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   Table of Contents - Current issue
October-December 2020
Volume 4 | Issue 4
Page Nos. 147-209

Online since Tuesday, November 3, 2020

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The impact of case reports in medical science p. 147
Ankur Khandelwal
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Effectiveness of continuous adductor canal block versus continuous epidural analgesia in patients with total knee arthroplasty: A systematic review p. 148
Tjokorda Gde Agung Senapathi, I Putu Fajar Narakusuma, Aninda Tanggono, Christopher Ryalino, Adinda Putra Pradhana
Background: This systematic review aimed to summarize the evidence base on randomized controlled trials (RCTs) comparing the continuous adductor canal block (CACB) and continuous epidural analgesia (CEA) in total knee arthroplasty (TKA) surgery. Methods: We searched the Cochrane Library, PubMed, and EMBASE database from the beginning of 2016 until 2020 to find RCTs published in English language, which have investigated pain score, length of stay (LOS), ambulation distance, and total opioid consumption in TKA. Results: Three RCTs were included in the final analysis. All of them employed similar argument that CACB is better than CEA in pain score, but only two of three studies investigated the other parameters such as LOS, ambulation distance, and opioid consumption, with the result that CACB is better than CEA. Conclusion: It was found that CACB was better in pain control compared to CEA, but there are very few similar studies. Future research is required to establish the therapeutic efficiency of CACB than CEA in TKA surgery.
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Dysregulated immune response in SARS-CoV-2 infections p. 152
Marilaeta Cindryani, Bianca Jeanne, I Made Gede Widnyana
Coronaviruses have caused several global challenges for health-care providers all over the world. The notorious SARS-CoV-2 could attack the lower respiratory tract and trigger the immune systems to release massive number of immune cells and pro-inflammatory cytokines and cause immunopathology consequences called cytokine release syndrome. These pro-inflammatory cytokines and other immune cells caused lung injury and severe acute respiratory distress syndrome in COVID-19 (CARDS) and multiple organ failure. There are still many intertwined immune responses that not yet been discovered in SARS-CoV-2 infections. Targeted and specific cell therapy would be reasonable and considered safer to be employed in patients who present with comorbidities and at risk of complications.
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Analgesic effect of magnesium sulfate as an adjuvant to ropivacaine in pectoral nerve block p. 156
Haramritpal Kaur, Harmanpreet Kaur Jhand, Naresh Baghla, Druvika Chaudhry, Amandeep Singh, Rupinder Kaur
Background: Pectoral nerve (Pecs) block is an effective component of multimodal analgesia regimens for breast surgeries. It has been used as a supplement to general anesthesia for intraoperative and postoperative analgesia. In the present study, we aimed to evaluate and compare the analgesic effect of magnesium sulfate 150 mg as an adjuvant to 0.25% ropivacaine in pecs block. Patients and Methods: A total of 60 American Society of Anaesthesiologists Grades I and II female patients with age between 18 and 65 years were enrolled in this study. Group A received ultrasound (US)-guided Pecs block with 40 ml volume containing 30 ml of 0.25% ropivacaine with 10 ml of normal saline as a placebo. Group B received US-guided Pecs block with 40 ml volume containing 30 ml of 0.25% ropivacaine and 150 mg of magnesium sulfate diluted to 10 ml of normal saline. Postoperative pain was assessed using the visual analog scale. Duration of analgesia and total analgesic consumption was noted in 24 h. Student's t-test, Mann–Whitney U–test, and Chi-square test were used for the statistical analysis. Results: The mean duration of analgesia was prolonged in Group B as compared to Group A (493.17 ± 12.54 min vs. 307.70 ± 22.37 min). Total analgesic consumption in the first 24 h postoperatively was also statistically lower in Group B as compared to Group A (132.50 ± 32.26 vs. 167 ± 32.26 mg in Group A) (P ≤ 0.001). Hemodynamics were comparable. Conclusion: The addition of 150 mg magnesium sulfate as adjuvant to 0.25% ropivacaine for Pecs block increases the duration of analgesia and significantly reduces the amount of analgesic requirement.
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Comparison of nalbuphine versus fentanyl as an adjuvant to 0.75% isobaric ropivacaine in subarachnoid block for orthopedic surgery of lower limbs: A randomized, double-blind study p. 161
Vivek Mavaliya, Babita , ML Tak, Bhupendra Singh, Satveer Singh Gurjar
Background: Ropivacaine is an effective and safe alternative local anesthetic for subarachnoid block with a lesser duration of motor blockade and less neuro-cardiotoxicity. While fentanyl is commonly used as an adjuvant, nalbuphine recently got popular by its μ-attenuation and k-accentuation effects. We compared the efficacy of intrathecal fentanyl versus nalbuphine as an adjuvant to ropivacaine in subarachnoid block. Materials and Methods: In this prospective, randomized, double-blind study, seventy adult patients who were posted for elective lower limb orthopedic surgeries were randomly allocated to two groups. Group F received 22.5 mg of 0.75% isobaric ropivacaine with 25 μg fentanyl, and Group N received 22.5 mg of 0.75% isobaric ropivacaine with 1 mg nalbuphine intrathecally. Hemodynamics, onset, block duration, peak sensory level, two-segment regression time, and adverse effects such as nausea, vomiting, pruritus, sedation, hypotension, and bradycardia were studied. P < 0.05 was considered statistically significant. Results: Both groups achieved the target sensory level of T10. Time for onset of sensory and motor blockade, time to achieve peak sensory level, and motor block duration were statistically comparable in both groups. The duration of the sensory block was 254.45 ± 20.69 min in Group F and 297.4 ± 19.0 min in Group N (P < 0.001). The duration of analgesia was 275.6 ± 18.76 min in Group F and 318.2 ± 14.14 min in Group N (P < 0.001). Conclusions: Nalbuphine prolongs the duration of the sensory block along with the duration of postoperative analgesia in comparison to fentanyl as an intrathecal adjuvant to 0.75% isobaric ropivacaine for subarachnoid block.
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Immature granulocyte and mean platelet volume as a predictor of 30-day postoperative mortality in patients with sepsis caused by peritonitis p. 166
Rudi Hartono Sinaga, Arie Utariani, Puspa Wardhani, Hardiono Hardiono
Background: Prompt and reliable identification and risk stratification in sepsis patients are needed to reduce the risk of mortality. Immature granulocytes (IG) and mean platelet volume (MPV) are considered as the predictors of 30-day mortality in sepsis patients. This study aims to analyze the relationship between IG and MPV with 30-day mortality following emergency laparotomy in patients with sepsis due to peritonitis. Materials and Methods: In this observational retrospective study, IG, MPV value, and 30-day mortality were obtained from the medical records of sepsis patients due to peritonitis who underwent an emergency laparotomy that met the inclusion criteria. We recorded the patients' data that met the inclusion criteria from the medical records that consisted of age, sex, diagnosis, sequential organ failure assessment score, and routine laboratory examination at the time of admission. Then, we analyzed each variable to determine the valid predictors of mortality. Results: From a total of 107 patients, the mortality rate was 34.58%. IG of day 1 (cutoff = 1.05), MPV of day 3 (cutoff = 10.35), and mean difference of platelet volume between day-0 and day-3 (cutoff = 0.35) were valid predictors for 30-day mortality (P = 0.004, P = 0.006, and P < 0.001, respectively). The mean difference of platelet volume day-0 and day-3 had the highest sensitivity and specificity, which was 67.6% and 72.9%, respectively. Conclusion: The number of IG on day-1, MPV on day-3, and mean difference of platelet volume between day-0 and day-3 are the valid predictors of mortality in sepsis patients due to peritonitis who underwent emergency surgery within 30 days.
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An observational study to evaluate the role of ultrasound in the prediction of difficult laryngoscopy p. 172
Mamta Gupta, Shikha Sharma, Sourabh Katoch
Background: Difficult laryngoscopy (DL) is challenging when difficult ventilation occurs during standard laryngoscopy. For airway assessment, the common clinical airway predictors have low sensitivity (Sn) and specificity (Sp) with a limited predictive value. Ultrasound can be a useful tool for predicting such difficulties. We aimed to evaluate the usefulness of several sonographic airway parameters in predicting DL in adults. Patients and Methods: This prospective observational study included 120 patients who underwent elective surgery requiring general anesthesia with direct laryngoscopy (Macintosh blade) and endotracheal intubation. Ultrasonography (USG) assessment included preepiglottic space (PES), hyomental distance (HMD), distance from skin to the hyoid bone-skin (DSHB), and distance from skin-to-epiglottis midway between the hyoid bone and thyroid cartilage distance from skin to epiglottis midway (DSEM). Demographic variables and Cormack-Lehane (CL) grading for laryngoscopy (CL grade 1, 2-easy; 3, 4-difficult). Receiver operating characteristic (ROC) analysis was done, and area under the curve (AUC) was calculated to determine the best predictor of DL. Results: DL was present in 22.50% of patients. Compared to those with easy laryngoscopy, patients with DL had lesser HMD (4.55 vs. 4.96, P = 0.002), and comparable DSHB, DSEM, and PES. Among the various US parameters for predicting DL, we found the highest Sn of DSHB (74.07%); highest Sp of HMD (86.02%); highest positive predictive value of HMD (50%); and highest negative predictive value of HMD (85.1%). ROC curve analysis showed HMD to be the best predictor for DL with the highest AUC of 0.684. Conclusion: DL is common, present in 22.5% patients. US is a novel modality for predicting the DL, especially HMD, which showed the highest AUC among DSHB, DSEM, and PES.
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Saddle block versus subarachnoid block for transurethral resection of prostate surgery: A randomized comparative study p. 178
Revathy Bejoy, Derlin Thomas, Suhura Beevi
Background: Regional anesthesia is usually preferred over general anesthesia for transurethral resection of the prostate (TURP). Spinal anesthesia increases the risk of hypotension. Saddle block provides a block that is dense in lumbosacral and lower thoracic dermatomes; hence, hemodynamic derangement will be less. In this study, we aimed at comparing the hemodynamic stability and anesthetic efficacy of subarachnoid block versus saddle block in patients undergoing TURP. Patients and Methods: After obtaining written informed consent, a prospective randomized comparative study was conducted in 90 patients, 50–70 years, of ASA physical status 1–2 scheduled for TURP. They were randomly allocated into two groups of 45 each. Group SA received spinal and Group SB received saddle block using the same volume (2.5 ml) of hyperbaric bupivacaine. Hemodynamic parameters such as heart rate (HR), systolic, diastolic, and mean arterial blood pressure (BP), and height of block were recorded in both groups. If hypotension was present, ephedrine bolus intravenously was administered, and the total requirement of vasopressor was noted. Results: Maximum decrease in HR from baseline was low in Group SB (P = 0.008). Maximum fall in systolic, diastolic, and mean BP was also found to be low (P = 0.005), (P = 0.001), and (P = 0.001), respectively, in Group SB. In Group SB, time to achieve T10 sensory level was delayed, whereas the level of motor blockade was low according to the modified Bromage score. Ephedrine consumption was also low in Group SB (P = 0.001) versus Group SA. Conclusion: Saddle block can be safely administered in TURP for elderly patients, with the reduced hemodynamic imbalance and vasopressor requirement.
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Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial p. 183
Raman Kumar, Vinod Kumar Verma, Swati , Chandrakant Prasad
Background: Postdural puncture headache (PDPH) is a well-known iatrogenic and distressing complication of a subarachnoid block. In this study, we aimed to see if the sphenopalatine ganglion block (SPGB) is beneficial for the treatment of PDPH in comparison to conservative management or not. Patients and Methods: This prospective, randomized, observational study registered in the Clinical Trials Registry of India (CTRI/2018/02/011883). We included 60 patients, divided into three groups of 20 each. Group C patients were managed conservatively. Group L4 patients were given SPGB with 4% lignocaine per SPGB. Group L10 patients were given SPGB with lignocaine 10% puffs. The patients were assessed at predefined durations for Visual Analog Scale (VAS) score, readiness to discharge, and feel-good index. SPSS 20.0 software was used for data analysis. Results: There was a statistically significant reduction in VAS score and mean treatment duration in group L4 and group L10 in comparison to group C. At 72 h of treatment, 5.26% of Group C patients, 88.89% of Group L4, and 95% of Group L10 patients were found ready to discharge. The feel-good index was assessed after 15 min of treatment was found best in Group L10, followed by L4 and C groups. Conclusion: SPGB increases the proportion of patients ready to discharge at 72 h of treatment. Lignocaine 10% is more effective than lignocaine 4% solution for SPGB. SPGB decreases the hospital stay, hence cost-effective.
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Comparison of analgesic efficacy of ropivacaine and levobupivacaine in ultrasound-guided transversus abdominis plane block and port site infiltration in laparoscopic live-donor nephrectomy, a double-blind randomized parallel group trial p. 188
Sandeep Sahu, Zakia Sayeed, Tapas Kumar Singh, Divya Srivastava, Aneesh Srivastava, Dharmendra Bhadauria
Background: Laparoscopic live-donor nephrectomy (LLDN) produces reduced donor's pain, early recovery, and a better cosmetic compared to open surgeries. We compared the analgesic efficacy of ropivacaine and levobupivacaine in unilateral ultrasound-guided transversus abdominis plane block (UTAPB) and port-site infiltration (PSI) in LLDN. Patients and Methods: The 120 donors, American Society of Anesthesiologists I-II, of either sex were randomly divided into two groups. The ropivacaine (Group-R = 60 patients given 20 ml of 0.2%) or levobupivacaine (Group-L = 60 patients, 20 ml, 0.25%) in unilateral UTAPB and 10 ml of either drug for PSI at the end of the surgery. All patients received intravenous (IV) patient-controlled analgesia pump (fentanyl) and IV paracetamol 1 g up to 48 h of study duration. Seventy-five milligram IV diclofenac was used as rescue analgesia. The duration of analgesia, time to the first requirement, and number of times rescue analgesia, total amount of fentanyl consumed and pain score Visual Analog Scale noted. Results: In UTAPB, the duration of sensory block in the levobupivacaine group was significantly longer to the ropivacaine group, 12.70 + 7.12 versus 10.55 + 6.64 h (P = 0.090), with lesser rescue analgesic requirement 37 versus 49 (of 60 patients) and lesser total fentanyl consumption 57.50 ± 53.54 mg versus 82.50 ± 65.63 mg. The first-time rescue analgesic delayed, 80.25 ± 137.78 versus 53.67 ± 79.85 min and a number of times rescue analgesic used significantly lesser in the levobupivacaine group 0.87 ± 0.84 versus 1.15 ± 0.92, with better patient satisfaction. Conclusion: Both the levobupivacaine and ropivacaine are effective in UTAPB for the management of postoperative pain after LLDN. The duration of sensory block was longer, total opioid consumption, and rescue analgesic requirement use were significantly lesser in the levobupivacaine group.
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Contact force exerted on the maxillary incisors by direct laryngoscopy with Macintosh and McGrath video laryngoscopy p. 194
Tjokorda Gde Agung Senapathi, I Made Gede Widnyana, I Gusti Ngurah Mahaalit Aribawa, Christopher Ryalino, I Nyoman Trisna Wirakusuma Yudi
During laryngoscopy the laryngoscope blade occasionally comes in contact with the teeth. In this case series, we described the measured force exerted on the maxillary incisors on ten patients undergoing general anesthesia requiring tracheal intubation, divided into two groups: direct laryngoscopy with Macintosh and video (McGrath) laryngoscopy. The contact force applied during laryngoscopy was measured using a pressure meter tool. This report shows that despite the prediction of uncomplicated laryngoscopy during tracheal intubation, the contact force exerted on the maxillary incisors was multifarious.
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Atypical picture of peripheral arterial access in a neonate p. 198
Ravi Shankar Sharma, Narayanan Balakrishnan, Narendra Kaloria, Manoj Kamal, Suyashi
Arterial line placement in the pediatric population is a challenging task. Even with the help of ultrasound, multiple attempts may be required for its successful placement. Even in the expert hands, complications such as thrombosis and distal gangrene have been encountered in the past. In recent times, Doppler's ultrasound assistance has reduced the number of attempts required for its successful placement, thereby reducing the unforeseen complications. Sometimes, pediatric arterial line placement can produce a picture like extravasations of injectate into subcutaneous tissue. Hence, one must confirm the position of arterial line with blood pressure tracing and arterial blood gas analysis before removal of the placed cannula in order to avoid unnecessary pricks. We present a case of an atypical picture of a radial artery cannulation in a neonate, which may have led to unnecessary repeated arterial puncture.
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Anesthesia management of a patient undergoing exploration-decompression spinal canal and lumbar fusion procedure with diaphragmatic hernia p. 200
Tjokorda Gde Agung Senapathi, Andi Irawan, Adinda Putra Pradhana
A diaphragmatic hernia is an abnormality of abdominal organs entering the thoracic cavity due to a defect in the diaphragm. Diaphragmatic hernias are divided into congenital or acquired that can develop from blunt or sharp trauma. In hernias due to blunt trauma, the common symptoms reported are limited to gastric disorders. The patient can come to the health facility for other reasons and, in this case, is a radicular pain due to spondylolisthesis. In this case report, a 67-year-old woman suffered from spondylolisthesis, which would carry out a decompression-stabilization and fusion procedure in a prone position, and at the time of preoperative examination was found to have a diaphragmatic hernia comorbid. Anesthetic management in cases of comorbid diaphragmatic hernias must emphasize the possibility of a full gastric condition. With careful anesthesia management, the challenges to overcome the condition in this patient can be done properly.
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Erector spinae plane block for different surgeries: A case series p. 203
Tjokorda Gde Agung Senapathi, I Made Subagiartha, I Ketut Wibawa Nada, Ida Bagus Putu Oka Mahendra
Erector spinae plane block (ESPB) is an interfascial plane block where a local anesthetic is injected below the erector spinae muscle. It is supposed to work at the origin of spinal nerves based on cadaveric and contrast study. It has emerged as an effective and safe analgesic regional technique. We report ten cases of thoracic and abdominal surgeries using this technique. We compared the hemodynamic stability through systolic blood pressure, mean arterial pressure, and heart rate before and after ESPB. Postoperative analgesia was given through patient-controlled analgesia or continuous opioids. The opioid needed and pain scale were assessed 24 h post surgery.
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Contact dermatitis secondary to tegaderm application in a case of cochlear implant p. 206
Ravi Shankar Sharma, Hariprasad Ramalingam, Manoj Kamal, Nilay Pal, Suyashi
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Oxycodone as a replacement to opioid to facilitate tracheal intubation p. 208
Aninda Tanggono, Cynthia Dewi Sinardja, I Putu Pramana Suarjaya
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