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   Table of Contents - Current issue
October-December 2021
Volume 5 | Issue 4
Page Nos. 223-293

Online since Wednesday, November 24, 2021

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Blood transfusion and venous cannulation — medical publication and innovation across 350 years of history: A narrative review Highly accessed article p. 223
Andre Van Zundert, Floris S S Wiepking, Michelle Roets, Tom Christophe R V Van Zundert, Stephen P Gatt
This article reviews historical milestones during the last 350 years starting with early experiments in intravenous injections of drugs and blood transfusion conducted in a climate of scientific discovery rather than clinical application. Technical problems encountered during attempts of vascular cannulation and a lack of knowledge of physiology resulted in complications related to intravenous access, sometimes fatal, which resulted in a complete ban on blood transfusion in Europe for 150 years. Meticulous documentation of these first 17th century experiments was published in Britain, in the “Philosophical Transactions of the Royal Society of London,” the oldest continuously published scientific journal still in existence, and in France, in the “Journal des Sçavans.” These journals became the primary means of communication of scientific research and letters amongst the community of scientists. Intravenous therapy marked the start of the first primitive anesthetic and laid the foundations for anesthesia and blood transfusion, although their clinical application came centuries later. Successful intravenous anesthesia was established around the turn of the 19th century. Brave men in the 17th century endeavored to awaken the spirit of inquiry and research among their peers at the Royal Society of London. Thanks to these bold medical men acting at a time of accelerated change, there was a great impact on clinical practice in many medical fields. Anesthesia now bears the fruits of these initial experiments so that, ultimately, anesthetists can provide safe and effective anesthesia while delivering anesthetic drugs, intravenous fluids, and blood transfusions for the benefit of patients.
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Role of telemedicine in anesthesia: Are we ready yet? p. 230
Seema Mishra, Raghav Gupta, Swagata Biswas
Telemedicine is a modality which utilizes technology to provide and support health care across large distances. It has redefined the practices of medicine in many specialties and continues to be a boon for clinicians on many frontiers. Its role in the branch of anesthesia remains largely unexplored but has shown to be beneficial in all the three phases: pre-operative, intra-operative, and post-operative. Now time has come that anesthesiologists across the globe reassess their strategies and utilize the telemedicine facilities in the field of anesthesia.
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Post-spinal backache after cesarean section: A systematic review Highly accessed article p. 234
Tjahya Aryasa, Adinda Putra Pradhana, Christopher Ryalino, I Gusti Agung Gede Utara Hartawan
The most frequent patients’ complaints of spinal anesthesia are post-spinal headache and post-spinal backache. As many as 13.4% of the patients have backache as the major reason for refusing spinal anesthesia. This systematic review was conducted using keywords: “post spinal backache,” “post spinal backpain,” “caesarean section,” “caesarean delivery,” and “obstetric,” which were combined using Boolean operator “OR” and “AND.” The time filter was set from 2000 until 2020. We included six studies that included a total of 2721 subjects who underwent elective cesarean delivery under spinal anesthesia, of which 675 subjects or about 24% of them experienced backache. Many factors were thought to be responsible for the incidence of post-spinal backache. Trauma due to needle injection, hematoma, and excessive stretching of ligaments until infection which leads to abscess are possibly being the main causes of post-spinal backache. There are several efforts that can be made to reduce the risk of post-spinal backache, such as using a small needle without an introducer, performing spinal anesthesia with a paramedian approach, and reducing the number of attempts.
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Introduction of direct observation of procedural skills as workplace-based assessment tool in department of anesthesiology: Evaluation of students’ and teachers’ perceptions p. 239
Pooja R Mathur
Background: The direct observation of procedural skills (DOPS) was introduced for the workplace-based assessment of procedural skills. It offers an opportunity to provide feedback to trainees. This makes DOPS an authentic measure of clinical competence in anesthesiology training. The goal of this study was to assess the perceptions of both trainees and consultants regarding the use of DOPS and to evaluate the performance of anesthesia postgraduate (PG) trainees over consecutive assessments. Materials and Methods: After approval from the ethical committee and sensitization workshop, two exposures of DOPS per trainee were given for three common anesthesia skills as per their years in training. Thereafter anonymous feedback was collected from faculty and trainees to gather their perception regarding DOPS. Consecutive DOPS scores for trainees were analyzed. Data were presented in terms of percentages, mean, and standard deviation. A P value of <0.05 was considered significant. Results: More than 50% of participants were satisfied with the way DOPS was conducted and thought it was feasible for formative assessment. About 80% of participants were of the view that DOPS is helpful for anesthesia training and improving anesthesia procedural skills. Yet only 40%–50% favored the addition of DOPS to the departmental assessment plan. Significant improvement was observed in DOPS scores of PG trainees. Mean DOPS scores of postgraduate trainee year 1, 2, and 3 (JR 1, JR 2, and JR 3) increased from 2.6 to 4.8, 4 to 5.7, and 5.6 to 7, respectively (P < 0.05). Conclusions: DOPS may be considered as a useful tool for workplace-based assessment for anesthesia PG training.
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Knowledge, attitude, and practices of Indian anesthesiologists regarding the comprehensive preanesthetic assessment of geriatric patients: A cross-sectional survey p. 246
Pallavi Ahluwalia, Bhavna Gupta
Background: Comprehensive preoperative geriatric evaluations, including frailty, diet, mobility aid use, physical activity, cognitive testing, and mood state assessment, help predict perioperative outcomes in elderly patients. Material and Methods: An online questionnaire-based Google survey was prepared to assess preanesthetic checkup (PAC) in elderly patients by practicing anesthesiologists over 3 months. Data about respondent demographics, knowledge about preoperative investigations, and utilization of validated tools for risk assessment in geriatric patients were collected and analyzed descriptively using different percentages and frequencies. Results: The invitation was sent to 500 anesthesiologists. One hundred and fifty-six recipients responded to the e-mail invitation producing an overall response rate of 31.2%. About 47.4% and 42.4% of anesthesiologists had an equal preference for regional/general anesthesia in conducting elderly elective cases for surgeries, the choice of anesthesia was mainly regional anesthesia in cognitively impaired elderly patients. Nearly 88.5% and 78.2% of practicing anesthesiologists were well aware and conducted the functional assessment and mini—mental state examination in geriatric patients, but only 48.7% were aware of frailty scoring, 30.8% were aware of Charlson comorbidity scoring index, and 24.4% were about Elderly Mobility Scale (EMS). Conclusion: Surgical results are strongly influenced by the general health, work, and life expectancy of patients. A comprehensive preoperative geriatric evaluation of patients must be extended beyond an organ-based or disease-based evaluation. We support the inclusion in the PAC of geriatric patients of validated score systems, including frailty score, Charlson comorbidity score index, EMS, functional assessment, and mini—mental state assessment.
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Clonidine versus dexmedetomidine as premedication to intrathecal 0.5% bupivacaine: A randomized, double-blind, prospective study p. 252
Arvind Khare, Beena Thada, Laxmi Narayan Solanky, Veena Mathur, Deepak Garg, Pradeep Kumar
Background: Alpha-2‑adrenergic agonists have synergistic action with local anesthetics and may prolong the duration of sensory and motor blockade and postoperative analgesia obtained with spinal anesthesia. The primary objective of this study was to compare the duration of analgesia, and the secondary objectives were to evaluate onset of sensory and motor blockade, perioperative sedation, hemodynamic changes, and adverse effects after intravenous (IV) infusion of clonidine and dexmedetomidine on spinal block characteristics as premedication to intrathecal 0.5% bupivacaine. Patients and Methods: This prospective, randomized, double blind study was conducted on a total of 100 patients belonging to the American Society of Anaesthesiologist class I and II undergoing lower limb and lower abdominal surgeries and were randomly allocated into two groups: Group CN (n = 50) received 1.5 µg/kg clonidine infusion and Group DM (n = 50) received 0.75 µg/kg dexmedetomidine infusion in 100 mL NS over 15 min before spinal anesthesia. Results: The duration of analgesia was statistically significantly prolonged in Group DM (251.70 ± 6.264 min) when compared with Group CN (213.02±10.374 min) (P < 0.001). The onset of sensory and motor blockade was faster in Group DM when compared with Group CN (P < 0.001). Recovery of sensory block was prolonged in Group DM when compared with Group CN (P < 0.001), but recovery of motor block was comparable in both the groups. The hemodynamic parameters were comparable in both the groups without any significant adverse effects. Conclusion: Premedication with IV dexmedetomidine infusion is better than that with IV clonidine infusion to provide intraoperative sedation and postoperative analgesia as premedication with hyperbaric bupivacaine 0.5% spinal anesthesia.
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Challenging anesthesia in pediatric pheochromocytoma and paraganglioma tumors resection p. 260
Putu Kurniyanta, Kadek Heryana Putra
Pheochromocytoma (PCC) and paraganglioma (PGL) are chromaffin cell tumors that secrete catecholamines and are some of the rarest pediatric tumors. Perioperative care poses a challenge for the anesthetist. Hemodynamic regulation, surgery manipulation, and perioperative care require special attention. These tumors provide major treatment challenges as well as a high risk of hypertensive crisis-related cardiovascular consequences. We present a successfully managed case of PCC removal in a 13-year-old male. He presented with typical hypertensive crisis symptoms (i.e., vomiting, headaches, and seizures), and he was managed well to prepare him for surgery. We anticipated hemodynamic alterations during the surgery and controlled them with a combination of antihypertension, vasodilator, and epidural analgesia. The safe perioperative care of such patients requires good communication between an experienced multidisciplinary team of surgeons, pediatric endocrinologists, and anesthetists.
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Airway obstruction by subcutaneous tissues growing into tracheal lumen below tracheostomy stoma: A case report p. 263
Indrajith Renjith, Ramalingam Revathi
Tube obstruction is one of the common complications of tracheostomy. The most frequent cause of tube obstruction is the plugging of tracheostomy tube with mucous plug, clots, or crust. We report a case of low tracheostomy obstructed by a mass of subcutaneous tissue proliferating into the tracheal lumen. When the patient was posted for radical surgery, trachea was cannulated using a regular endotracheal tube (ETT) inserted into the stoma under fiber optic bronchoscope guidance, and general anesthesia was administered. Anatomically distorted tracheostomy tracts may be maintained with customized tracheostomy tubes if available to prevent complications. Any difficulty in inserting tracheostomy tube can be temporarily managed with the ETT inserted into the stoma.
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Anesthetic management of patients undergoing one-step surgical tracheoesophageal fistula: Case series p. 267
Desy Permatasari, Putu Kurniyanta, Tjokorda Gde Agung Senapathi
The anesthetic management of newborns with tracheoesophageal fistula (TEF) and esophageal atresia (EA) can be challenging due to fistula between the airway and esophagus leading to difficulty in perioperative airway management. Maintaining the endotracheal tube (ETT) position during surgical manipulation and adequate ventilation without gastric distention complications is crucial. This study presents two cases of full-term and normal-birthweight newborns with Type C TEF/EA. Both of the patients underwent one-step surgical repair without gastrostomy insertion. Instead of using gastrostomy, correct placement of ETT might be checked by physical examination. Induction of anesthesia was done using volatile inhalational agents and fentanyl as analgetic. For intubation facilitation, spontaneous breath and ventilation were maintained to prevent gastric distention. This report showed that good intubation conditions could be achieved with deep volatile agents and without muscle relaxants. Patients were ventilated with an assisted-controlled technique following their spontaneous breath until the defect was ligated. Hemodynamic was maintained stably in both patients during the operation. Full-term babies with normal birthweight and no other congenital anomalies are generally associated with a better prognosis.
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Paradoxical heart rate response after atropine sulfate administration in total atrioventricular block complicating acute myocardial infarction: A case report p. 271
Dita Aulia Rachmi, Rina Yudha Novira, Eka Prasetya Budi Mulia, Andrianto Andrianto
Acute myocardial infarction is sometimes complicated by atrioventricular block. Advanced cardiac life support guideline for the treatment of atrioventricular block suggests early use of atropine. Atropine works as a parasympatholytic drug that enhances SA node automaticity and AV node conduction. We report a case of a male patient with inferior myocardial infarction and total atrioventricular block who showed a marked reduction in heart rate after first and second atropine administration, a paradoxical worsening of the block. Atropine has been associated with some adverse consequences, including proarrhythmic effect, worsening of the high-grade atrioventricular block, and worsening of the ischemic situation. In this case of total atrioventricular block caused by acute myocardial infarction, immediate revascularization can be the only required management. Awareness of this potential adverse reaction will help the clinician make a risk/benefit ratio consideration regarding the use of atropine for certain patients.
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Challenges in management of severe COVID-19 in a post renal transplant patient co-infected with cytomegalovirus p. 275
Yashwanth Patnaik Rajamahanthi, Guriqbal Singh
Post-renal transplant patients are at higher risk of severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection due to suppressed immune system, underlying co-morbidities and antimetabolites used to prevent graft rejection. Cytomegalovirus infection causes memory inflation and further alters the clinical outcome. We report a case of severe COVID-19 in a post-renal transplant patient co-infected with cytomegalovirus and challenges in its management. The use of conventional protocol for treatment is a matter of concern in view of the complex clinical profile in them. Thus, it requires a multidisciplinary approach and individualization of the therapy to attain a fine balance between risk of graft rejection and complications of overimmunosuppression especially during cytokine storm. This brings us to explore other treatment modalities like cytosorb and plasmapheresis to prevent systemic inflammation in body while also targeting the cytomegalovirus infection.
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Emergency management of cyanotic spell in a COVID-19 suspect tetralogy of Fallot child p. 279
Rohan Magoon, Iti Shri, Jasvinder Kaur Kohli, Ramesh Chand Kashav
The novel coronavirus (SARS-CoV-2) is suggested to increase the risk of morbidity and mortality in patients with underlying cardiac and pulmonary disorders. Reports of COVID-19-related multisystem inflammatory syndrome in children, past experiences with influenza virus and the respiratory syncytial virus, and British Congenital Cardiac Association recommendation on congenital heart disease warrant caution even in children. We present a case of a 2-year-old child with tetralogy of Fallot, who got admitted in the emergency with cyanotic spell and fever (suspected to be due to COVID-19), potentially compounding the challenge of managing cyanotic spell emergency.
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The invisible frontrunner: Anesthesiologist 5.0 p. 282
Bambang Tutuko, Marilaeta Cindryani
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Target and goal mismatch during mechanical ventilation in COVID-19 patients p. 284
Amarjeet Kumar, Neeraj Kumar
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Amisulpride for postoperative nausea and vomiting: A new answer to an old question p. 286
Rohan Magoon, Nitin Choudhary
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U–Turn of suction catheter within i-gel during elective surgery: An unusual presentation p. 288
Aniruddha Banerjee, Vijay Adabala, Mridul Dhar
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Non-traumatic “saline flush stylet” technique as an alternative rescue approach in difficult peripheral arterial catheter insertion p. 290
Mridul Dhar
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Anesthetic drug repurposing: Laurels to anesthetic pharmacology p. 292
Jasvinder Kaur Kohli, Rohan Magoon, Iti Shri, Ramesh Chand Kashav
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