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   Table of Contents - Current issue
April-June 2020
Volume 4 | Issue 2
Page Nos. 33-87

Online since Monday, May 11, 2020

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How indonesia copes with coronavirus disease 2019 so far (part one): The country, the government, and the society Highly accessed article p. 33
Christopher Ryalino
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Comparison of glottis views with fixed-height pillow versus adjustable-pillow height by pressure infusion bag for successful intubation p. 35
Kinna Shah, Jayshree Thakkar, Dushyant Vaidya
Background: This study aimed to get optimal sniffing position for successful intubation rate and measuring intubation time. The classical rationale for the sniffing position is that the alignment of the mandibular axis, pharyngeal axis, and laryngeal axis is facilitated, permitting successful direct laryngoscopy. Patients and Methods: A total of 100 patients without any anticipated difficult airway were enrolled after informed consent is given. After induction of anesthesia, patients were randomly divided into two groups. In Group PB, a deflated pressure infusion bag was put under the nape of the neck and occiput. The anesthetist performed laryngoscopy with the left hand while inflating the bag with the right hand up to the best glottic view without external pressure is achieved. The height of the bag was measured. In Group PI, 10-cm fixed-height noncompressible pillow was placed behind the head up to the shoulder. The best glottic view of the entire glottis without external pressure was noticed. Grading of glottic opening grade, SPO2, intubation time, and intubation trials were also noted. Results: Failure to intubate was noted in one patient in Group PB and two in Group PI. Intubations successful in 45 (90%) patients in Group PB as compared to 38 (76%) patients in Group PI (P < 0.05). Laryngoscopic view in Group PB was superior to that with Group PI (P < 0.05), with mean pressure bag height of 4.86 cm. Conclusion: The use of pressure infusion bag for adjustable-pillow height provides more success in intubation condition by head elevated position than the fixed height of 10 cm.
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Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section Highly accessed article p. 39
Nived Mohanan, K Raghu
Background: Pain relief after cesarean section is essential for the early mobilization of the mother and proper care of the newborn. Among the several modalities available,transverse abdominis plane (TAP) block is newer and attractive. This study aims to compare the efficacy of TAP block compared to sodium diclofenac-acetaminophen combination for postoperative pain following cesarean section. Patients and Methods: Sixty patients undergoing elective cesarean section were included and divided into two groups: Group A received TAP block with 20 ml of 0.25% bupivacaine and Group B received 100 mg diclofenac suppositories followed by intravenous 1 g acetaminophen every 8 h. Participants were assessed for the severity of pain at 0, 4, 8, 12, 24, 36, and 48 h after surgery using the Numeric Rating Scale, the time of first demand for rescue analgesia, and total consumption of rescue analgesia. Results: Pain scores were lower at each point of time during 48 h in Group A as compared to Group B. Time of the first analgesia was statistically significantly longer (7.93 ± 0.70 vs. 4.47 ± 1.36;P < 0.001), and total consumption of rescue analgesia was also lower in Group A (78.13 ± 39.66 mg vs. 140.79 ± 40.15 mg;P < 0.001). Conclusion: TAP block was effective in controlling postoperative pain following cesarean section with a significant reduction in the use of rescue analgesia and their side effects.
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Comparison of efficacy and safety of dexmedetomidine versus propofol infusion for maintaining depth of general anesthesia when muscle relaxants are not used p. 42
Pulak Tosh, Sunil Rajan, Naina Narayani, Karthik Chandra Babu, Niranjan Kumar, Jerry Paul
Background: In surgeries where direct nerve stimulation is required intraoperatively, the use of long-acting muscle relaxants should be avoided. The study aimed to assess the efficacy of dexmedetomidine versus propofol infusion in providing an adequate depth of general anesthesia where long-acting muscle relaxants were not used intraoperatively and to compare hemodynamics in both the groups. Patients and Methods: It was a prospective randomized controlled study done in forty patients undergoing total parotidectomy or brachial plexus surgeries. Group D received an intravenous (IV) bolus of dexmedetomidine 1 mcg/kg body weight before induction, followed by infusion at 0.7 mcg/kg/h intraoperatively. In Group B, the infusion of propofol was started at a rate of 1.5 mg/kg/h to a maximum of 100 mg/h after intubation. In both the groups, if the patient moved, bucked on the endotracheal tube, or if there were signs of inadequate depth of anesthesia, a bolus of propofol 0.5 mg/kg IV was given and repeated as required. Statistical analysis was performed using Mann–Whitney U-test and Fisher's exact test. Results: The number of times propofol bolus was required intraoperatively did not show any significant difference between groups. The mean heart rate was significantly lower in Group D before induction. At any other time points, the mean systolic blood pressure and mean arterial blood pressure were comparable in both the groups. Conclusion: Both dexmedetomidine and propofol infusions are equally effective and safe in providing an adequate depth of general anesthesia as reflected by patient immobility during surgeries where long-acting muscle relaxants were not used.
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The predictive value of skin-to-epiglottis distance to assess difficult intubation in patients who undergo surgery under general anesthesia p. 46
Tjokorda Gde Agung Senapathi, Made Wiryana, I Wayan Aryabiantara, Christopher Ryalino, Rina Lizza Roostati
Background: Intubation is crucial in the management of anesthesia because it is related to the maintenance of oxygenation and ventilation during general anesthesia. Clinical markers for predicting difficult airway have limitations, including requiring coordination with patients. The use of ultrasonography (USG) to measure the distance of the skin to epiglottis is expected to estimate the difficulty level of intubation. Patients and Methods: This was a cross-sectional study of 128 patients who underwent surgery under general anesthesia. We examined the skin-to-epiglottis distance using US prior to surgery. We then assessed the Cormack–Lehane scores during direct laryngoscopy for intubation. The unpaired t-test was used to assess differences in the skin-to-epiglottis distance between patients with easy intubation (Cormack–Lehane I and IIa) and difficult intubation (Cormack–Lehane IIb, III, and IV). Results: The cutoff value of skin-to-epiglottis distance between easy and difficult intubation was 26.05 mm. The sensitivity and specificity of this method to predict difficult airway were 69.4% and 93.5%, respectively. The positive and negative predictive values were 80.6% and 88.7%, respectively. Conclusion: The skin-to-epiglottis distance of >26.05 is a risk factor for difficult intubation.
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Adductor Canal block with 0.5% ropivacaine for postoperative pain relief in lower limb surgeries performed under spinal anesthesia p. 49
Manisha Agrawal
Background: Postoperative pain is an essential consequence of lower limb surgeries that can affect early ambulation, range of motion, and duration of stay in the hospital. This study aimed to evaluate the effect of the adductor canal block in the postoperative pain control and analgesic consumption in the lower limb surgeries done under spinal anesthesia. The adductor canal block is a compartment block of the saphenous nerve (branch of femoral nerve), which can provide adequate analgesia with the preservation of motor function. Patients and Methods: Sixty patients aged 18–70 years scheduled for lower limb surgeries under spinal anesthesia were included in this prospective, placebo-controlled randomized study. The patients were randomly divided into two equal groups of 30 each. At the end of the surgery, single-shot ultrasound-guided adductor canal blockade was given with 30 ml of 0.5% ropivacaine (Group A) or 30 ml of 0.9% saline (Group C). The pain was assessed for 24 h postoperatively by a visual analog scale (VAS). Postoperative analgesia consumption was also studied. Motor function was assessed with a straight leg raise test. Results: Analgesic consumption was lesser in the ropivacaine group as compared to the control group. VAS was favorable in the ropivacaine group. There was no prolonged loss of motor function in either group. Conclusions: The adductor canal block significantly reduces pain and analgesic consumption. It also does not affect motor function. Hence, it can be effectively used as an adjuvant to spinal anesthesia for lower limb surgeries.
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Evaluation of POSSUM scoring systems in predicting postoperative morbidity and mortality in indian patients operated for esophageal cancer p. 53
Priya Ramakrishnan, Manisa Pattanayak, Anshika Arora, Ankit Singh, Veena Asthana, Sunil Saini
Background: Surgical treatment for esophageal cancer is a high-risk procedure. Prediction of postoperative adverse events could aid in the stratification of patients, thus improving outcomes as well as achieving optimal use of resources. The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a prediction model that utilizes both physiological and surgical parameters to assess risk. This study evaluates the effectiveness of POSSUM, Portsmouth-POSSUM (P-POSSUM), and esophagogastric-POSSUM (O-POSSUM) scoring systems in predicting postoperative morbidity and mortality in Indian patients operated for esophageal cancers. Patients and Methods: It is a retrospective study conducted in a tertiary care teaching hospital with data collected from esophagectomies performed from January 2015 to January 2019. The calibration and discriminative abilities of the scores to predict 30-day morbidity and mortality were analyzed using the Hosmer–Lemeshow test, observed to predicted ratios (observed/expected [O/E]), and the receiver operating characteristic curve tests. Results: A total of sixty patients were included. The 30-day mortality and morbidity were 6.67% (4/60) and 46.66% (28/60), respectively. POSSUM morbidity showed proper calibration and discrimination (O/E: 0.86) with a modest predictive ability (area under the curve [AUC]: 0.701). While analyzing mortality, though all scores displayed good calibration, O-POSSUM displayed superior predictive ability (O/E: 1.02). The POSSUM score overpredicted mortality by nearly twice (O/E: 0.52), whereas P-POSSUM underpredicted it (O/E: 1.71). All scores showed moderate discrimination with P-POSSUM outperforming other tests (AUC: 0.825). Conclusions: The POSSUM scoring system was useful in predicting morbidity risk following esophageal resection for cancer, with O-POSSUM more accurate for mortality prediction in this group of patients.
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Effect of nebulized versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery p. 59
Jaideep Singh, D Premkumar, Aditya Agarwal
Background: This study was aimed to compare the effect of nebulized fentanyl versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery. Patients and Methods: A total of sixty patients scheduled for unilateral femur interlock surgery under subarachnoid block were enrolled in the study and were randomly divided into two groups. Group I included thirty patients who received 2 μg/kg of fentanyl intravenously, and Group N included thirty patients who received 4 μg/kg of fentanyl nebulization using a standard venturi mask. In the postoperative period, whenever the Visual Analog Scale ≥4, patients received the analgesic corresponding to their respective groups. The data obtained were statistically analyzed using IBM SPSS software. Results: There was no significant difference in the demographic characteristics, duration of surgery, the number of patients who required rescue analgesia, and the onset of analgesia in Group N in comparison with Group I. The duration of analgesia was significantly longer in Group N in comparison to Group I. In Group I, the rise in Ramsay sedation score was faster and peaked at 5 min. In Group N, however, it was lesser than that of Group I. Side effects in Group N were significantly lesser compared to Group I. Conclusion: Nebulization with fentanyl is a good alternative to intravenous fentanyl for adequate postoperative pain relief with fewer side effects.
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The effectiveness and clinical outcomes of low-dose ketamine on the inflammatory stress response in digestive laparotomy surgery: A case series p. 62
Tjokord Gade Agung Senapathi, I Putu Pramana Suarjaya, I Made Gede Widnyana, Made Septyana Parama Adi
Surgery and anesthesia may cause inflammatory response. Ketamine, through its various anti-inflammatory activities, is expected to control this inflammatory response. Six patients who underwent digestive laparotomy surgery were randomly assigned to receive ketamine 0.3 mg/kgBW or intravenous NaCl 0.9%. Patients' blood was collected twice; pain score and total morphine consumption were also recorded. Pain score was assessed using the visual analog score and total morphine requirement was measured using patient-controlled analgesia. In this case series, we found that inflammation markers such as neutrophils count and C-reactive protein in the ketamine group were lower than the normal saline group. We also found that pain score and total morphine requirements were lower in the ketamine group compared to the normal saline group. In conclusion, the administration of a low dose of ketamine at the end of surgery showed decrease in inflammation markers, pain scores, and the need for postoperative opioid.
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Beneficial effects of negative fluid balance in preventing global increased permeability syndrome of septic shock patient p. 66
M Azhari Taufik, Vera Irawany, Marilaeta Cindryani
Fluid is considered a successful tool for resuscitation based on the worldwide guideline for sepsis since 2001. However, recent publications have studied of a deleterious effect of overload in fluid resuscitation. Overload is suggested to contribute to many severe complications such as acute respiratory distress syndrome, acute kidney injury, and higher mortalities. About more than 10 years later, another theory emerged and successfully changing the whole paradigm. Sometimes we need to resuscitate, sometimes we need to hold, and sometimes we need to evacuate. Our patient had several advantages from a negative fluid balance to prevent deteriorating conditions.
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Negative-pressure pulmonary edema following percutaneous nephrolithotomy p. 69
Jay Prakash, Ramesh Kumar Kharwar, Partha Sarathi Ghosh, Shio Priye
Negative pressure pulmonary edema (NPPE) or post-extubation pulmonary edema is an infrequent complication that usually occurs immediately or within several minutes after tracheal extubation in healthy, muscular adolescents and young adults. NPPE begins when upper airway obstruction occurs which causes an increase in negative intrathoracic pressure to pull fluid from the pulmonary capillary bed and into the alveoli which leads to ventilation and perfusion difficulties. Presenting here a case of bilateral renal stone posted for percutaneous nephrolithotomy under general anesthesia in prone position who desaturated immediately in the post-operative period after extubation. It also suggests the importance, prevention, diagnosis and treatment of NPPE.
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Oxycodone in mastectomy surgery p. 72
Putu Pramana Suarjaya, Cynthia Dewi Sinardja, Aninda Tanggono
The pharmacological effects of oxycodone and morphine are close. The analgesic potency between oxycodone and morphine is presumed to have a 1:1 ratio. Fentanyl-to-morphine ratio was 1:100. The plasma levels of oxycodone are more active than morphine. The analgesic potency of oxycodone is about 30% greater than that of morphine and slightly longer acting than morphine. Oxycodone showed a longer duration of action and a better analgesic effect than fentanyl. Oxycodone could minimize patient hemodynamic responses to sudden stimuli such as endotracheal intubation, similar to fentanyl. A 41-year-old woman admitted to the hospital with elective surgery of mastectomy surgery. There was no complaint about the lump in mammae dextra. For the surgery, induction bolus of oxycodone 0.2 mg/kg was diluted with normal saline; for endotracheal intubation and postoperative, we used oxycodone with patient-controlled analgesia. Hemodynamic curves were within the normal limits, she had no complaints of postoperative nausea and vomiting or pruritus, and she was discharged on the 3rd day.
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Anesthetic management of urinary bladder paraganglioma p. 75
Priyanka Singh, Jasvinder Kohli, MD Kaur
Extra-adrenal paraganglioma is a rare neuroendocrine tumor that produces stores and secretes catecholamine. The mainstay in the management of the patients posted for resection of these tumors includes adequate preoperative preparation, good collaboration between the surgeons and the anesthesiologist, and use of modern anesthetic drugs and advanced monitoring to avoid any hemodynamic fluctuations intraoperatively. These will decrease the rate of complications and improve the overall outcome of such surgeries.
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Retrieval of aspirated iatrogenic, sharp foreign body using fiberoptic bronchoscope p. 78
Mageshwaran Thirunavukkarasu, Ajay Mishra, Priyanka Gupta, Subodh Kumar, Gaurav Gupta
Foreign body (FB) aspiration into the tracheobronchial tree is a fairly common occurrence in the pediatric age group. The most common FBs aspirated are organic materials. However, aspiration of iatrogenic FB is rare and infrequently reported. It is a challenge to retrieve a sharp and pointed FB without further injuring the tracheobronchial tree. We report an unusual case of sharp and pointed dental instrument aspiration in a 4-year-old boy, which was safely removed by a flexible fiberoptic bronchoscope and sequestering the FB within the endotracheal tube without injuring the tracheobronchial mucosa.
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Airway obstruction after anesthesia in a 3-month-old baby with lymphangioma p. 81
Andi Ade Wijaya Ramlan, Meliani Ang, Fildza Sasri Peddyandhari
Lymphangiomas are commonly benign. However, in rare cases, it may enlarge and cause airway obstruction. The objective of this clinical case report is to highlight the appropriate course of action in cases of airway obstruction. A 3-month-old boy presented with progressive inspiratory stridor since birth. Computed tomography of the thorax revealed multiple lesions on the bilateral neck, right supraclavicular and right supra-anterior to superior mediastinum. The patient was scheduled for tumor resection and injection of sclerosing agent. Induction was done using sevoflurane, and intubation was carried out and presented without complications. The operation was uneventful. After extubation, retraction in the suprasternal, intercostal, and epigastrium was observed; hence, the patient was reintubated. Extubation was then done the following day after careful positioning in intensive care. In this case, laryngeal edema was caused by the obstruction of the lymphatic drainage, which was present since before the intubation. However, after the surgery, there was worsening of the edema. It may be caused by inflammatory response toward lymphatic drainage, thus worsening lymphatic outflow obstruction.
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Accidental endotracheal tube migration following diffusion of nitrous oxide in mastoid surgery p. 84
Neeraj Kumar, Abhyuday Kumar, Kirti Vishwas
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Saturday night palsy p. 86
Vijay Adabala, Nishith Govil, Revanth Challa
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