diwan
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Point of care neck ultrasonography may be useful during anesthesia for carotid body tumor excision p. 266
Prakash K Dubey, Ravi Kant, Rahul Ranjan, Akhileshwar
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Erector spinae plane block: Anatomical landmark-guided technique p. 268
Hetal K Vadera, Tuhin Mistry
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General or neuraxial in the hip fractured patient? I choose the third option p. 269
Romualdo Del Buono, Giuseppe Pascarella, Enrico Barbara
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Short endotracheal tube: An approach to shorten procedure time in bronchial thermoplasty p. 271
Sachidanand Jee Bharati, Deepti Ahuja, Vijay Hadda, Himanshu Prince Yadav
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Anesthetic challenges for pleuro-pericardial window p. 272
Rakhi Bansal, Ankur Sharma, Varuna Vyas, Narender Kaloria, Priyanka Sethi, Rakesh Kumar
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Cesarean delivery in congenital heart block and need of temporary pacing: A case report p. 274
Sumit Soni, Amarjyoti Hazarika
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Adductor canal and femoral triangle: Two different rooms with the same door p. 276
Giuseppe Pascarella, Fabio Costa, Romualdo Del Buono, Felice Eugenio Agrò
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Journey of a quadratus lumborum plane catheter: Is it important to know? p. 278
Sandeep Diwan, Medha Kulkarni, Narendra Kulkarni, Abhijit Nair
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A novel technique of ultrasound-guided glossopharyngeal nerve block to relieve cancer pain p. 279
Dinesh Manoharan, Sachidanand J Bharati, Mukesh K Yadav
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Polite invitation to submit article: Predatory journal's new strategy p. 281
Thorakkal Shamim
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Book Review Reports p. 282
Abdelazeem Eldawlatly
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