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January-March 2018
Volume 12 | Issue 1
Page Nos. 1-174

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EDITORIAL  

Intravenous lidocaine and postextubation laryngospasm p. 1
Muhammad Faisal Khan, Ullah Saleem
DOI:10.4103/sja.SJA_504_17  PMID:29416448
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ORIGINAL ARTICLES Top

Effect of intravenous lidocaine on the incidence of postextubation laryngospasm: A double-blind, placebo-controlled randomized trial Highly accessed article p. 3
Khalid Ibrahim Aljonaieh
DOI:10.4103/sja.SJA_440_17  PMID:29416449
Objectives: The study aimed to test the effect of intraoperative intravenous (IV) lidocaine on the incidence of postextubation laryngospasm in adult patients. Methods: The prospective randomized clinical trial was conducted at tertiary care hospital in Riyadh, between January and December 2012. Seventy-two patients undergoing laparoscopic cholecystectomy were randomly assigned to receive either placebo (n = 36) or IV lidocaine (n = 36), 1 mg/kg bolus after desflurane was discontinued. Laryngospasm was graded from 0 to 3 based on the absence or presence of signs and the severity of postextubation laryngospasm. Results: The study was terminated early by the data monitoring committee because of safety concerns due to an increased incidence of postextubation laryngospasm. Patient demographics were similar for both groups. The incidence of postextubation laryngospasm was 19.5% in the placebo group and 0% in the treatment (lidocaine) group; this difference was statistically significant (P = 0.017; 95% confidence interval, 4.6% to 36.0%). Conclusions: The cause of laryngospasm in our study was most likely the rapid increase in the concentration of inspired desflurane, which might have caused airway irritation. Therefore, we believe that pretreating patients at risk of developing laryngospasm with IV lidocaine could be effective.
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Evaluation of the neurotoxicity of intrathecal dexmedetomidine on rat spinal cord (electromicroscopic observations) Highly accessed article p. 10
Dilek Ozdamar, Huban Dayıoglu, Ihsan Anık, Seyhun Solakoglu, Mine Solak, Kamil Toker
DOI:10.4103/sja.SJA_143_17  PMID:29416450
Background: Spinal administration of dexmedetomidine has been proposed as an adjuvant in spinal anesthesia. However, there is limited information about its possible neurotoxic effect after its neuraxial administration. Potential spinal neurotoxicity should be investigated in animals before administering drugs through the spinal cord. Our aim was to investigate the neurotoxic effects of intrathecal dexmedetomidine in rats. Methods: Two groups were performed: the dexmedetomidine (D) group (n = 10) received 10 μg (0.5 ml), whereas the control (C) group (n = 10) received 0.9% (0.5 ml) sodium chloride through indwelling intrathecal catheter. Seven days after the injection, the medulla spinalis was extracted. Samples were withdrawn from both groups for histologic, electron microscopic examination. The histologic examination was performed separately on each of the four sites. The findings were categorized as follows: 0 - normal neuron; 1 - intermediate neuron damage; and 2 - neurotoxicity. Results: Intrathecal administration of dexmedetomidine sensorial block was seen in the dexmedetomidine group and significant differences in the dexmedetomidine group than control group in 15th and 30th min (P < 0.05). Histological examination did not show evidence suggestive of neuronal body or axonal lesion, gliosis, or myelin sheath damage in any group. In all animals, there were observed changes compatible with unspecific inflammation at the tip of the needle location. On the four-area scoring histologic examination, the scores of both groups were 0–1, and no statistical difference was observed between the groups. Conclusions: A single dose of intrathecal dexmedetomidine did not produce histologic evidence of neurotoxicity.
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Which is better for pain reduction during transrectal ultrasound-guided biopsy of the prostate: Intravenous diazepam, local periprostatic nerve block, or combination? controlled randomized study p. 16
Haisam Atta, Mohamed F Mostafa, Mahmoud Shalaby
DOI:10.4103/sja.SJA_141_17  PMID:29416451
Background: Transrectal ultrasound-guided prostate biopsy (TRUSPB) is considered the procedure of choice for the diagnosis of prostate cancer. Men undergoing this biopsy experience high psychological stress. Different studies recommend techniques as sedation, lidocaine gel intrarectally, periprostatic nerve block alone, or nitrous oxide inhalation as effective methods of analgesia during procedural-related pain or discomfort. We evaluated three techniques for pain relief during TRUSPB and evaluated if there was any increase in the incidence of complications when employing either technique. Setting: Assiut University Hospital, Assiut, Egypt. Methods: Three hundred patients of age 43–92-year-old underwent TRUSPBs. Patients were allocated randomly into three equal groups to receive intravenous (IV) diazepam 5 mg slowly (Group I), bilateral periprostatic nerve block by 10 ml of 1% lidocaine solution injected under ultrasound guidance (Group II), or combined IV diazepam and the periprostatic nerve block (Group III). Results: The mean pain score was 4.95 for patients in Group I, 4.15 for patients in Group II, and 2.18 for patients in Group III with statistically significant findings (F = 120.27, P < 0.001). TRUSPB under combined IV sedation and local anesthesia had no significant increase in the incidence of complications. Conclusions: Patients should have analgesia during TRUSPB to decrease the procedure pain and to improve tolerance permitting proper aiming for biopsy cores without increasing the patient distress. The combined IV sedation and local periprostatic nerve block are efficient in controlling and limiting pain better than employing each technique alone with no significant increase in complications incidence.
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Comparative study of anatomical landmark-guided versus ultrasound-guided suprascapular nerve block in chronic shoulder pain p. 22
Kirti Kamal, Naresh Dahiya, Roop Singh, Savita Saini, Susheela Taxak, Saloni Kapoor
DOI:10.4103/sja.SJA_123_17  PMID:29416452
Background: Suprascapular nerve block (SSNB) is an effective method for the treatment of shoulder disorders. The present study was conducted to evaluate and compare the effectiveness of SSNB under ultrasonographic guidance with anatomical landmark-guided (LMG) technique in the treatment of chronic shoulder pain. Materials and Methods: A total of fifty patients with shoulder pain were enrolled in the present prospective randomized study. Patients in Group I (n = 25) received SSNB using the anatomical LMG as technique described by Dangoisse, in whom a total of 6 ml of drug (5 ml of 0.25% bupivacaine and 40 mg methylprednisolone) was injected. Group II patients (n = 25) were given SSNB using the ultrasound guidance with the same amount of drug. Pain was measured using visual analog scale (VAS), range of motion and Shoulder Pain and Disability Index (SPADI) were recorded. Observations were recorded before the block, immediately after the block, and 1 and 4 weeks after the block. Results: There was no statistically significant difference between the VAS score, range of motion and SPADI before the procedure (P > 0.05) in both the groups. Both the groups showed statistically similar improvement of VAS, range of motion and SPADI at 4-week (P > 0.05) follow-up. In Group I, VAS decreased from baseline value of 6.64 ± 1.50–2.04 ± 0.94 at 4 weeks (P < 0.001). In Group II, the VAS decreased from 6.92 ± 1.00 to 1.84 ± 1.03 at 4 weeks (P < 0.01). Conclusion: In our study, both the techniques have produced comparable relief of pain, improvement in shoulder movement, and decreased SPADI 4 weeks after the block.
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Effect of dexmedetomidine on emergence agitation using desflurane in pediatric cataract surgery p. 28
Shikha Jain, Sameer Sethi, Babita Ghai, Jagat Ram
DOI:10.4103/sja.SJA_235_17  PMID:29416453
Background: In this study, we compared effectiveness of two doses of dexmedetomidine (0.15 μg/kg and 0.3 μg/kg) in preventing desflurane-induced emergence agitation (EA) in pediatric patients undergoing elective cataract surgery. Methods: It is a prospective double-blinded randomized study conducted on 65 American Society of Anesthesiologists 1 children (2–10 years) who underwent elective cataract surgery at our institute. They were randomized into two equal groups, who received either dexmedetomidine 0.15 μg/kg (Group D0.15) or dexmedetomidine 0.30 μg/kg (Group D0.3) intravenously after induction of anesthesia. An observer blinded to groups recorded heart rate (HR), arterial blood pressure, oxygen saturation, end-tidal carbon dioxide, and respiratory rate (RR) at regular intervals and evaluated preoperative anxiety, state of agitation, and postoperative pain using validated scores. Results: Both groups (Group D0.15, n = 27 vs. Group D0.3, n = 26) were demographically identical. In intraoperative period, the difference in HRs was significantly lower in Group D0.3from 5 min till 15 min of the surgery (P < 0.05), but thereafter, from 20 min till end of surgery, the rates were comparable in both the groups, whereas RR and blood pressure fluctuations were comparable throughout. Postoperative pain scores and postoperative agitation score were significantly lower in Group D0.3than D0.15at all time intervals (P < 0.05). Conclusions: In our study, 0.3 μg/kg intravenous dexmedetomidine was found to be superior to 0.15 μg/kg group in effectively reducing EA and postoperative pain, without producing adverse effects such as hypotension or bradycardia.
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A randomized controlled trial comparing C Mac D Blade and Macintosh laryngoscope for nasotracheal intubation in patients undergoing surgeries for head and neck cancer p. 35
Hrishikesh Hazarika, Anudeep Saxena, Pradeep Meshram, Ajay Kumar Bhargava
DOI:10.4103/sja.SJA_239_17  PMID:29416454
Purpose: Several devices are available to take care of difficult airway, but C-MAC D-Blade has scant evidence of its use in nasotracheal intubation in a difficult airway scenario. Aims and Objectives: We compared the C-MAC D-Blade videolaryngoscope, and the standard Macintosh laryngoscope for nasal intubation in patients with difficult airways selected by El-Ganzouri risk index using parameters of time and attempts required for intubation, glottic view in terms of Cormack–Lehane grade, ease of intubation, success rate, use of accessory maneuvers, incidence of complications, and hemodynamic changes. Methods: One hundred American Society of Anesthesiologists (ASA) I–III patients aged 20–70 years with EGRI score 1–≤7 scheduled for head and neck surgery requiring nasal intubation. ASA IV patients, patients with mouth opening <2.5 cm, patients difficult to mask ventilate, and patients with hyperkalemia and history of malignant hyperthermia were excluded from the study. Primary outcome was time taken to intubation, and secondary outcomes were a number of attempts, glottic view in terms of C/L grade, use of accessory maneuvers, success rate, incidence of trauma, ease of intubation, and hemodynamic changes before and after intubation. Results: Time required for intubation was less (39.56 ± 15.65 s) in Group C than in Group M (50.34 ± 15.65 s). Cormack–Lehane Grade I and II view were more in C-MAC D-Blade group (P < 0.05). Success rate and ease of intubation were found to be more in C-MAC D-Blade group than in Macintosh group (P < 0.05). A number of attempts and incidence of complications such as trauma, bleeding, and failed intubation were greater in Macintosh group than in C-MAC D-Blade group. Hemodynamic changes were observed to be comparable in both the groups. Conclusion: C-MAC D-Blade videolaryngoscope is a better tool in anesthetic management of difficult airway for nasal intubation compared to conventional Macintosh laryngoscope.
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Fluid choice during perioperative care in children: A survey of present-day proposing practice by anesthesiologists in a tertiary care hospital p. 42
Muhammad Faisal Khan, Khalid Maudood Siddiqui, Muhammad Ali Asghar
DOI:10.4103/sja.SJA_258_17  PMID:29416455
Background: Perioperative fluid therapy in pediatrics has always been a challenging avenue for anesthesiologists. Inappropriate choice of fluid leads to multiple side effects, for instance iatrogenic hyponatremia. Our aim was to observe the current practice of perioperative fluid therapy in pediatric population undergoing surgery in a tertiary care hospital. Methods: After obtaining approval from the Departmental Research Review Committee, a survey form including questions was emailed to anesthesiologists from January 2015 to June 2015. Individual responses were recorded and analyzed. Results: Overall response was 100% from consultant and resident, and total 55 anesthesiologists were participated in this survey. Majority of anesthesiologist have used, 1/2 dextrose saline (52.7%) as fluid of choice in routine intraoperative maintenance, while Hartmann's solution (41.8%) and normal saline 0.9% (5.5%) were used for rest of the them. The Holliday-Segar method for maintenance fluid was mentioned by 92.7% of anesthesiologists. Conclusion: The use of hypotonic fluid in perioperative care in pediatric population is still being practiced despite the current guidelines. These results point to a considerable gap between the available evidence and practice.
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Evaluation of safety and efficacy of regional anesthesia compared with general anesthesia in thoracoscopic lung biopsy procedure on patient with idiopathic pulmonary fibrosis p. 46
Waseem M Hajjar, Sami A Al-Nassar, Ghaida S Al-Sugair, Alaa Al-Oqail, Shahd Al-Mansour, Rand Al-Haweel, Adnan W Hajjar
DOI:10.4103/sja.SJA_265_17  PMID:29416456
Background: Interstitial lung diseases are diseases that need histology diagnosis or obtaining a lung biopsy to establish the diagnosis. Surgical biopsies are performed usually using the thoracoscopy technique under general anesthesia (GA) although this procedure is still associated with morbidity rate. The aim of this study is to determine the effectiveness and safety of regional anesthesia (RA) compared with GA in thoracoscopic lung biopsy procedures done on patients with idiopathic pulmonary fibrosis (IPF). Subjects and Methods: This is a retrospective qualitative study based on adult cases of video-assisted thoracoscopy (VAT) lung biopsy on patients with IPF admitted in the division of Thoracic Surgery, Department of General Surgery, King Khalid University Hospital, Riyadh, KSA. We included 67 patients with IPF, 26 with RA, and 41 with GA, who underwent this procedure from January 2008 to December 2015. Procedures performed under RA were done using three different approaches, intercostal nerve blocks, extrapleural infusion, and paravertebral block while GA was performed using double-lumen endotracheal tube placement. For statistical analysis, SPSS program, version 21.0. Software used to analyze the obtained data. The statistical significance was defined as P < 0.05. Results: Sixty-seven patients underwent the procedure of thoracoscopic lung biopsy. Twenty-six of them (38.8%) underwent the procedure under RA and 41 (61.2%) under GA. The cross tabulation of the intercostal chest tube duration showed that it was significantly longer in GA group (6.23 ± 5.1 days) compared to RA group (3.12 ± 1.5 days), P = 0.004. Furthermore, for the Intensive Care Unit (ICU) stay, it was significantly longer in GA group (3.38 ± 2.1 days) compared to RA group (1.09 ± 0.7 days), P = 0.019. Regarding the relation between the number of biopsies taken and type of anesthesia performed, the probability values for GA group as well as RA group come out to be >0.05 (statistically independent) and the results of risk estimate also show that there was no significant association found between them. The cross tabulation of the representation of biopsies taken by the two methods showed that all biopsies taken under both settings were representative of the disease. Of 41 procedures done under GA, 16 of the total showed a number of complications. Likewise, of 26 procedures under RA, five cases showed complications. The significant (two-sided) value was (P = 0.110), there was no statistical significance between the risks of complications and the two types of anesthesia. Conclusion: There was a significant decrease in chest tube duration and ICU stay in RA group compared to the GA group. There was no statistical difference between both types of anesthesia in the number of biopsy, representation, and postoperative complications although the rate of these complications was much less in the RA group. Based on this outcome, we can conclude that VAT lung biopsy procedure on patients with IPF under RA is safe, representative, and effective operation. In addition, high-risk patients for GA can go through this procedure under RA as an alternative and safe option with no added complications.
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Assessment of procedural skills in residents working in a research and training institute: An effort to ensure patient safety and quality control p. 52
Kamlesh Kumari, Tanvir Samra, B Naveen Naik, Vikas Saini
DOI:10.4103/sja.SJA_400_17  PMID:29416457
Background: To ensure patient safety, it is important to regularly assess the knowledge and practical skills of anesthesia trainees. This study was conducted to evaluate the competency of the residents and the impact of various corrective measures in the form of didactic lectures and clinical skill demonstrations on the conduct of various procedural skills by the residents. Materials and Methods: Ninety-five junior residents were enrolled in this study. Assessment of competency of 1st, 2nd, and 3rd year residents in performing various procedure skills of anesthesia was done in two stages using procedure specific checklist (PSC) and Global Rating Scales (GRSs). Preliminary results of the first assessment (Score 1) were discussed with the residents; deficiencies were identified and corrective measures suggested by didactic lectures and clinical skill demonstrations which were followed by a subsequent assessment after 3 months (Score 2). Results: There was a statistically significant improvement in the PSC and GRS scores after corrective measures for all the procedural interventions studied. Percentage increase in scores was maximum in 1st year (42.98 ± 6.62) followed by 2nd year (34.62 ± 5.49) and minimum in 3rd year residents (18.06 ± 3.69). The percentage increase of scores was almost similar for all subset of procedural skills; low, intermediate, and high skill anesthetic procedures. Conclusion: For assessment of procedural skills of residents, use of PSC and GRS scores should be incorporated and the same should be used to monitor the impact of various corrective measures (didactic lectures and clinical skill demonstrations) on the conduct of various procedural skills by the resident.
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Randomized comparison between dexmedetomidine and midazolam for prevention of emergence agitation after nasal surgeries p. 61
Pranjali Kurhekar, Krishnagopal Vinod, Buddhan Rajarathinam, J Shesha Dhiviya Krishna, MS Raghuraman
DOI:10.4103/sja.SJA_419_17  PMID:29416458
Background: Emergence agitation (EA) in nasal surgeries is seen in around 22% of patients, which can go to dangerous levels. Dexmedetomidine is effective in prevention of EA in such patients. Midazolam given as premedication fails to prevent EA due to its short half-life. In this study, we compared efficacy of dexmedetomidine and midazolam by intravenous infusion for prevention of EA in adult nasal surgeries. Materials and Methods: Seventy patients belonging to American society of anesthesiologist Status I and II, between 18 and 60 years of age posted for elective nasal surgeries were randomly divided into two groups. Group D received intravenous dexmedetomidine 0.5 mcg/kg over 15 min followed by 0.1 mcg/kg/h. Group M received intravenous midazolam 0.02 mg/kg over 15 min followed by 0.02 mg/kg/h. EA scores, emergence times, and hemodynamic parameters were monitored and compared between the groups. Statistical analysis was done by independent t-test, Mann–Whitney U-test, and Chi-square test as applicable. Results: Incidence of EA was comparable between the groups (P = 0.23). Two patients in midazolam group developed dangerous agitation while none in dexmedetomidine group. Patients in midazolam group (12.4%) were agitated even in postoperative period, which was not seen with dexmedetomidine group. Hypotension and bradycardia were seen more in dexmedetomidine group. Conclusion: Efficacy of midazolam when given as an intravenous infusion is comparable to dexmedetomidine in prevention of EA in nasal surgeries.
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Neck fat volume as a potential indicator of difficult intubation: A pilot study p. 67
Romualdo Del Buono, Lorenzo Sabatino, Federico Greco
DOI:10.4103/sja.SJA_398_17  PMID:29416459
Background: Direct laryngoscopy is the gold standard of the airway management in patients without predicted difficulties. If unpredicted difficulties are encountered instead, different algorithms to follow have been developed. To date, no single predictor is sufficiently valid. In clinical practice, it is used a combination of them to enhance the estimate, and despite the variety of parameters used, not all the difficult intubations are predicted. The aim of this work is to retrospectively analyze neck computed tomography scans of 37 patients who have had tracheal intubation and search for anatomic neck fat compartments that correlate with the intubation difficulty, and eventually find a suitable, clinical parameter that can potentially enhance the prediction of a difficult airway when used in combination of the preexisting scores. Materials and Methods: the patients are divided by direct laryngoscopy view into two groups: Group A (n = 31): Normal airway, with a Cormack Lehane, Score I or II; Group B (n = 6): Difficult airway, with a Cormack Lehane Score III or IV. In the zone of interest, it was measured the neck volume parameter and other subparameters. Results: Despite a positive trend is shown for anterior fat volume (AFV) (P = 0.23) and fat volume (FV) (P = 0.28), statistically significant differences (P < 0.05) were not found between Group A and B in any of the measurements acquired. Conclusions: According to the literature, our results confirmed that there is still no single element that can predict a difficult intubation. Although no statistical significance was found, the AFV and FV have shown to have a potential predictive role for difficult intubation. Further studies with bigger samples are advisable to confirm this encouraging result.
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Endotrol tracheal tube and McGrath Mac are an effective combination for oral tracheal intubation p. 72
Azusa Shimazaki, Hironobu Ueshima, Hiroshi Otake
DOI:10.4103/sja.SJA_301_17  PMID:29416460
Background: Tracheal intubation using the 2nd-generation video laryngoscope sometimes cannot be performed easily because there is no functional endotracheal tube (ETT) guide. Therefore, a rigid stylet is often required during tracheal intubation. The Endotrol® tracheal tube (Endotrol) is a single use ETT that whole tube can be bent and slide easily into the trachea. We studied the intubation ease of a combination of an Endtrol and the McGrath® video laryngoscope (McGrath), which is one of the 2nd-generation video laryngoscopes. Methods: Sixty adult patients under general anesthesia were randomized into three groups: Group A: McGrath with Endotrol, B: McGrath with a rigid stylet attached ETT, and C: Direct laryngoscope with an ETT. The primary outcome measure was intubation time. Secondary outcomes were the number of insertion attempts required and the number of patients who complained of a sore throat after the procedure. The level of significance for each test was set at P < 0.05. Results: Intubation time (median [range] in seconds) was shorter in Group A (32 [27–54]) than Group B (37 [27–49]) and C (37 [27–50]) (P = 0.01 for both comparison). There was no significant difference among groups for the number of insertion attempts required. The number of patients with a sore throat was lower in Group A (0) than Group B (5) and C (6) (P = 0.02 and 0.01, respectively). Conclusion: A combination of an Endtrol and a McGrath is effective for shortening intubation time and avoiding sore throats.
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Does neck circumference help to predict difficult intubation in obstetric patients? A prospective observational study p. 77
Waleed Riad, Tarek Ansari, Nanda Shetty
DOI:10.4103/sja.SJA_385_17  PMID:29416461
Background: Failed intubation in obstetrics remains the most common cause of death directly related to anesthesia. Neck circumference has been shown to be a predictor for difficult intubation in morbidly obese patients. The aim of this study was to determine an optimal cutoff point of neck circumference for prediction of difficult intubation in obstetric patients. Methods: Ninety-four parturients scheduled for cesarean section under general anesthesia were included in the study. Preoperative airway assessment and neck circumference were measured. Difficult intubation was the primary outcome according to the intubation difficulty scale (IDS), intubation reported difficult if the IDS score was ≥5. Results: Univariate analysis showed that Mallampati score and neck circumference were positive predictors for difficult intubation (P = 0.005 and P = 0.011, respectively). Mouth opening, thyromental distance, sternomental distance, and the hyomental distance ratio were not useful predictors (P = 0.68, P = 0.87, P = 0.48, and P = 0.27, respectively). Logistic regression for the Mallampati score and neck circumference negative results as independent predictors of difficult intubation in obstetric (P = 0.53). Sensitivity analysis showed that neck circumference of 33.5 cm is the cutoff point to detect difficult intubation with 100% sensitivity (95% confidence interval [CI]: 69.2–100) and 50% specificity (95% CI: 38.9–61.1). The area under the curve for neck circumference was 0.746 (95% CI: 0.646–0.830) with a positive predictive value of 19.2 (95% CI: 9.6–32.5), a negative predicative value of 100 (95% CI: 91.6–100), and a P < 0.0001. Conclusions: In obstetric patients, a neck circumference ≥33.5 cm is a sensitive predictor for difficult intubation.
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An observational study of perioperative antibiotic-prophylaxis use at a major quaternary care and referral hospital in Saudi Arabia p. 82
Yasser Younis A. Tolba, Ahmed Osama El-Kabbani, NorAldeen Suhail Al-Kayyali
DOI:10.4103/sja.SJA_187_17  PMID:29416462
Context: The use of perioperative antimicrobial prophylaxis has been consistently considered an effective means of reducing the risk of surgical site infections. However, inappropriate use of surgical antibiotic prophylaxis is associated with complications such as reduced treatment efficacy, development of antibiotic resistance, and increased health-care costs. Aims: The aim of this study is to investigate the adherence to international/national guidelines regarding the use of surgical antibiotic prophylaxis in the perioperative period. Settings and Design: King Faisal Specialist Hospital and Research Centre (KFSH&RC) a 1589-bed tertiary/quaternary care and referral hospital based in Riyadh, Saudi Arabia. Subjects and Methods: A retrospective observational study, in which antibiotic prophylaxis parameters were assessed against recommendations provided by international/national guidelines in elective/emergency procedures performed at the general operating suite. Data was obtained from the medical records starting of 174 cases over a period of 2 weeks in May 2016. Results: Preoperative antibiotic prophylaxis (PAP) was prescribed for 118 (78.7%) patients, 72 (61%) of which were “recommended,” whereas 46 (39%) were “not recommended.” Of the 72 patients for whom the antibiotics were “recommended” and given, 19 (26.4%) received “inadequate” choice of antibiotics, 50 (69.4%) received a sub-therapeutic dose, 14 (19.4%) had “improper” timing of the first dose, 11 (15.3%) were given an “inappropriate” second intraoperative dose, and 43 (59.7%) had an unnecessarily extended duration of prophylaxis. The overall compliance to guidelines was achieved in only 23 (15.3%) patients. Conclusions: A significant gap between current KFSH & RC practice and international/national guidelines regarding surgical antibiotic prophylaxis usage has been demonstrated which calls for immediate action to ensure effective guideline adoption and implementation.
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Effect of extended infusion of meropenem and nebulized amikacin on Gram-negative multidrug-resistant ventilator-associated pneumonia p. 89
Mona Ahmed Ammar, Waleed Abdalla
DOI:10.4103/sja.SJA_148_17  PMID:29416463
Background: Ventilator-associated pneumonia (VAP) due to multidrug-resistant organisms (MDROs) is associated with a significant mortality in the Intensive Care Unit (ICU). The aim of this study was to compare the efficacy and safety of extended infusion of meropenem and nebulized amikacin on VAP caused by Gram-negative MDRO versus intravenous (IV) meropenem and amikacin alone. Methodology: A randomized nonblinded controlled trial was performed on ninety patients with VAP. Patients were randomized into three equal groups: Group I received IV amikacin 20 mg/kg/24 h and meropenem 2 g over 30 min/8 h. Group II received the same as Group I in addition to nebulized amikacin 25 mg/kg/day every 8 h. Group III received IV amikacin 20 mg/kg/24 h, nebulized amikacin 25 mg/kg/day every 8 h, and meropenem 2 g diluted in 240 ml normal saline over 3 h/8 h. The primary outcome was the clinical outcome of VAP. Secondary outcomes were microbiological outcome, VAP-related mortality, duration of MV, ICU stay, and nephrotoxicity. Results: Group II and Group III compared to Group I showed higher incidence of clinical cure (53.33% in Group II and 66.67% in Group III vs. 26.67% in Group I, P = 0.007). Group II compared to Group I showed significant reduction in ventilator days (5.32 ± 1.86 vs. 7.3 ± 2.1 days, respectively, P < 0.001) and reduction in ICU days (11.87 ± 2.6 vs. 15.3 ± 3.1 days, respectively, P < 0.001). Group III compared to Group II showed significant reduction in ventilator days (4.22 ± 1.32 vs. 5.32 ± 1.86, respectively, P = 0.011) and highly significant reduction in ICU days (9.21 ± 1.17 vs. 11.87 ± 2.6, respectively, P < 0.001). All groups were comparable as regards nephrotoxicity or mortality. Conclusions: Adding nebulized amikacin to systemic antibiotics in patients with VAP caused by Gram-negative MDRO may offer efficacy benefits, and the use of extended infusions of meropenem could improve the clinical outcomes in critically ill populations.
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Impact of duloxetine and dexamethasone for improving postoperative pain after laparoscopic gynecological surgeries: A randomized clinical trial p. 95
Dina Y Kassim, Ibrahim M Esmat, Mohammed A Elgendy
DOI:10.4103/sja.SJA_519_17  PMID:29416464
Background: Patients' surgical experiences are influenced by their perception of pain management. Duloxetine (Dulox) and dexamethasone (Dex) are used in multimodal analgesia to reduce opioid use and side effects. Dulox is a selective serotonin and norepinephrine reuptake inhibitor and has efficacy in chronic pain conditions. Dex enhances postoperative (PO) analgesia and reduces PO nausea and vomiting (PONV). Methods: Seventy-five female patients were randomly allocated into one of three equal groups. GI received Dulox 60 mg orally and 100 ml 0.9% sodium chloride (normal saline [NS]) intravenous infusion (IVI) over 15 min, GII: received as GI except Dex 0.1 mg/kg was mixed with NS and GIII received identical placebo for Dulox capsule and Dex IVI, 2 h preoperatively. Patients' vitals, visual analog scale (VAS), and sedation score were assessed at 30 min, 1 h, 2 h, 6 h, and 12 h postoperatively. Total pethidine requirements, plasma cortisol, PONV, and patients satisfaction were recorded. Results: PO time for 1st rescue analgesic was significantly high in GI and GII compared to GIII and in GII compared to GI. There was a significant less VAS score, heart rate, mean arterial pressure, and a high sedation score in GI and GII compared to GIII at 30 min, 1, 2, and 6 h postoperatively. Total pethidine requirements were significantly less in GI and GII compared to GIII 12 h postoperatively. There was a significant reduction in the 2 h PO serum cortisol (μg/dl) and a significant increase in the PO patients satisfaction score in GI and GII compared to GIII. PONV was decreased significantly in GII compared to GI and GIII. Conclusion: The use of oral Dulox 60 mg combined with Dex 0.1 mg/kg IVI is more effective than oral Dulox 60 mg alone, 2 h preoperatively, for improving PO pain by reducing the requirements for rescue analgesia and PONV.
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REVIEW ARTICLE Top

Opioid-sparing effects of the thoracic interfascial plane blocks: A meta-analysis of randomized controlled trials p. 103
Preet Mohinder Singh, Anuradha Borle, Manpreet Kaur, Anjan Trikha, Ashish Sinha
DOI:10.4103/sja.SJA_382_17  PMID:29416465
Background: Thoracic interfascial plane blocks and modification (PECS) have recently gained popularity for analgesic potential during breast surgery. We evaluate/consolidate the evidence on opioid-sparing effect of PECS blocks in comparison with conventional intravenous analgesia (IVA) and paravertebral block (PVB). Materials and Methods: Prospective, randomized controlled trials comparing PECS block to conventional IVA or PVB in patients undergoing breast surgery published till June 2017 were searched in the medical database. Comparisons were made for 24-h postoperative morphine consumption and intraoperative fentanyl-equivalent consumption. Results: Final analysis included nine trials (PECS vs. IVA 4 trials and PECS vs. PVB 5 trials). PECS block showed a decreased intraoperative fentanyl consumption over IVA by 49.20 mcg (95% confidence interval [CI] =42.67–55.74) (I2 = 98.47%, P < 0.001) and PVB by 15.88 mcg (95% CI = 12.95–18.81) (I2 = 95.51%, P < 0.001). Postoperative, 24-h morphine consumption with PECS block was lower than IVA by 7.66 mg (95% CI being 6.23–9.10) (I2 = 63.15, P < 0.001) but was higher than PVB group by 1.26 mg (95% CI being 0.91–1.62) (I2 = 99.53%, P < 0.001). Two cases of pneumothorax were reported with PVB, and no complication was reported in any other group. Conclusions: Use of PECS block and its modifications with general anesthesia for breast surgery has significant opioid-sparing effect intraoperatively and during the first 24 h after surgery. It also has higher intraoperative opioid-sparing effect when compared to PVB. During the 1st postoperative day, PVB has slightly more morphine sparing potential that may however be associated with higher complication rates. The present PECS block techniques show marked interstudy variations and need standardization.
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CASE REPORTS Top

Exacerbation of chronic pain after dental extractions in a patient with post-treatment Lyme disease syndrome Highly accessed article p. 112
Stephanie Lim, Sakura Kinjo
DOI:10.4103/sja.SJA_47_17  PMID:29416466
A subset of patients who had Lyme disease experience postinfectious signs or symptoms called post-treatment Lyme disease syndrome (PTLDS). PTLDS is a chronic condition including pain in joints and muscles, neurological symptoms including demyelinating diseases, peripheral neuropathy, headaches, sleep disturbances, fatigue, and cardiac conditions. We report a case of difficult acute pain management in a patient with PTLDS who underwent dental extractions and required admission to an intensive care unit for pain control.
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Apnea 6 h after a cesarean section p. 115
Sara H Farsi
DOI:10.4103/sja.SJA_252_17  PMID:29416467
Intrathecal narcotics have proven to be invaluable in providing pain relief following a cesarean section. They also aid in earlier mobilization. Unfortunately, they come at the risk of delayed apnea requiring close monitoring for a prolonged period of time. Physicians may sometimes underestimate the risk of these delayed complications. This especially a big concern in hospitals that cannot provide the necessary postoperative monitoring required for these women. I present a case where it took more than 6 h after injection of narcotics before the complication occurred.
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Nonfatal cardiac perforation after central venous catheter insertion p. 118
Vedran Premuzic, Lea Katalinic, Marijan Pasalic, Hrvoje Jurin
DOI:10.4103/sja.SJA_365_17  PMID:29416468
Cardiac tamponade caused by perforation of the cardiac wall is a rare complication related to central venous catheter (CVC) placement. A 71-year-old female with a previous history of moderate aortic stenosis and kidney transplantation was admitted to hospital due to global heart failure and worsening of allograft function. Intensified hemodialysis was commenced through a CVC placed in the right subclavian vein. Chest radiography revealed catheter tip in the right atrium and no signs of pneumothorax. Thorough diagnostics outruled immediate life-threatening conditions, such as myocardial infarction and pulmonary embolism. However, not previously seen, 2 cm thick pericardial effusion without repercussion on the blood flow was visualized during echocardiography, predominantly reclining the free surface of the right atrium, with fibrin scar tissue covering the epicardium – it was the spot of spontaneously recovered cardiac wall perforation. Follow-up echocardiogram performed before the discharge showed regression of the previously found pericardial effusion.
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Successful removal of an intractable mucoid impaction in the bronchus using a Fogarty catheter with flexible bronchoscopy p. 121
Eun Kyung Choi, Shiback Lee, Deokhee Lee, Sang-Jin Park
DOI:10.4103/sja.SJA_399_17  PMID:29416469
Rigid bronchoscopy is commonly used as the standard method to diagnosis and remove obstructive material from the tracheobronchial tree. However, a rigid bronchoscope has limitations when removing a foreign body with surface properties that make it difficult to grasp. We experienced a case that involved the removal of a mucoid impaction, which was accompanied by a near-total unilateral lung collapse, using a Fogarty catheter with flexible bronchoscopy.
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Bilateral bispectral index monitoring to detect cerebral hypoperfusion during carotid endarterectomy under general anesthesia p. 125
Jin Xi Zheng
DOI:10.4103/sja.SJA_347_17  PMID:29416470
The bilateral use of bispectral index (BIS) monitoring in a 68-year-old male who underwent right carotid endarterectomy (CEA) under general anesthesia (GA) is described. During three episodes of right internal carotid artery cross-clamping intraoperatively, the right BIS value rose relative to the left within 1 min of clamping, followed by a return to baseline within 1–2 min of clamp release. Since unilateral BIS values can decrease or increase in response to cross-clamping, a significant difference in left and right BIS values may provide a simple and easily available method to detect cerebral hypoperfusion during CEA under GA.
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A successful anesthetic approach in a patient with Schwartz–Jampel syndrome p. 128
Fernando Calado de Oliveira Camacho, Tânia Marina Lopes Amaral, Joana Irene de Barros Mourão
DOI:10.4103/sja.SJA_393_17  PMID:29416471
Schwartz–Jampel syndrome (SJS) is a rare genetic condition that is characterized by several musculoskeletal abnormalities, such as myotonia, joint contractures, and facial dysmorphisms. Patients with this syndrome can present an anesthetic challenge, due to an increased risk of developing malignant hyperthermia (MH) and the possibility of encountering a difficult airway. Several precautions must be taken when general anesthesia is required, such as the avoidance of potential triggers for MH, continuous core temperature, and end-tidal CO2monitoring, assuring that dantrolene is readily available. It is also fundamental to prepare for a possible difficult airway, guaranteeing that difficult airway devices are available. We describe the anesthetic management of a 14-year-old boy diagnosed with SJS who was scheduled for multiple dental extractions and was successfully anesthetized with our approach.
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Anesthetic considerations for video-assisted thoracoscopic surgery in a child with Glenn shunt for thoracic duct ligation and pleurodesis p. 131
Bhavna Kakkar, Munisha Agarwal, Aakanksha Sehgal, Neelam Prasad Govil
DOI:10.4103/sja.SJA_395_17  PMID:29416472
Glenn shunt is an anastomosis between superior vena cava and right pulmonary artery to palliate patients with single ventricle physiology of the heart. Chylothorax is a frequent and troublesome complication after the creation of this shunt, which if not controlled with medical management, might require pleurodesis, and thoracic duct ligation. Video-assisted thoracoscopic surgery (VATS) causes less postoperative pain, earlier mobilization, lower overall morbidity, a shortened hospital stay with reduced cost, and a cosmetic incision. A comprehensive understanding of physiology of Glenn shunt and implications of the proposed surgical procedure (VATS) is necessary to plan the anesthetic agents, cardiovascular drugs, ventilation strategies, and other perioperative factors.
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Anesthetic management of a parturient with Kearns–Sayre syndrome, dual-chamber and VVI implantable defibrillator pacemaker/defibrillator, and preeclampsia for cesarean delivery: A case report and review of the literature p. 134
Abdulmohsen Al Ghamdi
DOI:10.4103/sja.SJA_630_17  PMID:29416473
Kearns–Sayre syndrome (KSS), a rare form of mitochondrial myopathy, is a triad of chronic progressive external ophthalmoplegia, bilateral pigmentary retinopathy, and cardiac conduction abnormalities. In this report, we show how a combined spinal epidural anesthesia can be useful for cesarean delivery, as we illustrate in a dual-chamber and VVI implantable defibrillator pacemaker/defibrillator parturient with a KSS and preeclampsia.
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LETTERS TO EDITOR Top

Surgical evacuation of subdural hematoma in a patient with transplanted heart under anesthesia p. 139
Shalendra Singh, Kunal Sarin, Girija Prasad Rath
DOI:10.4103/sja.SJA_154_17  PMID:29416474
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Necrotizing fasciitis following spinal anesthesia: A rare and devastating complication p. 140
Vipul D Yagnik
DOI:10.4103/sja.SJA_146_17  PMID:29416475
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Fractured tracheostomy tube posted for bronchoscopic removal: An anesthetic challenge p. 142
Suruchi Ambasta, Suman Lata Gupta, G Rajiv, Srinivasan Swaminathan
DOI:10.4103/sja.SJA_144_17  PMID:29416476
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Delayed migration of coil into the nasopharynx following embolization of internal carotid artery pseudoaneurysm: A rare complication p. 144
Ashutosh Kaushal, Gyaninder Pal Singh, Shalendra Singh, Surya Kumar Dube
DOI:10.4103/sja.SJA_179_17  PMID:29416477
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Hyponatremia and unexpected use of cardiopulmonary bypass p. 145
Yasuhiko Imashuku
DOI:10.4103/sja.SJA_195_17  PMID:29416478
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Management of a difficult-to-ventilate and difficult-to-intubate airway: Anesthetists' nightmare p. 146
B Naveen Naik, Anudeep Jafra, Ankur Luthra, Savinder Sethi
DOI:10.4103/sja.SJA_173_17  PMID:29416479
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Time to introduce diameter index safety system for resuscitation bag!! p. 148
Akshaya Narayan Shetti, Bhavika Singla, Rachita G Mustilwar
DOI:10.4103/sja.SJA_222_17  PMID:29416480
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Aspiration of severed tracheal tube: An anesthesiologist's nightmare p. 149
Neeraj Kumar, Surya K Dube, Hirok Roy, Gyaninder P Singh, Bikram Kumar Gupta
DOI:10.4103/sja.SJA_147_17  PMID:29416481
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Painless palatal local anesthetic injection: A low-cost, effective technique p. 151
Nakul Uppal, Mayank Kumar
DOI:10.4103/sja.SJA_220_17  PMID:29416482
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Ultrasound-guided interscalene block in a patient with halo brace p. 152
Jai Singh, Versha Verma, Aman Thakur, Priyanka Sood
DOI:10.4103/sja.SJA_276_17  PMID:29416483
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Pneumothorax in a preterm during tracheoesophageal fistula repair: Challenges in diagnosis and management p. 154
Ridhima Sharma, Deepak Dwivedi, Ripon Choudhary
DOI:10.4103/sja.SJA_231_17  PMID:29416484
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Surgical Apgar Score for predicting patient outcome after hepatopancreaticobiliary surgeries p. 155
Abhijit S Nair
DOI:10.4103/sja.SJA_267_17  PMID:29416485
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Misplacement of central venous catheters: Was excessive length of the guide wire responsible? p. 157
Prakash K Dubey, Chandra K Prasad, Nishant Tripathi
DOI:10.4103/sja.SJA_321_17  PMID:29416486
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A reliable alternative of fiberoptic bronchoscope in unanticipated difficult airway: Flexible fiberoptic cystoscope p. 158
Muhammad Sohaib, Khalid Maudood Siddiqui, Muhammad Faisal Khan
DOI:10.4103/sja.SJA_346_17  PMID:29416487
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Bilateral greater orbital nerve block: Efficacy in postdural puncture headache p. 159
Abhijit S Nair
DOI:10.4103/sja.SJA_350_17  PMID:29416488
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Use of high-flow nasal cannula for emergency pericardiocentesis in a case of anterior mediastinal mass p. 161
Ketan Sakharam Kulkarni, Pushkar Mahendra Desai, Amruta Milind Shringarpure, Manjula Sarkar
DOI:10.4103/sja.SJA_387_17  PMID:29416489
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Ciproxifan in preventing inhalational anesthetic-induced neurotoxicity! p. 162
Abhijit S Nair
DOI:10.4103/sja.SJA_394_17  PMID:29416490
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Airway management in a case of large congenital ranula p. 163
Ajay Singh, Karthik V Iyer, Anshu Gupta
DOI:10.4103/sja.SJA_289_17  PMID:29416491
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Split nasopharyngeal airway as a conduit for oral fiber-optic intubation in a case of difficult airway p. 165
Ravinder Kumar Pandey, Udismita Baruah, S Swetha, Meenu Batra, Jyotsna Punj, V Darlong
DOI:10.4103/sja.SJA_257_17  PMID:29416492
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Anesthetic issues in pregnancy with Ebstein's anomaly, hypothyroidism, and sepsis p. 167
Jay Prakash, Natesh S Rao, Neeraj Kumar, Mumtaz Hussain
DOI:10.4103/sja.SJA_417_17  PMID:29416493
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Ultrasound-guided lumbar transforaminal injection through interfacet approach p. 169
Amarjeet Kumar, Chandni Sinha, Umesh Kumar Bhadani, Shalini Sharma
DOI:10.4103/sja.SJA_373_17  PMID:29416494
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Radial nerve injury following lengthy general anesthesia procedure p. 170
Seyhan Yağar, Rabia Koçulu, Ülkühan Düzgün
DOI:10.4103/sja.SJA_341_17  PMID:29416495
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Is homocystinuria a real challenge for anesthetist? Are we making a difference? p. 172
Muhammad Umar Slote, Karima Karam Khan, Ausaf Ahmed Khan, Mohsin Nazir Butt
DOI:10.4103/sja.SJA_274_17  PMID:29416496
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Undiagnosed myxedema coma: Rare but life-threatening p. 173
Priyanka Sethi, Manoj Kamal, Shilpi Verma, Pradeep Bhatia
DOI:10.4103/1658-354X.222365  PMID:29416497
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