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   Table of Contents - Current issue
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July-September 2020
Volume 4 | Issue 3
Page Nos. 89-146

Online since Saturday, July 18, 2020

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EDITORIAL  

How indonesia copes with coronavirus disease 2019 so far (part two): Is the country ready for the new norm? p. 89
Christopher Ryalino
DOI:10.4103/BJOA.BJOA_108_20  
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ORIGINAL ARTICLES Top

Effect of music on preoperative anxiety in patients undergoing laparoscopic cholecystectomy p. 90
Nidhi Yadav, Shubhi Singhal, Devang Bharti
DOI:10.4103/BJOA.BJOA_19_20  
Introduction: Anxiety is a common phenomenon among hospitalized patients awaiting any surgical procedure and causes acute psychological distress in the perioperative period. It activates the sympathetic nervous system, adversely affecting the induction and maintenance of anesthesia and postoperative recovery, leading to a lower level of satisfaction with the treatment. The current study aims to explore the effect of music on preoperative anxiety. Patients and Methods: In this randomized controlled study, 104 patients posted for laparoscopic cholecystectomy were randomly divided into two groups. Patients in both groups received oral alprazolam 0.25 mg on the night before surgery. In addition, patients in Group II were also exposed to 30 min of soft, soothing music, 1 h before the surgery. Vitals of patients, including heart rate (HR), blood pressure, and respiratory rate, in both the groups along with the general anxiety – visual analog scale (GA-VAS), were recorded and compared. Results: On comparing T30 vitals between the two groups, a statistically significant difference was seen in all the monitored parameters, with vitals in Group II being lower than in Group I. T60 vitals in Group II were found to be lower than Group I in all the monitored parameters, except for HR (P = 0.051). The GA-VAS scores in Group II were lower compared to Group I (P = 0.008). Conclusion: Exposure to music, as an addition to alprazolam 0.25 mg, in the preoperative period for patients who underwent laparoscopic cholecystectomy reduces the patient's anxiety compared to alprazolam alone.
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Comparison of epidural levobupivacaine and bupivacaine in lower abdominal and lower limb surgeries p. 95
Jay Prakash, J Prashanth Prabhu, Ramesh Kumar Kharwar, Shio Priye, Dipali Singh, Khushboo Saran
DOI:10.4103/BJOA.BJOA_21_20  
Background: Bupivacaine, the most commonly used drug for a central neuraxial blockade, also carries undesirable effects like a prolonged postoperative motor blockade. The objective of the study was to compare the intensity of sensory and motor blockade, hemodynamic effects, and adverse effects, if any, between the two drugs. Patients and Methods: A randomized, double-blind study was carried out on 100 patients. Patients were divided into two groups of 50 patients each. Group L received 20 ml of 0.5% levobupivacaine epidurally, and Group B received 20 ml of 0.5% bupivacaine epidurally. We observed the characteristics of the sensory and motor blockade in both groups. Results: The hemodynamic effects of both drugs were statistically and clinically comparable. The total duration of the sensory blockade with levobupivacaine was 366.60 ± 29.25 min compared to 370.80 ± 37.73 min with bupivacaine (P = 0.535). The total duration of the motor blockade with levobupivacaine was 139.20 ± 27.15 min compared to 172.80 ± 26.77 min (P < 0.001) with bupivacaine. Conclusion: Levobupivacaine produces shorter motor blockade, which may provide early ambulation of patients in day care surgeries. In surgical procedures requiring extensive motor blockade, epidural levobupivacaine may not be an appropriate choice.
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Correlation of red cell distribution width value with the duration of mechanical ventilator usage in patients treated in pediatric intensive care unit p. 99
I Nyoman Budi Hartawan, Yullyantara Saputra, Christopher Ryalino
DOI:10.4103/BJOA.BJOA_27_20  
Background: Red cell distribution width (RDW) is the coefficient of erythrocyte volume variation. High RDW may indicate heterogeneous erythrocyte size in terms of size and volume (anisocytosis). RDW is affected by the degree of hypoxic tissue; the higher the hypoxia, the higher the RDW. The goal of the study was to see the correlation between RDW and the duration of ventilator usage on patients treated in the intensive care unit. Patients and Methods: This study employed a cross-sectional design. The participants of this research are children treated with mechanical ventilator in the pediatric intensive care unit (PICU) in Sanglah General Hospital from January to December 2018. The duration of mechanical ventilator usage and RDW value data was generated from the medical records. Results: There were sixty patients treated in the PICU during the study period, including 24 females (40%) and 36 males (60%). The average of oxygen index (OI) was 6.9 (0.9–20.57) and ventilator usage duration was 7.43 (1–32). Analysis of correlation between RDW and hemoglobin (Hb), FiO2, positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), mean airway pressure, OI, and days of ventilator usage revealed that RDW has a strong positive correlation with Hb (r = 0.43), FiO2(r = 0.82), PEEP (r = 0.17), PIP (r = 0.41), OI (r = 0.76), and days of ventilator usage (r = 0.87). The result of a subgroup analysis of days of ventilator usage had a strong positive correlation with RDW. In mild-degree pediatric acute respiratory distress syndrome, the correlation score was r = 0.89, moderate degree was r = 0.766, and severe degree was r = 0.71. Conclusion: There is a strong positive correlation between RDW and the duration of mechanical ventilator usage.
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Correlation of red cell distribution width and serum lactate levels in critically ill pediatric patients p. 104
Ni Made Sukewanti, I Nyoman Budi Hartawan, Dyah Kanya Wati, Ida Bagus Gede Suparyatha, Christopher Ryalino
DOI:10.4103/BJOA.BJOA_28_20  
Background: Blood lactate concentration has been widely used as a marker of altered tissue perfusion. An increase in lactate concentration to >1.5 mEq/L is associated with a higher mortality rate. Red cell distribution width (RDW) measures variability in red blood cell size. The purpose of this research is to see the correlation between lactate levels and RDW. Patients and Methods: We performed a cross-sectional study to assess the correlation between blood lactate concentration and RDW in critically ill children admitted to the pediatric intensive care unit (PICU) from October 2018 until February 2019. Blood lactate and RDW were taken during the first 24 h of admission. Data were obtained from the medical report. The association between RDW and lactate was determined using Spearman's correlation test. Results: There were forty patients enrolled in this study with a median age of 27 months (ranged from 2 months to 17 years), with an equal proportion of male and female. The median PICU length of stay was 7.5 days, with a mortality rate of 42.5%. The most common underlying disease was pneumonia (35%), followed by sepsis (17.5%) and meningitis (10%). The median lactate level was significantly higher in the nonsurvivor group compared to the survivor group (P = 0.002). The median RDW was also higher in the nonsurvivor group (P = 0.001). There is a moderate correlation between RDW and lactate (r = 0.532, P < 0.001). Conclusion: There was a moderate and significant correlation between RDW and serum lactate level in critically ill pediatric patients.
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The role of focused echocardiography in optimizing lactate clearance in the first 3 h of pediatric sepsis resuscitation p. 109
Yos Kowara, Arie Utariani, Bambang Pujo Semedi, Elizeus Hanindito
DOI:10.4103/BJOA.BJOA_43_20  
Background: Sepsis causes high morbidity and mortality in pediatric patients globally. Early shock diagnosis and management are important to determine patient survival. Fluid boluses, early inotropic, and vasopressor usage are the keys to improve lactate clearance. Echocardiography helps both determining the type of shock and selecting the hemodynamic therapies. Patients and Methods: A quasi-experimental with one group posttest only design was conducted on 23 pediatric patients who were treated in the resuscitation room of Dr. Soetomo Hospital Surabaya. Patients who met the inclusion and exclusion criteria became the research sample and resuscitated, according to the 1-h sepsis bundle. Patients' hemodynamic status was assessed by echocardiography, and their early blood lactate was checked. Therapies such as fluid adequacy maintenance, cardiac contractility optimization, and vasopressor administration were given according to the type of shock. On the 3rd h, evaluation of clinical improvement, lactate level, and the posttherapy echocardiography were done. Results: As many as 39% of the patients suffered normotension cold shock, 26% with hypotension cold shock, 9% with normotension warm shock, and the rest 26% with hypotension warm shock. Echocardiographic-guided hemodynamic therapy statistically significantly improved the patient's volume status, contractility, and vascular resistance (P < 0.05). Reversal of shock within the first 3 h, which were derived from clinical improvement and echocardiography measurement, was statistically significantly correlated with >10% lactate clearance (P = 0.001; r = 0.558). Conclusion: Focused echocardiography was effective in evaluating the hemodynamics and lowering the clearance of lactate of pediatric patients with septic shock.
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Evaluation of postoperative analgesic effects of infraorbital nerve block by levobupivacaine vs. Ropivacaine after cleft palate surgery: A double-blinded randomized trial p. 115
Vijay Adabala, Ajit Kumar, Shipra Tandon, Debarati Chattopadhyay, Eswar Prasad
DOI:10.4103/BJOA.BJOA_15_20  
Background: Both ropivacaine and levobupivacaine have been used for the peripheral block in children for surgical pain. The present study is aimed to compare the effectiveness of 0.375% levobupivacaine and 0.375% ropivacaine in the infraorbital block for cleft palate surgery. Patients and Methods: Eighty patients between the age group of 2–12 years planned for elective surgery for cleft palate were included in the study. The solution for Group L was a mixture of 0.375% levobupivacaine and the solution for Group R was a mixture of 0.375% ropivacaine. Infraorbital nerve blocks were conducted by landmark-guided technique. We used the Verbal Rating Scale (VRS) to assess the postoperative pain. Results: There was a statistically significant difference in the time interval until the first request for pain medication was made by the participants in the two groups (10.6 [8.4, 12.8] vs. 8.5 [6.1, 10.8] h, P = 0.002). There were differences in pain scores calculated at regular intervals after surgery comparing the two groups (2.7 ± 0.3 vs. 3.6 ± 0.3, P = 0.01). There were differences in the need for rescue analgesics comparing the two groups. Conclusion: The analgesic effects of levobupivacaine are statistically better than ropivacaine in the infraorbital block in children who underwent cleft palate surgery.
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Comparison of outcome between patients receiving general anesthesia combined with continuous epidural anesthesia and patients receiving general anesthesia combined with intermittent epidural anesthesia p. 118
Hamzah Hamzah, I Nyoman Yesua Darma Surya Bratha, Christrijogo Sumartono, Arie Utariani, Bambang Pujo Semedi, Yoppie Prim Avidar
DOI:10.4103/BJOA.BJOA_18_20  
Background: The use of combined anesthesia including general and epidural anesthesia has been known to have better outcomes than the use of general anesthesia alone. The combination technique results in fewer complications and lower mortality rates, in addition to better control of pain. This study aims to analyze the outcomes of patients receiving a combination of general and continuous epidural anesthesia (GA-CEA) compared to patients receiving a combination of general and intermittent epidural anesthesia (GA-IEA). Patients and Methods: Thirty patients undergoing hysterectomy were randomly divided into two groups: those receiving a combination of GA-CEA and those receiving a combination of GA-IEA. After the surgery, patients were assessed for their pain levels, physical performances (using the Seven-Level Mobilization Scale), mortality, and morbidities. Results: There were neither mortalities nor morbidities observed among participants in both groups. The pain levels and physical performance between the two groups showed no statistical difference on days 1, 3, and 7. GA-CEA group required fewer doses of epidural analgesia compared to the GA-IEA group (14.53 mL vs. 19.47 mL, P < 0.001). Conclusion: Overall, there was no difference between GA-CEA and GA-IEA techniques on mortality, morbidities, pain levels, and physical performance. However, the GA-CEA technique did require a fewer dose of analgesic.
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CASE REPORTS Top

Perioperative care in a patient with acute psychosis: Challenges and management p. 122
Jagannathan Balavenkatasubhramanian, Tuhin Mistry, Palanichamy Gurumoorthi, Balu Ravi Shankar
DOI:10.4103/BJOA.BJOA_24_20  
Providing perioperative care for patients with acute psychosis poses a unique challenge to the anesthesiologist. These patients are usually uncooperative, difficult to communicate with, and present with aggressive behavior. Such patients often have a history of substance abuse or chronic psychiatric illness and are on antipsychotic drugs. We report the successful perioperative management of a patient with acute psychosis, scheduled for open reduction and internal fixation of right humerus and clavicle fractures under regional anesthesia and conscious sedation.
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Infrapatellar neuralgia due to bullous morphea in postknee arthroplasty patients treated with radiofrequency p. 125
Ashok Jadon, Neelam Sinha
DOI:10.4103/BJOA.BJOA_36_20  
Injury or entrapment of the infrapatellar branch of the saphenous nerve (IPS) can cause persistent anterior and medial knee pain. However, IPS neuralgia because of bullous morphea is rare and not reported earlier. We present a case of IPS neuralgia after total knee replacement where the pain was attributed to local skin lesion of bullous morphea (BM). After a successful diagnostic block, radiofrequency treatment was done to provide prolonged relief. We have discussed the possible pathogenesis of nerve entrapment and pain by BM in our case and the basis of treatment by radiofrequency ablation.
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Bilateral C5 palsy after posterior cervical spine decompression surgery: A case report and literature review p. 129
Yuen-Mei Chow
DOI:10.4103/BJOA.BJOA_49_20  
C5 palsy is a well-known complication following cervical spine surgery. We describe a case of a 68-year-old male who underwent C3 to C6 posterior instrumentation and fusion with laminectomy and C7 hemilaminectomy for severe multilevel cervical stenosis. This is complicated by severe bilateral C5 palsy and neuropathic symptoms postoperatively, which improved with conservative management and acupuncture. This is the first described case of acupuncture being used in the treatment of C5 palsy. Further studies are needed to determine the efficacy of acupuncture in the management of neuropathic symptoms in patients with C5 palsy.
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Anaesthetic management and challenges involved in goldenhar's syndrome; A series of two cases p. 132
Sudha Puhal, Sudhir Kumar Bisherwal, Rahul Saini, Anju Rani
DOI:10.4103/BJOA.BJOA_32_20  
Goldenhar's syndrome is a congenital defect caused by maldevelopment of the first and second brachial arch. This causes maldevelopment of the ears, nose, soft palate, mandible, and vertebral column. These patients pose a unique challenge to anesthetists in having difficult management of the airway and neuraxial blockade. This report describes two patients of Goldenhar syndrome who came for the surgery under anesthesia and their management.
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Clonidine 0.5 μg/kg intravenous as prevention of shivering after spinal anesthesia in cesarean section p. 136
Teresa Wilfrida Mangkung, Pontisomaya Parami, I Gede Budiarta, Tjokorda Gde Agung Senapathi
DOI:10.4103/BJOA.BJOA_25_20  
Shivering is a common complication after spinal anesthesia. Shivering can increase oxygen consumption, increase the risk of hypoxemia, and increase complications after surgery. Shivering can be prevented with pharmacological and nonpharmacological therapy. One of the pharmacological therapies that can be used is clonidine. Clonidine is an α2 agonist that works in changing thermoregulation control and decrease the threshold of vasoconstriction and shivering during hypothermia. Clonidine 0.5 μg/kg intravenous was given before spinal anesthesia in ten cases of cesarean section. Clonidine can be used as the prevention of shivering of spinal anesthesia in 60% of cases with a low incidence of nausea and vomiting.
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Regional anesthesia options in managing mastectomy: A case series p. 140
Hinarto Hinarto, Tjokorda Gde Agung Senapathi, I Gede Budiarta, Cynthia Dewi Sinardja
DOI:10.4103/BJOA.BJOA_20_20  
Regional anesthesia can be a choice of technique in mastectomy surgery. The paravertebral block provides a safer setting by maintaining stable hemodynamic compared to thoracic epidural block and less of opioid needed in the postoperative period. We report our observations to ten patients who underwent a modified radical mastectomy. We either manage the case by thoracic paravertebral block or thoracic epidural anesthesia, both by combination to laryngeal mask airway.
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LETTERS TO EDITOR Top

Low-dose ketamine with propofol sedation lowers the mean flow velocity of the middle cerebral artery measured by transcranial Doppler p. 143
Tjokorda Gde Agung Senapathi, I Putu Pramana Suarjaya, I Made Agus Kresna Sucandra, Roy Lizal
DOI:10.4103/BJOA.BJOA_56_20  
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Adult anesthesia mask for inhalational induction in a child with large Tessier facial cleft-7 p. 145
Rajnish Kumar, Ashish Kumar, Rajesh Kumar
DOI:10.4103/BJOA.BJOA_23_20  
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