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   Table of Contents - Current issue
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October 2020
Volume 4 | Issue 6 (Supplement)
Page Nos. 31-80

Online since Monday, October 12, 2020

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REVIEW ARTICLES  

Influence of patient's age on the clinical presentation, morbidity, and mortality in COVID-19: A brief review Highly accessed article p. 31
Chandrakant Prasad, Surya Kumar Dube, Vanitha Rajagopalan, Arvind Chaturvedi
DOI:10.4103/BJOA.BJOA_110_20  
Currently, COVID-19 is spreading rapidly and presenting with different clinical features with different mortality rates worldwide. In the initial days of the pandemic, most of the patients presented with the complaints of lower respiratory tract infection of varying severity, and most of the deaths were also attributable to respiratory failure. As time progressed, more atypical presentations and causes of mortality were encountered according to different age groups. In the present scenario, a surge of COVID-19 cases is expected. Those new cases will also include patients with various problems requiring surgical interventions. In this brief review, we have discussed various presentations and mortality risks of COVID-19 infections in different age groups. We did literature searched on the PubMed database and included studies published in 2019 and 2020. Altogether, 503 articles were retrieved out of which 31 were analyzed to put up this summary. Important atypical findings in neonates and infants were axial hypotonia, drowsiness, moaning sound, intussusception, and late-onset neonatal sepsis with the cause of death being multi-organ failure. Frequently reported comorbidities among children were hydronephrosis, leukemia, and intussusception. Observed risk factors for unfavorable outcome in the adult population were obesity, HIV, tuberculosis, and the intake of immunosuppressive agents in the form of anticancer drugs and steroids. The factors adding to the vulnerability in the elderly population could be enumerated as diabetes, hypertension, ischemic heart diseases, obesity, and cancers.
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Postoperative management of obstetrics and gynecology patients in the coronavirus disease 2019 era Highly accessed article p. 36
I Gde Sastra Winata, Polo Ishak Kurniawan
DOI:10.4103/BJOA.BJOA_115_20  
Coronavirus disease 2019 (COVID-19) is an infection caused by the severe acute respiratory syndrome-CoV-2 virus. The WHO declared COVID-19 as a global pandemic. There is a difference in the postoperative care of COVID-19 patients than ordinary patients. After surgery, the number of personnel transporting the patient must be as minimal as possible. The patient is treated in a particular room with negative pressure. The management of postoperative pain uses the principle of multimodal analgesia both types and techniques of administration. All infants born from mothers confirmed COVID-19 should be isolated from both the mother and other babies, and tested for COVID-19. Patients are advised to postpone the next pregnancy until the pandemic ends.
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ORIGINAL ARTICLES Top

Dexmedetomidine versus magnesium sulfate for induced hypotension during functional endoscopic sinus surgery: A randomized, double-blind study p. 39
Usha Bafna, Satveer Singh Gurjar, Jahnu Bhoj Nagal
DOI:10.4103/BJOA.BJOA_35_20  
Background: Bleeding during functional endoscopic sinus surgery (FESS) can compromise surgical field quality. Intraoperative controlled hypotension by various hypotensive agents can reduce blood loss and improves surgical field visibility with less need for intraoperative blood transfusions. This study compared the hypotensive effectiveness and safety of dexmedetomidine and magnesium sulfate in patients undergoing elective FESS. Patients and Methods: Sixty adult patients posted for elective FESS were randomly assigned to two groups. Group A received a loading dose of dexmedetomidine 1 μg/kg, followed by infusion of 1 μg/kg/h, and Group B received a loading dose of magnesium sulfate 40 mg/kg, followed by 15 mg/kg/h infusion. Surgical field quality, emergence time, sedation score, Visual Analog Scale score, recovery profile, and vital signs were recorded. Mean arterial pressure (MAP) was kept above 65 mmHg during induced hypotension. Results: Both the groups achieved the target MAP (65–70 mmHg) and improved the surgical field visibility with reduced blood loss. Hemodynamics was superior in the dexmedetomidine group with the additional advantage of postoperative conscious sedation and analgesia (P < 0.05). None of the groups showed any statically significant adverse effects (P > 0.05). Conclusions: Both dexmedetomidine and magnesium sulfate are safe agents for controlled hypotension for improving surgical field quality. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.
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A randomized controlled trial on epidural volume extension in combined spinal epidural anesthesia for lower limb surgeries using intrathecal ropivacaine in older adults p. 44
Shagufta Naaz, Usha Shukla, Rachana Gupta, Erum Ozair, Adil Asghar
DOI:10.4103/BJOA.BJOA_75_20  
Background: Epidural volume extension (EVE) is a technique wherein normal saline is injected into epidural space, soon after the neuraxial block. We studied the effectiveness of EVE using intrathecal ropivacaine and normal saline in the elderly. Patients and Methods: This was randomized, control, double-blinded, double arm, parallel study of 75 patients of American Society of Anesthesiologists I and II, age ≥60 years, undergoing lower limb orthopedic surgery. Patients were allocated into two groups (E and NE), both receiving 3 ml of 0.75% injection ropivacaine intrathecally. Group E also received EVE. The primary outcome was the maximum level of sensory block. Secondary outcomes were the characteristics of blocks, hemodynamic changes, adverse effects, and analgesic requirements until 24 h. The statistical analysis of quantitative data was done by the Student's t-test and that of qualitative data using the Chi-square test. Results: The sensory level of block achieved in Group E T4(T2–T5) was higher as compared to Group NE, T6(T3-T8). Time to two-segment sensory regression was earlier in Group NE (mean = 66.5 min; 95% confidence interval [CI], 63.31–69.69) than in Group E (mean = 91.5 min; 95% CI, 87.70–95.31) (P < 0.001; df = 58). The duration of analgesia in Group E (mean = 316.5 min; 95% CI, 309.09–323.91) was more than in Group NE (mean = 230.67 min; 95% CI, 226.49–234.850) (P < 0.001). There was no statistically significant difference in the 24 h analgesic consumption (P = 0.64), hemodynamic stability, or adverse effects. Conclusion: EVE results in a higher level of the sensory block and a longer duration of postoperative analgesia than that without EVE with no hemodynamic instability in the older population.
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Ultrasound-guided supra-axillary block as a supplement to subclavian perivascular brachial plexus block for surgeries around the elbow: A prospective feasibility study p. 50
Chelliah Sekar, Poonoly Varkey Sheela, Vipin Kumar Goel, Tuhin Mistry, Balasubramanian Senthilkumar, Kartik Sonawane
DOI:10.4103/BJOA.BJOA_81_20  
Background: The dermatomal area supplied by the intercostobrachial nerve (ICBN) and medial cutaneous nerve of the arm (MCNA) are not reliably blocked by currently used approaches of the brachial plexus block. This feasibility study is aimed at determining the efficacy of the novel ultrasound-guided supraaxillary block. Patients and Methods: This prospective, observational study was conducted on patients undergoing surgeries around the elbow. Sixty American Society of Anesthesiologists Physical Status I and II patients aged between 18 and 60 years were recruited. The supraaxillary block was performed in addition to the subclavian perivascular brachial plexus block in all patients. The local anesthetic (LA) mixture was prepared with 10 ml of 2% lignocaine-adrenaline, 15 ml of 0.5% bupivacaine, and 10 ml of 0.9% saline. 20 ml of the LA solution was used for supraclavicular block, and 15 ml was injected in the supra-axillary area. Results: The onset of sensory and motor block for the subclavian perivascular block was 4.30 ± 0.891 and 8.12 ± 0.872 min, respectively. The onset of the supra-axillary block was 9.50 ± 0.707 min. Only 6.67% of the patients needed additional local infiltration. Conclusion: Ultrasound-guided single-shot injection of LA in the supra-axillary area as a supplement to subclavian perivascular brachial plexus block achieved complete anesthesia for surgical procedures around the elbow by blocking the ICBN and MCNA.
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Urinary tract infection in critically ill patients with diabetes mellitus: Spectrum of uropathogens and antimicrobial susceptibility pattern p. 55
Nand Kishore, Sagar Modi, Sushant Khanduri, Barnali Kakati
DOI:10.4103/BJOA.BJOA_97_20  
Background: Urinary tract infections (UTIs) are common and more severe among patients with diabetes mellitus (DM). UTI in DM is more likely to be caused by bacteria resistant to various antimicrobials. The present study aims to assess the spectrum of bacteria causing UTI and its antimicrobial susceptibility pattern among critically ill patients with DM. Materials and Methods: The present study included 272 patients with DM and UTI, age more than 18 years, admitted in the intensive care unit of a tertiary care hospital in the state of Uttarakhand, India. The pathogens causing UTI were isolated, identified and antimicrobial susceptibility testing was performed using automated VITEK method as described by the Clinical and Laboratory Standards Institute. Results: UTI was caused by Gram-negative bacteria of Enterobacteriaceae family in 89.7% and by Gram-positive bacteria in 10.3% of the study participants. Escherichia coli was the most common Gram-negative bacteria causing UTI followed by Klebsiella pneumoniae and Proteus spp. Enterococcus faecalis was most common Gram-positive isolate. Gram-negative bacteria were highly susceptible to colistin, fosfomycin, carbapenems, and aminoglycosides. Carbapenem resistance was observed in 16.4% of these isolates. Gram-positive bacteria were most susceptible to vancomycin, teicoplanin, linezolid, and fosfomycin. Conclusion: Gram-negative bacteria, particularly E. coli were the most common uropathogens causing UTI in critically ill patients with DM. These bacteria showed good antimicrobial susceptibility to colistin, fosfomycin, carbapenems, and aminoglycosides. Carbapenem-resistance was found in one-sixth of the Enterobacteriaceae isolates. Gram-positive bacteria caused UTI in about 10% of the study participants and were susceptible to vancomycin, teicoplanin, and linezolid.
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The incidence of postoperative cognitive dysfunction in elderly patients underwent elective surgery at Sanglah General Hospital p. 61
Pontisomaya Parami, Christopher Ryalino
DOI:10.4103/BJOA.BJOA_109_20  
Background: Postoperative cognitive dysfunction (POCD) causes an increase in social and economic burdens because of the prolonged length of stay in the hospital, increased costs, and decreased quality of life. No data on POCD has ever been recorded in Indonesia. The goal of this study was to determine the incidence of POCD in elderly people at Sanglah General Hospital, Indonesia. Patients and Methods: This is a descriptive study conducted at Sanglah General Hospital in 2018. Inclusion criteria included patients of 60 years old or more who came to anesthesia preoperative clinic with the American Society of Anesthesiologists physical status 1 and 2. Cognitive functions were assessed three times: 1 day before the surgery, 2 days after the surgery, and 4 weeks after the surgery. POCD was defined as an at least 20% decreased result of two out of three instruments used. Results: The study included 84 participants consisting of 52 males and 32 females. The mean age was 66.0 ± 5.1 years. Most participants were elementary school graduates (34.5%) and high school graduates (27.4%). There were 7 (8.3%) patients who developed POCD within 48 h and 4 weeks postoperatively. Conclusion: The incidence of POCD at Sanglah General Hospital was 8.33% both at 48 h and 4 weeks postoperatively.
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CASE REPORTS Top

Classic laryngeal mask airway insertion with laryngoscope mcgrath and macintosh: A case series p. 64
Tjokorda Gde Agung Senapathi, Putu Agus Surya Panji, I Gede Herry Yudiskara, Adinda Putra Pradhana
DOI:10.4103/BJOA.BJOA_40_20  
Laryngeal mask airway (LMA) is often performed for airway management. Correct placement of LMA can prevent severe leaks and even obstruction of the airway. Insertion under laryngoscope guidance has been used to achieve the ideal positioning of the LMA. Efficacy of LMA insertion by laryngoscope can be evaluated with cheap, safe, and easy to use method. This case series evaluates LMA insertion with McGrath video laryngoscope and Macintosh laryngoscope. We use 20 cases to evaluate oropharyngeal leak pressure, time taken for insertion, hemodynamic after insertion, first attempt insertion, ease of insertion, and adverse airway event after LMA insertion.
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An out-of-plane approach for pericapsular nerve group block: A case series p. 67
Ashok Jadon, Neelam Sinha, Swastika Chakraborty, Asif Ahmad
DOI:10.4103/BJOA.BJOA_41_20  
Pericapsular nerve group (PENG) block is a new ultrasound (US)-guided nerve block, which has been used successfully to manage fractured hip pain. As an alternative approach to give PENG block, we have investigated the out-of-plane (OOP) approach instead of the in-plane approach, which is conventionally used. Ten patients aged between 55 and 72 years scheduled for hip surgery under spinal anesthesia were given US-guided PENG block by the OOP approach. The success of block was assessed by reduction in rest pain and pain during 15° straight leg raising (SLR) (passive SLR test) on a numeric rating Score (NRS) after 30 min of block. Ease of positioning score was also assessed during spinal anesthesia. The procedural difficulty was assessed by the number of attempts (needle re-insertion at the skin). All patients had successful blocks and showed a significant pain relief in resting pain (6.5 ± 1.3 vs. 3.8 ± 0.78) as well as pain during 15° SLR (8.5 ± 1.1 vs. 5.1 ± 0.73). All blocks required single needle entry; however, in three patients, medial redirection of the needle was required before final positioning. No complication was observed in any case. PENG block provides effective analgesia during positioning for spinal anesthesia in patients with hip fracture. OOP approach can easily be used as an alternative to conventional in-plane technique.
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Successful resuscitation after cardiac arrest in a patient presenting with local anesthetic systemic toxicity p. 71
Shambhu Sharma, Gagan Bhardwaj, Vidhu Bhatnagar
DOI:10.4103/BJOA.BJOA_82_20  
Local anesthetics are used frequently in health-care practice, being used by physicians, surgeons, and anesthesiologists; however, the local anesthesia systemic toxicity (LAST) is still not taken very seriously by the health-care workers (HCWs). LAST is an underreported complication, and many HCWs need to experience it firsthand to realize the criticality of the situation. The idea behind publishing this case report is to increase the awareness of complication called LAST and familiarize HCWs with the management guidelines.
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The conundrum of perioperative management for emergency cesarean section in a patient with anaphylactic shock p. 74
Joseph Abraham Poonuraparampil, Habib Md Reazaul Karim, Apoorv Garhwal, Mittapalli Jeevan Babu
DOI:10.4103/BJOA.BJOA_87_20  
Anaphylaxis during pregnancy is uncommon and poses a great dilemma. The conundrum of drug therapy, optimal timing of delivery, and method of anesthesia is still unresolved. We report such a case of 30-year-old hypothyroid parturient at 36 weeks and 5 days of gestation, with a history of uneventful previous lower segment cesarean section (LSCS). She was having scar tenderness and fetal distress and was being prepared for planned emergency LSCS. She had an anaphylactic reaction to ceftriaxone and developed cardiorespiratory failure. The manuscript highlights the different dilemmas and discusses management options.
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LETTERS TO EDITOR Top

Usefulness of flexible bronchoscopy for securing the airway in traumatic tracheal perforation during tracheostomy with development of tracheo-esophageal fistula p. 77
Sunil Rajan, Jacob Mathew, Karthik Chandra Babu, Divya Daniel
DOI:10.4103/BJOA.BJOA_55_20  
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Agitation following midazolam administration: The paradox p. 79
Deep Sengupta, Surya K Dube, Vanitha Rajagopalan
DOI:10.4103/BJOA.BJOA_60_20  
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