Zahid Hussain Khan, M.D., FCCM.
Atabak Najafi, M.D.
Mehdi Sanatkar, M.D.
Parya Khalili, B.Eng.
Archives of Anesthesiology and Critical Care (AACC) is the journal of Department of Anesthesiology and Critical Care , Tehran University of Medical Sciences ever since its foundation about eight decades back. The journal has eminent members in its editorial board both from within the country and abroad. The journal welcomes manuscripts in all fields and subspecialties related to anesthesia and basic sciences including ethics, historical perspectives, commentaries and letters of interest for our readers and furthermore aims to publish manuscripts from researchers working in all the disciplines or sub-specialties related directly or indirectly to anesthesiology, critical care and patients’ welfare and safety. Review articles, meta-analysis, and editorials are also welcome from our experienced colleagues on the plethora of subjects that are there in our field and which they deem would be of interest to our readers in general and would be of incalculable benefit to our patients in particular and the care givers.
Background: Caudal epidural block (CEB) has been widely used to treat lumbar spine disorders, to manage chronic low back pain, and to provide analgesia and anesthesia in operations such as labor pain and orthopedic and genital surgeries. The CEB technique depends on the precise location of the sacral hiatus (SH) through which access to the sacral epidural space is obtained. For optimal access to the sacral epidural space, accurate knowledge of the SH descriptive profile is required.
Methods: The study was performed on 23 sacrum bones. All bones were of Iranian (Persian) origin. Bones that were worn, corroded, broken, or had any anatomical problems were excluded. The parameters were measured: Sacral hiatus Length, distance between base of hiatuse-S2, liner distances between apex of sacral hiatus till right and left ends of lateral sacral crest were measured. Distance between Apex of sacral hiatus till S2, Antherio-posterior diameter of SH and location of sacral hiatus and types of SH.
Results: This study showed that the highest type of sacral hiatus in Iranians with a frequency of 38% is inverted V shape and the lowest type of deficiency shape is with a frequency of 4.8%.
The position of sacral hiatus in the Iranian sacrum showed that the highest position was with a frequency of 45% in front of the sacral vertebra 4 and the lowest case in front of the third sacral with a frequency of 15%. The height of sacral hiatus was the highest case with a height of 21-30 mm (50% or cases 9). Anterior-posterior diameter of sacral hiatus was 4-6 mm in The most common case 75% or cases 15.
It was shown that the mean distances between S2 till apex of the sacral hiatus 56.65 mm and the mean distance between S2 till base of the sacral hiatus is 36.85 mm.
Conclusion: Successful application CEB enables comfortable anesthesia for patients and helps them to resume an active life soon. Accurate understanding of the SH location is important to reduce the risk of intraoperative as well as damage to vital structures. The present study aimed to determine positional changes and measure SH distances. Also, the aim of this study was to determine SH landmark points, perform accurate and standard morphometric measurements and calculate safe SH areas in CEB application.
Background: ALRIV, a simple, reliable, inexpensive and easily reproducible technique, is still little practised in sub-Saharan Africa. The objective of this study is to describe our practice in order to popularize this anesthetic technique.
Methods: This was a prospective and descriptive study covering a 12-month period. All patients admitted for surgical management of upper limb except the arm and lower limb except the thigh were included. The parameters studied were epidemiological, clinical, therapeutic, anaesthetic and evolutionary.
Results: We selected 73 patients out of 675 (10.81%). The majority of the patients were seen in the framework of a regulated surgery against only 13.69% in emergency. The operative indications were: removal of osteosynthesis materials (52.05%), limb osteosynthesis (43.83%) and phlegmon evacuation (4.10%). The double tourniquet technique was used in (93.15%). Lidocaine 0.5% was used at a dose of 0.5ml/kg. The average duration of the procedures was 57.28 minutes. Postoperatively, all our patients received multimodal analgesia. In the postoperative monitoring room, 64.38% of patients did not experience any discomfort or pain.
Conclusion: ALRIV is a simple technique of peripheral local anaesthesia that is easy to teach, consistently effective and inexpensive.
Background: The head's position during mask ventilation on the time of anesthesia induction in children may improve the lung ventilation.
Aim: Current study was designed to verify whether lateral head rotation improves face mask ventilation efficiency during anesthesia induction in children.
Methods: Fifty-six patients aged 1-4 years, candidate for elective surgery, were randomly divided into two equal groups. During induction of general anesthesia, face mask lung ventilation of patients continued with pressure-controlled mode, at a peak pressure level of 10 cmH2O for children 13-24 months and 14cmH20 for children 24-48 month. In patients in the N group, the head position during ventilation was initially in the neutral position for one minute, then the head was axially rotated 45-degree to the right position for one minute and pulmonary ventilation continued in this position, then the head was rotated again to the neutral position and ventilation continued for one minute. In group R patients, mode and time of ventilation was the same, but the order of head placement was first in the lateral rotated to the right, then neutral and then lateral rotated to the right. The primary outcome was the measurement of expiratory tidal volume in each position.
Results: Generally, the mean measured expiratory tidal volume did not change in the neutral position compared to laterally rotated head position, 256.6 vs. 233.5 ml: difference -23.1 [95% confidence interval: 10.8 to 39.4 ml]. Also, the change of head position from lateral to neutral position did not show a significant change in the mean expiratory tidal volume, 232.28 vs.247.86 ml: difference -15 .82 (p= 0.4).
Conclusion: The rotation of the head to the lateral position during induction of anesthesia in apnoeic children 1-4 years old could not improve the efficiency of mask ventilation relative to the neutral head position.
Background: Trauma is an injury to living tissue from an external source. The severity of traumatic injuries plays a crucial role in the determination of mortality in patients with trauma, thus a proper understanding of the severity of trauma is very important for improving trauma care. Several scoring systems are available for the objective, initial assessment of the severity of injury to help treatment strategy. Aim of the study was to compare Emergency Trauma Score (EMTRAS) with Rapid Emergency Medicine Score (REMS) for prediction of early mortality in adult trauma patients.
Methods: Study was conducted with 100 patients of either sex, age 18 years or above with history of trauma due to road accident, fall and assault. REMS and EMTRAS score was calculated from the laboratory and patient characteristics mentioned in the Trauma scoring datasheet, within 30 minutes of arrival of the patient in the hospital and 24 hours after hospitalization.
Results: Comparison of the REMS score within 30 mins of patient arrival and at 24 hrs was statistically significant (p=0.0099). Comparison of EMTRAS SCORE Within 30 mins of patient arrival and at 24 hrs was not statistically significant (p=0.0505). Comparison of REMS vs Outcome at 24 hrs (Non-Survivors and Survivors) was statistically significant (p=<0.0001). Comparison of EMTRAS vs Outcome at 24 hrs (Non-Survivors and Survivors) was statistically significant (p=<0.0001). Comparison of AUROC (Area Under the Receiver Operating Characteristics) of REMS and EMTRAS were 0.689 and 0.789 respectively, which was statistically significant.
Conclusion: We conclude that both REMS and EMTRAS are easy, accurate predictors of in-hospital early mortality in Adult Trauma Patients. But in our study, EMTRAS AUROC was greater than AUROC of REMS. Hence EMTRAS should have good prognostic power for predicting in-hospital early mortality in Adults Trauma patients.
Background: Ear surgeries performed under general anaesthesia mandate smooth emergence after surgery to facilitate a good surgical outcome. We conducted this study with primary objective of comparing dexmedetomidine and magnesium sulfate (MgSO4) in attenuating extubation response after mastoid surgeries. The secondary outcome was to study the adverse effects if any.
Methods: Sixty patients of ASA grade I and II, aged 18 -50 yrs were randomized into 2 groups of 30 each receiving either dexmedetomidine 0.5μg/kg or MgSO4 30 mg/kg respectively 10 minutes prior to completion of surgery. Efficacy of both drugs in attenuating cough reflex, PONV, shivering and fluctuations in haemodynamic response were recorded. Postoperative sedation was noted. Any laryngospasm, bronchospasm, hypotension, bradycardia, desaturation was also noted.
Statistical analysis: The observations were recorded and analysed using statistics calculator SPSS 19.00 version. Student’s t test and χ2 (chi square) test were used to analyze quantitative and qualitative data respectively. P-value<0.05 was considered statistically significant.
Results: The variations in systolic, diastolic blood pressure and heart rate were significantly less with dexmedetomidine as compared to MgSO4 (p<0.01). Incidence of coughing (p=0.002), PONV(p=0.002), was less with dexmedetomidine while shivering control was similar in both groups, the sedation was more with dexmedetomidine (p=0.004). Patients with dexmedetomidine infusion were more satisfied in terms of reduced nausea sensation, drowsiness.
Conclusion: Dexmedetomidine provides a smoother recovery profile as compared to MgSO4 when administered prior to extubation improving the surgical outcome and patient satisfaction in patients undergoing mastoidectomies.
Background: The "Severe Acute Respiratory Syndrome Coronavirus 2 disease has caused globally a challenging and threatening pandemic (COVID-19), with massive health and economic losses . In India national vaccination campaigns kick started officially on January 16, 2021, and the vaccines were prioritized for frontline workers and susceptible groups. Individual vaccination can prevent or minimise a number of outcomes, including lab confirmed infection, symptomatic illness, infectivity rate, or a combination of these [2-3]. India had initially approved two vaccines under the trade name Covishield and Covaxin against COVID.
Aim: Demonstrate the efficacy of a single / two -dose schedule of COVID vaccine in the prevention of ICU mortality.
Methods: In this retrospective study, we included all COVID 19 confirmed patients who were admitted in covid designated ICU from March 15 to July 31 2021. Demographic, clinical, laboratory and radiological data were collected from all patients received in ICU. Primary outcome was to assess the mortality outcome in vaccinated COVID patients. Secondary outcome measured were to find an association between severity of the pneumonia and comorbidities, PaO2/Fio2 ratio, Neutrophil lymphocyte ratio, D dimer and CT severity score.
Results: 319 patients were enrolled in the study. 252 patients were not vaccinated.59 had received the first dose and 8 patients had received both the doses. The mortality among vaccinated patients were less compared to nonvaccinated and significant (p value 0.030). Mortality among single and double dose vaccinated patients couldn’t be made out because only 8 patients had received both the doses. Among the demographic profile, difference in age between vaccinated and unvaccinated was statistically significant. (64.39 ±11.916/ 54.18±14.124 p<.001. Among comorbidities hypertension, diabetes, obesity was associated with significant mortality. Admission saturation and mean PaO2/FiO2 ratio were high among vaccinated and significant. Neutrophil lymphocyte ratio, D dimer CT severity score were high among non vaccinated compared to vaccinated. There is no difference in mode of oxygen delivery in both vaccinated and non vaccinated patient. Days of ICU stayal was less among vaccinated.
Conclusion: Effectiveness of vaccine against SARS-CoV-2 infection after the first dose of immunisation is convincingly evident. However second dose of immunization should be continued to attain total protection.
Background: To evaluate the satisfaction of patients operated under spinal anaesthesia and to identify its determinants.
Methods: We conducted a prospective analytical study in the hospital wards of the gynaecology-obstetrics, general surgery and traumatology departments of the Yopougon University Hospital in Abidjan (Côte d'Ivoire) over a period of 5 months from February to June 2019.
Results: At the end of the study, 156 patients were selected. The mean age was 38.89±14.28 years with extremes of 19 and 72 years and a sex ratio of 0.8. The unemployed represented 20.41% of the total number of patients. The types of intervention were dominated by caesarean sections with 53.21% of patients. All our patients had a pre-anaesthetic consultation which was carried out by an anaesthetist, however 44.23% were dissatisfied due to anxiety. During the operation, nausea and vomiting were the main sources of discomfort for 25% of patients. Thirst, hunger and pain were the most common discomforts encountered in the ICU by 40.38%, 42.31% and 36.52% respectively. The determinants of dissatisfaction were age over 45 years, female gender of patients. Osteosynthesis of the femur and osteotomy of the tibial plateau were significantly associated with a reduction in dissatisfaction.
Conclusion: Several causes of dissatisfaction remain during spinal anaesthesia. Their management would allow to improve the comfort of our patients, thus the quality of care.
Background: Due to the rapidly increasing prevalence of diabetes mellitus (DM), the number of patients undergoing surgery and therefore requiring anesthesia has become higher than ever. In this study we aimed to compare blood glucose levels and hemodynamic parameters of patients with and without overt DM who have received general anesthesia and local anesthesia with sedation for cataract surgery.
Methods: In this cross-sectional study, 120 patients with DM and 120 patients without DM were included. Each of these patients was randomly assigned to receive general anesthesia or local anesthesia with sedation. blood glucose levels and hemodynamic parameters were measured before surgery, 30 minutes after surgery and six hours after surgery.
Results: There was no significant difference between the four groups in terms of age, gender and duration of surgery (P > 0.05). Blood glucose levels didn’t differ between non-diabetic patients receiving general and local anesthesia before or at any time after surgery (P > 0.05). Blood glucose levels were higher in diabetic patients compared to non-diabetics before or at any time after surgery (P < 0.001). 30 minutes and six hours after surgery, blood glucose levels of diabetic patients receiving general anesthesia were significantly higher than diabetic patients receiving local anesthesia with sedation (P < 0.001). No significant difference was noted regarding blood glucose changes during the study time frames in any of the 4 study groups. Diabetic patients receiving general anesthesia had higher blood glucose levels compared to non-diabetics and diabetic patients receiving local anesthesia with sedation (p < 0.001). Before surgery, the four study groups did not differ significantly in SBP, DBP, HR, RR and O2 sat (P > 0.05DBP, HR and RR were not different among the study groups 30 minutes after surgery (P > 0.05). SBP, DBP, HR and RR were not different among the study groups six hours after surgery (P > 0.05).
Conclusion: Patients receiving general anesthesia should be monitored more closely to prevent anesthesia-induced respiratory depression. Using local anesthesia with sedation instead of general anesthesia can help prevent the detrimental effects of perioperative hyperglycemia in diabetic patients undergoing cataract surgery.
Background: Keeping in view the endemicity of tuberculosis in Jammu and Kashmir and the lack of information about the prevalence of Female Genital TB, this study was primarily undertaken to diagnose the genital tuberculosis in infertile women and to determine the utility of the existing standard diagnostic tests in our hospital.
Methods: A prospective cross-sectional study was conducted over a period of 1 year. A total of 500 women attended Gynaecology OPD to evaluate the incidence of genital tuberculosis using CBNAAT (Cartridge based nucleic acid amplification test) and culture to diagnose female genital tuberculosis.
Results: Majority of the respondents (82.35%) were having primary infertility. Majority of the respondents (91.20%) were negative for genital tuberculosis and followed by positive patients for genital tuberculosis (8.80%). the sensitivity and specificity for CBNAAT (Catridge Nucleic Acid Amplification) samples 82.40% and 100% respectively while as, the sensitivity and specificity for microscopic culture (Ziehl Neelsen) were 37.84% and 98.20% respectively.
Conclusion: FGTB is a prevalent condition, particularly among infertile women. Early detection and treatment can lead to successful pregnancies. Individualization, counselling, and a multidisciplinary approach will produce greater results in the advanced stages. ART should only be provided to a select few patients after establishing that the disease is dormant, as hormonal treatment of ART can result in disease reactivation, which is highly counterproductive.
Background: Brachial plexus block is a key technique in anesthesiologist’s practice. Ropivacaine is a long acting local anaesthetic, Dexmedetomidine has been included as an adjuvant to enhance block duration.
Aim: To elucidate the effect of addition of Dexmedetomidine to Ropivacaine in ultrasound guided parasagittal supraclavicular brachial plexus approach with respect to duration of analgesia, onset and duration of sensorimotor blockade.
Methods: A randomized single blinded prospective clinical study was conducted among Forty patients of 20-50yrs, ASA Grade I and II, weighing >60kgs scheduled for elective upper limb orthopedic surgeries. Group RN received 25ml of 0.75% ropivacaine with 1ml normal saline, Group RD received 25ml of 0.75% ropivacaine with 1mcg/kg dexmedetomidine diluted to 1ml. Analgesic efficacy, sensorimotor blockade was determined.
Statistical Analysis: Demographic and hemodynamic data was analyzed using student t-test. Unpaired t-test was used to analyze onset, duration of sensorimotor blockade and analgesic duration. Results were statistically significant if p-value <0.05. P-value <0.001 was considered highly significant.
Results: Analgesic duration was prolonged in Group RD rather than Group RN (646.82 +/- 21.56min vs 484.78 +/- 15.52min). Group RD had rapid onset of sensory (7.4 +/- 1.02min vs 9.9 +/- 1.16min) and motor blockade (10.25 +/- 1.13min vs 13.28+/- 1.22min). Duration of sensory (536.62 +/- 9.61min vs 413.79 +/- 15.61min) and motor blockade (430.13 +/- 11.68min vs 298.12 +/- 15.36min) was enhanced in Group RD.
Conclusion: Adding Dexmedetomidine to Ropivacaine provided superior analgesia along with rapid onset and longer duration of sensorimotor blockade.
Background: It has been seen that volatile anaesthetics agents which are speedily eliminated with minimal breakdown should facilitate faster recovery from general anaesthesia. As compared to isoflurane-based anaesthesia, both sevoflurane and desflurane have shorter emergence times due to rapid induction and elimination.
Aim: The aim of this study is to compare and analyse the superiority of both agents, with regards to the emergence and recovery from anaesthesia, intraoperative hemodynamics, postoperative side effects and estimate the average quantity and cost-benefit of both volatile agents consumed.
Methods: Total of 100 cases above the age of 6 years undergoing tonsillectomy surgeries of ASA grade 1& 2 was included. Patients were allocated into two groups by computer-generated numbers. Group S: Anaesthesia maintained with 50/50 mixture of nitrous oxide/oxygen and sevoflurane. Group D: Anaesthesia maintained with 50/50 mixture of nitrous oxide/oxygen and desflurane. The parameters recorded were compared between the two groups using the unpaired t-test for continuous variables and P≤0.005 is deemed significant.
Results: There was no significant hemodynamic difference intraoperatively between sevoflurane and desflurane except in the desflurane group, heart rate was higher. Recovery was faster and better in Group D.
Conclusion: Postoperative recovery was better and faster and postoperative complication was lower in the desflurane group. Though the total cost of desflurane group was higher compared to sevoflurane but the use of desflurane can be justified with lesser complication, faster emergence from anaesthesia, faster shifting from PACU, lesser hospital stays, lower chance of nosocomial infection and lower cost of hospital stay.
Background: Anorectal pathology is commonly perceived it and handled in common surgical practitioners’ fistula and abscess, hemorrhoids, fissures, condyloma, and other pathological conditions. Because of the strong sensory innervations of the canal of anal, patients endure severe discomfort during anorectal surgery. It is generally most severe in the first twenty-four hours especially after excisional hemorrhoidectomy. the aim of this study is a comparison between different analgesic protocols used to relieve pain postoperative anorectal surgery.
Methods: PubMed, Embase, Medline, Science Gate, Scientific Report, Elsevier, Google Scholar, and Cochrane Evidence Based Medicine Reviews were used to conduct a review search. Review of newly released books and papers with regard to the topic, as well as manual searches (Comparison of various analgesic protocols for control of postoperative pain following anorectal surgery), was started at (May,2021). we searched the published studies from 2011 to the present date by the full text:(various analgesic protocols post anorectal surgery).
Results: Anorectal surgery is marked by excruciating discomfort after the procedure. Using the new technique during anorectal surgery as hemorrhoidectomy to avoid more excision of anal mucosa and the skin, putting the suture nearest to the dentate line and away from the internal anal sphincter, and good hemostasis to avoid the inserting of the anal pack are the most essential methods to lessen pain postoperatively regardless of the type of anorectal surgery performed or the instrument to use during it. We found more protocols using multimodality pain management for the relief of pain, topical drugs that produce direct relaxation of the internal anal sphincter, topical intervention as a pudendal nerve block, a method of surgery as surgical sphincterotomy, and technical tips to reduce pain as ligasure.
Conclusion: Multimodal pain treatment has been demonstrated to minimize pain intensity and opioid doses in various kinds of surgery.
According to the highest degree of proof, using current technological procedures and tools as a ligasure with some topical agent as GTN glyceryl trinitrate ointment provided amazing excellent alleviation of postoperative pain following anorectal surgery.
Aortoesophageal Fistula (AEF) with no prior history of cardiac disease or trauma is an uncommon but a mortal cause of Upper Gastro Intestinal Bleeding (UGIB) in children.
In pediatric patients, AEF is mainly due to a congenital cardiac or vascular anomaly or foreign body ingestion. There are surgical, endoscopic, and interventional radiological treatment options; however, definitive treatment is surgical intervention. Because of the rapid and devastating course, diagnosis and treatment decision should be made quickly.
In this article, we report a case of an 11-months-old infant who presented with hematemesis due to a primary aortoesophageal fistula. The patient was transported to the operating theater for an emergency endoscopy. He suffered massive hematemesis in the operating room and an emergency laparotomy was performed but no source of bleeding was detected. An undiagnosed AEF was found and repaired during a left thoracotomy. Despite massive volume resuscitation, the patient passed away four hours later in the PICU. The etiology of the fistula remains unknown.
Muscular dystrophies are a group of genetic diseases which cause progressive degeneration of skeletal muscle along with weakness. They are characterized by an impaired synthesis or regeneration of contractile protein. Patients with muscular dystrophies possess high preoperative risk with significant anaesthetic implications (hyperkalaemia, rhabdomyolysis, cardiovascular instability, sudden death, etc.). We herein describe the anaesthetic management of a 31yr old male who was a known case of Duchenne muscular dystrophy posted for right percutaneous nephrolithotomy (PCNL). The patient was induced and maintained with TIVA and using nitrous oxide as the only inhalational agent supplemented with USG guided Erector spinae plane block (ESPB) for post-operative analgesia. A thorough preoperative evaluation and multidisciplinary approach is essential for perioperative management of such cases.
Pierre Robin sequence is associated with a triad of micrognathia, glossoptosis and airway obstruction. Securing the airway is of utmost importance in these patients. Use of vagolytic premedication, nebulisation with lignocaine to obtund airway reflexes, use of other airway devices (SGA) and equipment to assist in different airway scenarios helps in anaesthetising the patients.
Superior vena cava (SVC) syndrome, a potentially life threatening medical emergency, occurs due to SVC obstruction caused by extrinsic compression, intrinsic stenosis or thrombosis. Malignant mediastinal tumours account for more than 80% of cases of SVC syndrome. We hereby report a case of SVC syndrome who came with clinical features suggestive of SVC syndrome with dyspnea managed and diagnosed in the Intensive Care Unit with a multidisciplinary approach