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   Table of Contents - Current issue
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October-December 2020
Volume 14 | Issue 4
Page Nos. 423-577

Online since Thursday, September 24, 2020

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ORIGINAL ARTICLES  

Comparison of analgesic efficacy of ultrasound-guided thoracic paravertebral block versus surgeon-guided serratus anterior plane block for acute postoperative pain in patients undergoing thoracotomy for lung surgery-A prospective randomized study Highly accessed article p. 423
Anuradha Patel, Vinod Kumar, Rakesh Garg, Sushma Bhatnagar, Seema Mishra, Nishkarsh Gupta, Sachidanand Jee Bharti, Sunil Kumar
DOI:10.4103/sja.SJA_143_20  
Context: Inadequate pain relief after thoracotomy may lead to postoperative respiratory complications. Aims: We have compared total morphine consumption in 24 hours following thoracotomy. Settings and Design: This prospective randomized pilot study involved 50 patients undergoing elective thoracotomy for lung surgery at AIIMS, New Delhi. Patients and Methods: Fifty patients undergoing elective thoracotomy were randomly allocated into two groups. In Group I patients, ultrasound (USG)-guided paravertebral catheter was inserted preoperatively and in Group II patients, serratus anterior plane (SAP) catheter was inserted by the surgeon before closure. Ropivacaine bolus (group I: 0.2% 0.1 ml/kg and group II: 0.375% 0.4 ml/kg) was given before extubation, followed by its continuous infusion for 24 hours. If the numerical rating scale (NRS) was >3, then patients were given intravenous (i.v.) morphine 3 mg. Total 24-hour morphine consumption, duration of effective analgesia, hemodynamic parameters, side effects, and overall patient satisfaction were recorded. Statistical Analysis Used: T-test was used to compare the parametric values in both the groups, whereas the Mann–Whitney U-test was performed to compare the nonparametric values. Results: Postoperative morphine requirement in the ParaVertebral Block (PVB) group (8.65 ± 4.27 mg) was less as compared to the SAP group (11.87 ± 6.22 mg) but that was not statistically significant (p 0.052). Postoperative pain scores at rest and on movement, patient satisfaction, and incidence of chronic post-thoracotomy pain were comparable in both the groups. Conclusion: SAP block with continuous catheter technique seems to be a safe and effective modality for the management of acute postoperative pain after thoracotomy.
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The effect of tranexamic acid in reducing postoperative hemorrhage in patients undergoing coronary artery bypass graft Highly accessed article p. 431
Alireza Rostami, Amin Haj Hoseini, Alireza Kamali
DOI:10.4103/sja.SJA_800_19  
Introduction: Nowadays, cardiovascular diseases such as coronary heart disease are one of the most important causes of human mortality worldwide. Coronary artery bypass graft (CABG) surgery is a standard therapy approach for those suffering from coronary artery disease. Tranexamic acid (TXA), an antifibrinolytic drug, which, in turn, inhibits fibrinolysis, leading to the prevention of bleeding, thus, the present study aimed to evaluate the effect of topical TXA on bleeding reduction after coronary artery CABG. Materials and Methods: In this study 62 patients were randomly divided into two groups of TXA and control. After surgery and removal from the cardiopulmonary pump, TXA (2 g) was injected locally into the mediastinum by the surgeon. In the second group (control) the same amount of normal saline (100 cc) was given. Data were analyzed by SPSS 19 software via the t-test and Fisher's test. Results: A significant difference was found between the 2 groups in terms of postoperative hemorrhage, packed cell volume, platelet transfusion, duration of surgery, and received FFP (P = 0.0001; P = 0.01; P = 0.0001; P = 0.0001; P = 0.0001), where were found to be lower in the TXA group than in the placebo group. There was no significant difference in age, sex, return to the operating room, and discharge. Conclusion: The use of topical TXA in GABC significantly reduced postoperative hemorrhage, packed cell volume, platelet> transfusion, and FFP after surgery. Besides, it had no significant effect on the return to the operating room and mortality.
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Do the existing systemic diseases overstate anaesthetic intervention during cataract surgery under local anaesthesia? An observational study to correlate the association p. 436
Afroz S Khan, Vaijayanti N Gadre, Usha R Badole, Manoj D Gilvarkar, Mohammed Azhar Quazi
DOI:10.4103/sja.SJA_88_20  
Context: The objective was to study the extent of anaesthetic intervention and its association with systemic comorbidities. The secondary objectives were to estimate the prevalence of systemic comorbidities in age-related cataracts. Aims: To determine the prevalence of systemic comorbidities in cataract surgery patients and association with anaesthesiologists' intervention. Settings and Design: Prospective observational study. Methods and Materials: The study was done inatertiary care hospital over a period of 3 months. Adult and consenting patients were included and those having sensitivity or toxic reaction to local anaesthetics, uncooperative, and paediatric patients were excluded. Statistical Analysis: The sample size (717) was calculated according to the formula for the finite population.The total number of patients suffering from comorbidities, adverse events during surgery, and events attended by an anesthesiologist with percentages were calculated. Results: Of the 717 patients studied, comorbidities were associated with 385 (53.69%) patients; among which hypertension was most frequent and found in 174 (20.30%). As much as 113 (15.72%) patients had adverse events during surgery and required intervention by the attending anaesthesiologist in which 26 (15.72%) patients required drug administration for stabilization of condition of the patient. Conclusions: From this study, we conclude that there is a correlation between prevalent comorbidities and active intervention by the attending anaesthesiologist in patients undergoing cataract surgery.
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The perfusion index could early predict a nerve block success: A preliminary report Highly accessed article p. 442
Romualdo Del Buono, Giuseppe Pascarella, Fabio Costa, Felice Eugenio Agrò
DOI:10.4103/sja.SJA_171_20  
Introduction: In literature, there is plenty of material regarding regional anesthesia techniques and block safety, but lacks about block success prevision. The perfusion index (PI) is an oximetry reliability indicator, available on many monitors as non-invasive parameter, indicating the ratio of arterial blood flow (pulsatile flow) to venous, capillary, and tissue blood flow (non-pulsatile blood flow). We hypothesized that that analysis of PI variations after performing regional anesthesia could have a role in predicting a successful nerve block. Methods: Twenty-four consecutive patients regularly scheduled for limb surgery in regional anesthesia were included in our observation. PI measurements were recorded before regional anesthesia, and 1, 2, 3, 5, and 10 min after needle withdrawal. Along with PI, also sensation to cold (ice test), tactile sensation, and motor function were recorded before regional anesthesia, and 1, 2, 3, 5, and 10 min after needle withdrawal on the limb where the block were performed. Results: Ten sciatic nerve blocks, 6 spinal anesthesia, 8 brachial plexus block were performed and resulted successful. In all cases, PI values tripled at 5 min after the block execution and increased linearly, reaching at 10 min an average PI value 3.8 times higher for the interscalene group, 4 times for the spinal group, and 8 for the sciatic group. Conclusions: A tripled PI within 5 min from performing regional anesthesia showed to be a reliable indicator of nerve block success, but a bigger trial involving more patients and different anesthetic concentrations may be necessary to confirm this assumption.
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Perioperative complications of pediatric otorhinolaryngological operations p. 446
Yu S Aleksandrovich, VV Rybianov, KV Pshenisnov, SA Razumov
DOI:10.4103/sja.SJA_99_20  
Background: The identification of risk factors for the development of perioperative complications is one of the most important problems of pediatric anesthesiology. Purpose: To identify risk factors for the development of perioperative complications in children undergoing ambulatory surgical interventions on ENT organs. Methods: Total of 141 patients were examined at the age from 7 to 17 years. Depending on the presence of complications all patients were divided into three groups: “No complications” (n = 64), “One complication” (n = 55) and “Two or more complications” (n = 22). The study was carried out in the following areas: Preoperative clinical status, intraoperative and postoperative complications. The severity of nasal breathing disorders was determined rhinomanometrically. 31 children underwent somnography. In the study of heart rate variability was evaluated. Intraoperative complications included: Cardiac arrhythmias, arterial hypertension and desaturation less than 90%. Postoperative complications included: Cardiorespiratory complications, pain, delirium, postoperative nausea and vomiting. Results: The most significant complication in the intraoperative period is desaturation below 90%, in the postoperative period they are pain, nausea and vomiting. Risk factors for the development of complications in the perioperative period are a decrease in the thyromental distance, hyperplasia of the tonsils of the third degree, Malampati score ≥ to 2 points, parents' bad habits, combined neurological and respiratory pathologies in a child, an assessment of the class “allergology” of the ASPOND scale is not less than 180 points and the prevalence of vagal influences. Conclusions: The obtained results indicate that the presence of risk factors for perioperative complications during operations on ENT organs in children are associated with the initial autonomic status and the predominance of the parasympathetic nervous system as well as with clinical markers.
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Short-term memory impairment in patients undergoing general anesthesia and its contributing factors p. 454
Ali Ahmadzadeh Amiri, Kasra Karvandian, Nazanin Ramezani, Amir Ahmadzadeh Amiri
DOI:10.4103/sja.SJA_651_19  
Background: Short-term memory disorder following surgery and anesthesia is a common complication of anesthesia and a common complaint of the patients. Aims: This study was designed to assess memory impairment in patients undergoing elective surgery, investigate the effect of general anesthesia (GA) on memory, and identify the factors contributing to it, as well as the specific effect of anesthesia on each of the memory domains. Setting and Design: This cross-sectional study was performed in a university hospital. Methods and Materials: Patients with the American Society of Anesthesiologists (ASA) Class I, II, and III who were candidates for elective abdominal surgery were enrolled. Patients answered several questions based on the Wechsler Memory Scale–Revised V (WMS-R-V), a standardized questionnaire, minutes before entering the operating room (OR) and again after 24 h postoperation, and the differences were recorded. Statistical Analysis: Analysis was performed using T-independent and Chi-square tests with Pearson's coefficient and Fischer's exact test and Man–Whitney test. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software. Results: Four hundred patients (198 females and 202 males) with a mean age of 50.75 years were enrolled in our study. Our study results showed that short-term memory after GA was significantly decreased compared with preanesthesia (P < 0.05). There was no significant relationship between memory disorder following GA and gender (P = 0.18) or comorbidities (P = 0.138). However, older age was found to be a contributing factor to memory loss following GA (P < 0.001). The highest and lowest effect of GA were found on the number repeat (45.2%) and personal information (16.2%) domain of the memory. Conclusion: GA significantly reduces the patient's short-term memory after the surgery.
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Attitudes and knowledge of anesthesiology trainees to radiation exposure in a Tertiary care hospital p. 459
Mohammad Asghar Ali, Bushra Salim, Khalid Maudood Siddiqui, Muhammad Faisal Khan
DOI:10.4103/sja.SJA_659_19  
Background and Aims: Ionizing radiation procedures are indispensable in medical clinical practice. Exposure to radiation at any dose could have serious adverse effects. Anesthesiologists working in interventional radiology suites are at a higher risk of radiation exposure than other personnel. The aim of this study was to assess the knowledge and attitude of anesthesiology trainees towards the radiation hazards and current safety practices. Methods: This prospective cross-sectional survey was conducted at the department of anesthesiology at Aga Khan University. All anesthesiology trainees working in the department were given a 12-question paper-based survey after getting ethical review committee approval and informed consent. The questionnaire contained requests for personal demographic data and specific questions regarding radiation protection. Results: A total of 54 participants were included in this survey. Thirty-two (59.3%) were male, and 22 (40.7%) were female. The average year of experience working in anesthesia of the participants was 2.8 ± 1.65 years (range, one to eight years). Frequency of radiation exposure of 32 (59.3%) participants was 1-5 times per week. Approximately 68.5% (37/54) of participants believed they took adequate precautions for protection against radiation. Only 20.4% (11/54) used both a lead apron and a thyroid shield for prevention of radiation exposure. Most participants using the radiation shield or clothing (70.4%; 38/54) cited concerns about cancer. Conclusions: A lack of knowledge persists among anesthesiology trainees in our institute regarding the risks associated with ionizing radiation. This study also serves to highlight the need for anesthesiology trainees to protect themselves properly. Radiation dose, hazards, and protection strategies must be included in the basic curriculum of medical colleges.
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Analgesic efficacy and spread of local anesthetic in ultrasound-guided paravertebral, pectoralis II, and serratus anterior plane block for breast surgeries: A randomized controlled trial p. 464
Dhruv Jain, Virender K Mohan, Debesh Bhoi, Ravinder K Batra, Lokesh Kashyap, Dilip Shende, Sana Yasmin Hussain, Anurag Srivastava, Vathulru Seenu
DOI:10.4103/sja.SJA_822_19  
Background: Thoracic paravertebral block (TPVB) has become the gold standard to provide postoperative analgesia in breast surgery. Recently, ultrasound-guided (USG) pectoralis (PECS) block and serratus anterior plane (SAP) block have been described as an alternative to TPVB. The objectives were to compare TPVB, PECS, and SAP block in terms of analgesic efficacy and the spread of local anesthetic by ultrasound imaging, correlating it with the sensory blockade. Materials and Methods: Prospective randomized interventional study conducted in 45 ASA grades I–II patients scheduled for the elective breast surgery. Patients were randomly allocated into three groups, i.e., Gr.1 (USG –TPVB) (ropivacaine 0.375% 20 ml), Gr.2 (USG-PECS II) block (ropivacaine 0.375% 30 ml), and Gr.3 (USG-SAP) (ropivacaine 0.375% 30 ml). Spread of the local anesthetics was seen with ultrasound imaging. Onset of sensory blockade, postoperative fentanyl consumption, and pain scores was measured. Results: TPVB and SAP group had comparatively higher spread and sensory block compared to PECS group. Postoperative fentanyl requirement (mean ± SD) was 428.33 ± 243.1 μg, 644.67 ± 260.15 μg, and 415 ± 182.44 μg in the TPVB group, PECS II group, and SAP group, respectively. SAP group had significantly lesser requirement than PECS II group (P = 0.028) but similar requirement as in TPVB group (P = 1.0). Pain scores were not significantly different among the group in the postoperative period. Conclusion: TPVB and SAP group result in a greater spread of the drug and provide equivalent analgesia and are superior to the PECS II block in providing analgesia for breast surgeries. SAP block is easier to perform than TPVB with lesser chances of complications and results in faster onset.
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Pain, stress, analgesia and postpartum depression: Revisiting the controversy with a randomized controlled trial p. 473
Amrit Kaur, Sukanya Mitra, Jasveer Singh, Rashi Sarna, Dilpreet Kaur Pandher, Richa Saroa, Subhash Das
DOI:10.4103/sja.SJA_814_19  
Background: Pain and depression are associated, but it is uncertain if effective pain relief during labor by labor analgesia reduces the incidence of postpartum depression (PPD). This randomized, controlled study assessed whether combined spinal-epidural (CSE) labor analgesia is associated with a decreased risk of PPD. Other reported risk factors for PPD were also assessed. Materials and Methods: Parturients were randomly assigned to either CSE labor analgesia or normal vaginal delivery (n = 65 each). CSE parturients received 0.5 ml of 0.5% hyperbaric bupivacaine intrathecally and PCEA with continuous infusion of 0.1% levobupivacaine and 2 μg/ml fentanyl @5 ml/h along with patient-controlled boluses with a lockout interval of 15 min. Parturients of both the groups were assessed using Edinburgh Postnatal Depression Scale (EPDS) for depressive symptoms at day 3 and PPD at 6 weeks (primary outcome; defined as EPDS score ≥10 at 6 weeks postpartum). Secondary outcomes included pain scores, maternal satisfaction, and Apgar scores at 1 and 5 min. Parturients were also screened for several risk factors for PPD. Results: Incidence of PPD was 22.3%. The difference in incidence of PPD between the CSE group vs. control group was not significant (27.7% vs. 16.9%; Fisher's exact P = 0.103). Of all the risk factors analyzed in logistic regression model, perceived stress during pregnancy was the only significant predictor of the development of PPD (adjusted Odds Ratio 11.17, 95% Confidence interval 2.86–43.55; P = 0.001). Conclusion: CSE analgesia in laboring parturients does not reduce PPD at 6 weeks. Instead, perceived high stress during pregnancy appears to be the most important factor.
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Postoperative analgesic efficacy of fluoroscopy-guided erector spinae plane block after percutaneous nephrolithotomy (PCNL): A randomized controlled study p. 480
Mukesh K Prasad, Rohit K Varshney, Payal Jain, Amit K Choudhary, Aditi Khare, Gurdeep S Jheetay
DOI:10.4103/sja.SJA_26_20  
Background: Percutaneous nephrolithotomy (PCNL) a minimally invasive method for the removal of renal calculi and is associated with significant pain in postoperative period. Conventionally, intravenous opioids, local anesthetic infiltration, and regional blocks (intercostal/paravertebral blocks) have been tried with less efficacy to control postoperative pain. The present study is conducted to assess the effectiveness of erector spinae plane block (ESPB) performed under fluoroscopy guidance for postoperative analgesia during PCNL. Subjects and Methods: After obtaining ethical clearance, the study was conducted on 61 American Society of Anaesthesiologists (ASA) I and II patients aged between 18–65 years admitted for PCNL. Group I (n = 30) did not receive ESPB while Group II (n = 31) received ESPB under fluoroscopy guidance and 20 ml of 0.375% ropivacaine was administered after PCNL. Patient-reported pain intensity using visual analogue scale (VAS) was considered as a primary outcome. The hemodynamic variables (heart rate, systolic, diastolic, and mean blood pressure) was considered as a secondary outcome. Statistical analysis was performed using Student's t-test and Mann–Whitney U test. Data analysis was performed using the Statistical Package for the Social Sciences version 23.0. Results: Postoperatively VAS score was significantly lower in Group II at 0, 1, 2, 3, 4, 6, 12, 18, and 24 hours after PCNL (P < 0.001). Dose of rescue analgesia significantly decreased in Group II compared to Group I. Conclusion: ESPB performed under fluoroscopic guidance is a simple and effective technique and it provides significantly better postoperative pain relief.
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Modified electroconvulsive therapy in a resource-challenged setting: Comparison of two doses (0.5 mg/kg and 1 mg/kg) of suxamethonium chloride p. 487
Olurotimi I Aaron, Aramide F Faponle, Benjamin O Bolaji, Samuel K Mosaku, Anthony T Adenekan, Olakunle A Oginni
DOI:10.4103/sja.SJA_147_20  
Background: Suxamethonium has been shown to have a superior modification of the convulsion associated with ECT compared to other muscle relaxants. The dosage of suxamethonium used in ECT varies widely based on the experiences of practitioners. The study aimed to determine and compare the effectiveness and side effect profile of 0.5 mg/kg and 1 mg/kg in modified ECT. Subjects and Methods: This was a prospective randomized crossover study, comparing the effects of suxamethonium at a dose of 0.5 mg/kg, and 1.0 mg/kg in 27 patients who had a total of 54 sessions of modified ECT. The primary outcome parameters were quality of convulsion and onset and duration of apnoea. The secondary outcome parameters were hemodynamic variables, arterial oxygen saturation, delayed recovery, muscle pain, vomiting, headache, prolonged convulsion, and serum potassium. Data collected were entered into proforma and analyzed using Statistical Package for Social Sciences (SPSS) version 17.0. Parametric variables are presented as means and standard deviations while non-parametric variables are presented as frequencies and percentages. The level of significance (P-value) was considered at 0.05. Results: Sixteen patients (59%) had acceptable convulsion modification with 0.5 mg/kg suxamethonium compared to 23 patients (85%) with the use of 1.0 mg/kg suxamethonium (P = 0.016). There was no statistically significant difference in the duration of convulsion, the onset of apnoea, and the duration of apnoea with the two doses. Changes in heart rate, blood pressure, arterial oxygen saturation, and serum potassium level that accompany the mECT were comparable with the two doses of suxamethonium studied. Conclusions: A better modification of convulsion with comparable hemodynamic and side effect profile is achieved during mECT with the use of 1.0 mg/kg suxamethonium compared to 0.5 mg/kg.
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Comparison of the skin-to-epidural space distance at the thoracic and lumbar levels in children using magnetic resonance imaging p. 493
Tariq M Wani, AlAwwaab Dabaliz, Khalid Kadah, Giorgio Veneziano, Dmitry Tumin, Joseph D Tobias
DOI:10.4103/sja.SJA_292_20  
Background: Several studies have attempted to estimate the approximate distance from the skin-to-epidural space using different imaging modalities (computed tomography [CT], ultrasound, and magnetic resonance imaging [MRI]) and direct needle measurements. The objective of our study was to compare the distance from the skin to the epidural space (SED) at multiple levels, focusing on T6-7, T9-10, and L2-3using MRI. Methods: After institutional review board (IRB) approval, sagittal T2-weighted MRI images of the spine of 108 children in the age group ranging from 3 months to 8 years undergoing radiological evaluation in the supine position at our institution were analyzed. The SED at T6-7and T9-10levels (straight and inclined) and SED at L2-3 (straight) were determined and compared using repeated-measures ANOVA and paired t-tests with a Bonferroni correction for 10 pairwise comparisons (P < 0.005 was considered statistically significant). Results: The average SED (measured straight and inclined) was 18.2 mm and 21.6 mm at T6-7; 18.3 mm and 20.5 mm at T9-10; and 21.8 mm (straight) at L2-3. The repeated-measures ANOVA F-test indicated significant variability in SED (P < 0.001) among the 5 measurements obtained. At the P < 0.005 significance level, corrected for multiple comparisons, the SED (straight) at T9-10 straight was shorter than the other measured distances. Conclusion: The distance from the skin to the epidural space is not constant at various vertebral levels. At the levels measured, it was greatest at the lumbar level and at least at the thoracic level of T9-10. A single predictive formula was not applicable for calculating the approximate SED at all vertebral levels.
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REVIEW ARTICLES Top

Unusual routes for transmission of coronavirus disease (COVID-19): Recommendations to interrupt the vicious cycle of infection p. 498
Hunny Sharma, Swati Verma
DOI:10.4103/sja.SJA_301_20  
The outbreak of the novel COVID-19, which began silently in Wuhan City, China, has now taken the form of a pandemic, with its claws spreading rapidly in many countries, with new and new cases emerging rapidly. The COVID-19-associated CoV is a beta coronavirus, which spreads at such a deadly rate that the World Health Organization (WHO) has to declare it a Public Health Emergency of International Concern (PHEIC). The objective of the narrative review is to describe what is COVID-19-related coronavirus (CoV), its structure and particle size, potential transmission routes, the risk of infection in patients undergoing blood transfusion or in patients with diabetes and cancer, and recommendations to prevent its spread in office settings, travel / recreation settings, residential and health facilities. This paper also discusses several groundbreaking approaches that are used to counter COVID-19. With this narrative review, we hope to raise awareness of the usual and unusual pathways of transmission and prevent the spread of this pandemic disease.
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Cancer in corona times p. 504
Shagun Bhatia Shah, Rajiv Chawla
DOI:10.4103/sja.SJA_317_20  
Humanity is witnessing an unprecedented tsunami of corona virus disease 2019 (COVID-19) patients. Till date, India houses 10,453 confirmed COVID-19 patients with a death toll of 358 nationwide and the number is steadily rising with each passing day. The capital city of Delhi, harbouring 1510 patients, has the dubious distinction of being the second largest hotspot for COVID positive patients in India, second only to the state of Maharashtra. Being immuno-compromised, cancer patients are first more susceptible to catch this virus and secondly may witness a more devastating course. Having cancer is a bigger risk factor for contracting COVID-19 than even old age. “Death due to untreated cancer is a much bigger reality than death due to COVID-19,” is one perspective that advocates continuation of cancer therapy in corona times albeit by converting cancer hospitals into virtual corona-free fortresses with several tiers of barriers against corona. The immediate, short and long term implications of the corona pandemic and a nationwide lockdown to curtail it, on cancer patients and their caregivers is discussed at length here tempered with experience from the largest tertiary care oncology setup of Northern India. Rigorous literature review based on Medline, Google scholar, Embase, Cochrane and Scopus database search was utilized.
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CASE REPORTS Top

Laparoscopic bariatric surgery in a patient with idiopathic intracranial hypertension and lumboperitoneal shunt: Anesthetic implications p. 510
Teresa Lopez, Jacobo Trébol, José A Sastre
DOI:10.4103/sja.SJA_190_20  
Idiopathic intracranial hypertension (IIH) typically affects obese young women. Treatment is mainly medical, but some cases require surgery; ventriculoperitoneal (VPS) or lumboperitoneal shunts (LPS) being the most common procedures. Although bariatric surgery is not the first-line surgical treatment, it can be useful in refractory cases and allows treating the major underlying risk factor and its comorbidities. Laparoscopic bariatric surgery is the gold standard; however, literature in patients with shunts is scarce. In the present study, we report the case of a morbidly obese female with IIH treated with an LPS and with refractory headache, scheduled for laparoscopic Roux-en-Y gastric bypass. LPS position was checked before surgery (abdominal X-ray) and during pneumoperitoneum was clamped. Anesthetic management was guided to minimize increases in intracranial pressure (ICP). Surgery and anesthesia were uneventful. Three months later, headaches disappeared and analgesics were discontinued. In conclusion, laparoscopic bariatric surgery may be an option for IIH. It is safe in patients with LPS, although concerns should be taken into account (avoid any damage to the shunt, limit digestive tract contents spillage, and strict vigilance for early detection of intracranial hypertension signs). Although valve system could prevent pressure complications, the catheter can be clamped to avoid retrograde insufflation of CO2 or digestive tract content.
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Incidental finding of tracheobronchial foreign body during double lumen tube placement-lessons learned p. 514
Lakshmi N Kurnutala, Angela W Strother, Bryan J Hierlmeier
DOI:10.4103/sja.SJA_237_20  
Tracheobronchial foreign bodies are common in pediatric patients, but also seen in adult patients. Most of these patients present with history of foreign body inhalation, or with the symptoms like cough, respiratory distress. In this paper, we would like to report an incidental finding of a tablet in tracheobronchial tree during double lumen tube placement with fiberoptic bronchoscopy in a middle-aged patient scheduled for right lung decortication for hemothorax. We also learned that delay in removing the tablet would make the removal of foreign body complicated. The patient did not report any history of aspiration or have any signs and symptoms consistent with aspiration. We also discussed the difficult in diagnosing foreign-body aspiration in adults with nonspecific symptoms.
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Erector spinae plane block and rhomboid intercostal block for the treatment of post-mastectomy pain syndrome p. 517
Emanuele Piraccini, Morena Calli, Stefania Taddei, Stefano Maitan
DOI:10.4103/sja.SJA_203_20  
Post-mastectomy pain syndrome (PMPS) can have multiple pain generators, including neuropathic pain and myofascial pain syndrome (MPS). Erector spinae plane (ESP) block and rhomboid intercostal block (RIB) have been used to provide anesthesia of the thorax and also for some chronic pain conditions. We describe a 43-year-old man suffering from right PMPS after right mastectomy, full axillary, and mammary lymph node dissection. We treated her with ESP blocks and RIB to reduce neuralgia and MPS: Neuropathic pain disappeared and the patient experienced only slight residual pain. The result was maintained 3 months later. This report suggests that ESP block and RIB with local anesthetic and corticosteroids with might be useful to treat a PMPS.
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Oral teratoma in a neonate: A case report of anesthetic challenge p. 520
Rajneesh Singhal, Vishnu K Garg, Brajesh K Ratre, Mangilal Deganwa
DOI:10.4103/sja.SJA_299_20  
Congenital teratoma of oral cavity in a neonate is a rare condition associated with compromised airway and challenges anesthesiologist in airway management. In this report, we describe a scenario of neonate with multiple oral teratoma, cleft palate, and bifid tongue who presented with respiratory distress for surgical excision of mass. The compromised airway can be successfully managed by appropriate prior planning and effective communication between anesthesiologist and surgical team.
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Anesthetic nuances in Segawa's syndrome: A case report and review of the literature p. 524
Manbir Kaur, Umadatt Sharma, Rajendra K Solanki
DOI:10.4103/sja.SJA_809_19  
Segawa's syndrome, dopamine-responsive dystonia, is a rare genetic disorder that typically begins in childhood by around 4–6 years of age. It is characterized by abnormal gait and dystonia. A 33-year-old man presented for autologous skin grafting of a nonhealing wound under general anesthesia. Successful anesthetic management of patients with this rare disease, though analogous in many ways to that of patients with Parkinson's disease, still pose significant challenges. We present anesthetic nuances to be considered in the management of a patient with Segawa's disease along with a pertinent review of the literature.
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Erector spinae plane block in various abdominal surgeries: A case series p. 528
Toleska Marija, Dimitrovski Aleksandar
DOI:10.4103/sja.SJA_31_20  
Erector spinae plane (ESP) block is a regional anesthesia technique, which provides visceral and somatic analgesia for abdominal surgery; during surgery and in the postoperative period. The local anesthetic is injected between the erector spinae muscle and the transverse process and it spreads cranially and caudally into the paravertebral space, affecting the ventral and dorsal branches of the thoracic spinal nerves and the rami communicants that contain sympathetic nerve fibers. ESP block can replace thoracic epidural anesthesia and has a better analgesic effect compared to other plane blocks that are used in abdominal surgery. We described six case series of successfully performed ESP block for postoperative analgesia in various abdominal surgeries such as unilateral open inguinal hernia repair with a supraumbilical hernia, ileostomy reversal surgery, open diaphragmatic hernia repair, laparoscopic cholecystectomy, and abdominal abscess evacuation.
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Anesthetic management of a “Supercentenarian” (Oldest living person on Earth) posted for an emergency surgery p. 531
Ram M Sharma, Anurag Garg, Badal Parikh
DOI:10.4103/sja.SJA_85_20  
With the rise in living standards and evolution of science, there is a rise in life expectancy world over. This demographic transition has led to a rise in older persons, increasing the dependency ratios and “demographic burden.” Management of such old patients requires special considerations and understanding as aging is a physiological phenomenon in which the functional capacity of organs decreases due to degenerative changes in the structure. An important aspect to remember in Geriatric Anesthesia is that in spite of adequate compensatory mechanisms for age-related changes, there is a limitation of physiological reserve, especially in stressful circumstances like perioperative period. Geriatric patients are more sensitive to all medications and anesthetic agents. Lesser amount of drug is required to achieve the desired clinical effect, but have a prolonged effect. This elderly but well-preserved patient, possibly a case of small gut obstruction was posted for emergency laparoscopy and proceed. Seeing his age and easy friability, a well-planned preoperative assessment and optimization was done prior to wheeling him into operation theater. Administration of short-acting anesthetic drugs in titrated quantities and awareness about postoperative cognitive dysfunction (POCD) helped us to get better and faster recovery in the patient.
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Bilateral high thoracic continuous erector spinae plane blocks for postoperative analgesia in a posterior cervical fusion p. 535
Sandeep Diwan, Won Uk Koh, Ki Jinn Chin, Abhijit Nair
DOI:10.4103/sja.SJA_642_19  
Posterior decompression and instrumentation of the cervical spine are associated with severe postoperative pain due to extensive soft tissue and muscle dissection during the surgery. In this case series, we describe bilateral continuous cervical erector spinae plane block (CESPB) placed at T1-2 through the thoracic erector spinae plane. A series of 4 patients underwent posterior cervical decompression and stabilization for various surgical indications. The CESPB block provides intense analgesia with low requirements of anesthetic drugs in the perioperative period and opioid-free analgesia in the postoperative period. The spread of local anesthetic was studied by performing CT contrast studies after obtaining informed consent.
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Successful bilevel positive airway pressure therapy in a patient with amyotrophic lateral sclerosis after emergency laparotomy: A case report p. 538
Yukihide Koyama, Koichi Tsuzaki, Hideaki Shimizu, Junko Kuroda, Soichi Shimizu
DOI:10.4103/sja.SJA_375_20  
Patients with amyotrophic lateral sclerosis (ALS) present an increased risk of postoperative respiratory failure after general anesthesia. We report the case of a 71-year-old man with ALS who underwent emergency laparotomy for small bowel strangulation. After surgery, he remained intubated and was transferred to the high care unit under mechanical ventilation, due to unstable hemodynamics requiring inotropic support. On postoperative day (POD) 3, he was extubated under stable hemodynamics and respiratory status. Immediately after extubation, bilevel positive airway pressure (bilevel PAP) was prophylactically applied to prevent postoperative respiratory failure, which may have been caused by respiratory muscle fatigue, attributed to general anesthesia and surgical stress. On POD 7, bilevel PAP was smoothly weaned off because no signs and symptoms of respiratory failure were observed. On POD 10, he achieved 30 m-walk without rest. No postoperative complications were observed up to one month after surgery. Postoperative respiratory failure may lead to death in patients with neuromuscular disorder. Non-invasive ventilation (NIV) reduces respiratory muscle fatigue, resulting in easy sputum expectoration, promoting CO2washout, and better oxygenation. Consequently, the prophylactic use of NIV to avoid postoperative respiratory insufficiency should be considered in patients with ALS after emergency operation under general anesthesia.
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A mysterious case of fat embolism p. 541
Sangam Yadav, Amanpreet Ghalot, Vanitha Rajagopalan
DOI:10.4103/sja.SJA_109_20  
We report a patient who sustained catastrophic pulmonary fat embolism post-induction of general anesthesia during laparotomy for haemoperitoneum. The source being the fractured shaft of fracture femur which was missed during the primary survey in the chaos of a positive focused assessment with sonography for trauma and a transient responding patient. In this case report, we want to emphasize the importance of primary survey in a trauma patient, effective communication and documentation to prevent errors and for better management of patients.
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LETTERS TO EDITOR Top

Point-of-care nasal ultrasonography: A novel technique using “hockey stick” probe p. 544
Chitta R Mohanty, Vikas Saini, Sameer Sethi, Snigdha Bellapukonda
DOI:10.4103/sja.SJA_152_20  
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Changing nasal endotracheal tube to opposite nostril in a patient with no mouth opening under general anesthesia, after initial awake fiberoptic intubation p. 545
Kaushik Barua, Pulak Tosh, Naina Narayani, Sunil Rajan
DOI:10.4103/sja.SJA_160_20  
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Superior Trunk block for humerus surgery: Application beyond the shoulder analgesia p. 547
Tuhin Mistry, Samarjit Dey, Jitendra V Kalbande
DOI:10.4103/sja.SJA_198_20  
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Sphenopalatine ganglion block for abortive treatment of a migraine headache p. 548
Amnon A Berger, Jamal Hasoon
DOI:10.4103/sja.SJA_810_19  
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The role of the hyper-angulated videolaryngoscope in nasotracheal intubation p. 549
Kan Chandradeva, Divya Harshan
DOI:10.4103/sja.SJA_811_19  
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Anesthetic management of a patient with Susac syndrome: A rare neurological disorder p. 551
Ankur Khandelwal, Chandrakant Prasad, Navdeep Sokhal, Arvind Chaturvedi
DOI:10.4103/sja.SJA_66_20  
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Assessing adequacy of collateral foot circulation: A simple bedside test prior to lower extremity arterial cannulation p. 552
Ashutosh Kaushal, Shipra Verma, Rudrashish Haldar, Praveen Talawar
DOI:10.4103/sja.SJA_75_20  
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Yet another lost guide wire p. 554
Prakash K Dubey, Ranjan Rahul, Alok K Bharti
DOI:10.4103/sja.SJA_108_20  
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The novel “FIT” of endobronchial intubation: Whimsical contention or factitious science? p. 556
Akhil Kumar, Amitabh Dutta, Shikha Sharma, Jayashree Sood
DOI:10.4103/sja.SJA_165_20  
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Spread of local anesthetic after thoracic erector spinae and thoracic paravertebral block in patients with multiple posterolateral rib fractures p. 557
Sandeep Diwan, Abhijit Nair
DOI:10.4103/sja.SJA_158_20  
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Different standards of the variable pitch for oxygen saturation with pulse rate and heart rate monitoring: An avoidable complication p. 559
Tanya Aysha Edathodu, Renu Sinha, Thilaka Muthiah, V Yokasekar
DOI:10.4103/sja.SJA_163_20  
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Ultrasound to identify the cause of unilateral caudal anesthesia p. 560
Debendra Tripathy, Bhavna Gupta, S Naveen
DOI:10.4103/sja.SJA_192_20  
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Local anaesthetic systemic toxicity in paediatric patient: Tips to prevent p. 561
Renu Sinha, Nishant Patel, Kanil R Kumar
DOI:10.4103/sja.SJA_233_20  
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Use of lung ultrasound to diagnose intraoperative tension pneumothorax in a pediatric laparoscopic surgery p. 563
Tanya Mital, Shilpa Goyal, Nidhi Jain, Ankur Sharma
DOI:10.4103/sja.SJA_448_20  
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Aftermath of COVID-19: Need for developing novel bedside communication skills? p. 564
Niyati Dubey, Preksha Dubey, Prakash K Dubey
DOI:10.4103/sja.SJA_457_20  
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Treating postdural puncture headache in COVID-19 positive patient- is bilateral greater occipital nerve block the answer? p. 566
Abhijit Nair, Sandeep Diwan
DOI:10.4103/sja.SJA_383_20  
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An incidental diagnosis of tracheal bronchus using computed tomography in the congenital heart disease patient p. 567
Nithiyanandhan Palanisamy, Shrinivas V Gadhinglajkar, Rupa Sreedhar, GJ Murugendiran
DOI:10.4103/sja.SJA_479_20  
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Use of a bronchial blocker in the prone position p. 569
Mohamed S Hajnour, Amro Al-Habib
DOI:10.4103/sja.SJA_397_20  
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Response to the case submitted by Bellapukonda et al.- Can intubate but cannot ventilate! An unexpected event in a child with stridor after accidental aspiration of the potassium permanganate solution p. 570
Sujana Dontukurthy, Joseph D Tobias
DOI:10.4103/sja.SJA_413_20  
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Ultrasound-guided continuous retroclavicular brachial plexus block p. 572
Amarjeet Kumar, Chandni Sinha, Ajeet Kumar
DOI:10.4103/sja.SJA_314_20  
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In response to a comment on lung isolation for lobectomy in elderly post radiation fibrosis of a difficult airway-pediatric double-lumen tube and pediatric ureteroscope as rescue devices p. 573
Deyashinee Ghosh, Bhavna Gupta, Atif Khan
DOI:10.4103/sja.SJA_585_20  
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A novel transparent box for intubation in a suspect/confirmed coronavirus disease (COVID-19) patient p. 574
Tariq L Jilani, Mohammad A Simbawa, Sara M Aljohani, Kawthar T Barnawi, Saeed A Balubaid, Mojahid M Felimban, Hashim M Bin Samman
DOI:10.4103/sja.SJA_307_20  
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Possible use of low-molecular weight dextran as adjuvant for erector spinae plane block procedure p. 576
Masahiko Tsuchiya, Koh Mizutani, Mitsuhide Yabe, Takashi Mori
DOI:10.4103/sja.SJA_533_20  
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