Anaesthesia

How to design a questionnaire Sandhya Yaddanapudi, LN Yaddanapudi Indian Journal of Anaesthesia 2019 63(5):335-337

Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review SB Shah, U Hariharan, R Chawla Indian Journal of Anaesthesia 2019 63(5):338-349 Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

A prospective survey on knowledge, attitude and current practices of pre-operative fasting amongst anaesthesiologists: A nationwide survey Pratibha Panjiar, Anjali Kochhar, Homay Vajifdar, Kharat Bhat Indian Journal of Anaesthesia 2019 63(5):350-355 Background and Aims: Pre-operative fasting is a routine practice to minimise the risk of pulmonary aspiration. The leading societies of anaesthesia have adopted more liberal fasting guidelines to avoid the adverse effect of prolonged fasting. This survey was conducted to assess the knowledge, attitude and current practice of fasting guidelines among Indian anaesthesiologists and to analyse the reasons for non-compliance of these guidelines. Methods: A questionnaire consisted of 11 questions was distributed via 'Survey Monkey' software to 621 anaesthesiologists who attended the annual conference of the Indian Society of Anaesthesiologists held in Ludhiana, in 2016. American Society of Anaesthesiologists (ASA) practice guidelines for fasting were the standard of assessment. Results: The response rate to the survey was 52%. Of the respondents, 69% described correctly the practice guidelines to pre-operative fasting. Only seven percent respondents were aware of the benefits of liberalised fasting. More than 2/3rd of the respondents advised fasting as per ASA guidelines during pre-anaesthetic check-up (PAC). However, only about 50% respondents confirmed that these guidelines are actually followed in their institution. Not having control on scheduling of cases in operation theatre and poor knowledge of ward nurses and surgeons were the common reasons for non-compliance of these guidelines. Twenty four percent respondents did not use routinely any drug for aspiration prophylaxis. Conclusion: Majority of the respondents were aware of the ASA fasting guidelines. However, the implementation of the guidelines and knowledge regarding benefits of liberalised fasting is poor among respondents.

Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries Priyanka P Karnik, Nandini M Dave, Harick B Shah, Ketan Kulkarni Indian Journal of Anaesthesia 2019 63(5):356-360 Background and Aims: The purpose of this study was to compare the analgesic efficacy of ultrasonography-guided transversus abdominis plane (TAP) blocks with local port site infiltration in children undergoing laparoscopic surgeries. Methods: After ethics committee approval and informed consent, 92 children aged 2–12 years posted for laparoscopic surgeries were randomly divided into Group T and Group L. Port site infiltration was performed in Group L by the surgeon at the time of port placement and end of surgery with 0.4mL/kg of 0.25% bupivacaine. Bilateral TAP block was performed in Group T after induction of anaesthesia, under ultrasonographic guidance with a Logiq E7 GE portable ultrasound unit and a linear 5–10 MHz probe. A 22G hypodermic needle and 0.4 mL/kg of 0.25% bupivacaine were used on each side for the TAP block. The parameters recorded were intraoperative haemodynamics, opioid requirements, postoperative pain scores and the need for rescue analgesia in the first 6 h postoperatively. Results: The median (interquartile range) pain scores were significantly lower in the TAP block group than the local infiltration group at 10 min [2 (0–2.5) vs 2 (3–4); P = 0.011], 30 min [1.5 (0–3) vs 3 (2–5);P < 0.001], 1 h [1.5 (0–2) vs 2 (2–3);P < 0.001] and 2 h [2 (0–2) vs 2 (1.5–2.5); P = 0.010] postoperatively. The need for intraoperative opioids and rescue analgesia was also significantly lower in the TAP block group (P < 0.001). Conclusion: TAP block is superior to local infiltration for intra- and immediate postoperative analgesia in paediatric laparoscopic surgeries.

Optimised reversal without train-of-four monitoring versus reversal using quantitative train-of-four monitoring: An equivalence study Ardyan Wardhana, Juni Kurniawaty, Yusmein Uyun Indian Journal of Anaesthesia 2019 63(5):361-367 Background and Aims: Less residual paralysis in recovery room was demonstrated when train-of-four (TOF) monitoring was applied. The aim of this study was to know whether optimisation of neostigmine reversal without TOF monitoring was equivalent to reversal using TOF monitoring. Methods: Seventy two patients, aged 18–60 years, undergoing elective surgery under general anaesthesia (sevoflurane and rocuronium) with intubation were randomised into two interventions: an optimised neostigmine reversal strategy without TOF monitoring (group A, n = 36) and a neostigmine reversal strategy using quantitative TOF monitoring (group B, n = 36). Per-protocol analysis was performed to compare incidence of residual paralysis in the recovery room between the two groups. Results: Six residual paralyses occurred in group A in the recovery room, whereas one case occurred in group B. The equivalence test showed that the 95% confidence interval of this study was outside the range of equivalence margin (15%). The absolute difference was 13.9%: standard error (SE) =0.068 (P = 0.107; 95% confidence interval (CI): 1%, 27.2%). No subjects had TOF ratio <0.70 in the recovery room. The TOF ratio in the recovery room did not differ between the two groups (mean difference: −2.58; P = 0.05; 95% CI: −5.20, 0.29). One respiratory adverse event occurred in this study. Conclusion: An optimised reversal strategy without TOF monitoring is not equivalent to a reversal strategy based on quantitative TOF monitoring. TOF monitoring should be used whenever applicable, although neostigmine is optimised.

Chronic pain following thoracotomy for lung surgeries: It's risk factors, prevalence, and impact on quality of life - A retrospective study Prachi Kar, K Durga Sudheshna, Durga Padmaja, Archana Pathy, Ramachandran Gopinath Indian Journal of Anaesthesia 2019 63(5):368-374 Background and Aims: Chronic post thoracotomy pain (CPTP) is a nagging complication and can affect quality of life (QOL). Studies conducted across globe have found a wide variability in the risk factors predisposing to chronic pain following thoracotomy. As no study on CPTP is available from India, we aim to detect the prevalence of CPTP, assess the predisposing factors implicated in its causation and study the impact of CPTP on QOL. Methods: After obtaining clearance from Institutional ethics committee, medical records of patients who underwent open posterolateral thoracotomy between January 2012 and December 2015 were reviewed. Data on perioperative variables, address, and contact number were collected from the patient records. All patients were mailed the Telugu translation of medical outcome study short form -36(MOS-SF-36) QOL questionnaire and were contacted telephonically to enquire about presence of CPTP and QOL. A univariate analysis was done to assess factors associated with CPTP and a multivariate logistic regression analysis was done subsequently to identify independent risk factors of CPTP. QOL indices were compared between those patients who suffered from CPTP and those who did not. Results: The prevalence of pain in our study was 40.86% (85/208). The factors implicated in the causation of CPTP were diabetes mellitus, preoperative pain, rib resection, and duration of chest tube drainage with odds ratio of 9.8, 2.6, 6.7, and 1.03, respectively. The health-related QOL showed poor scores in all domains in patients suffering from CPTP. Conclusion: The prevalence of CPTP was high. It significantly impacts health-related QOL.

Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial Basavaraja Ayyanagouda, Vinod Hosalli, Prableen Kaur, Uday Ambi, SY Hulkund Indian Journal of Anaesthesia 2019 63(5):375-381 Background and Aims: Hemidiaphragmatic paresis occurs in almost all patients undergoing interscalene block for proximal upper limb surgeries. This study tested hypothesis that ultrasound-guided extrafascial approach of interscalene block under nerve stimulator guidance reduces incidence of hemidiaphragmatic paresis in comparison to intrafascial approach by achieving same degree of anaesthesia and analgesia. Methods: Sixty patients undergoing proximal upper limb surgeries were randomised to receive an ultrasound-guided interscalene brachial plexus block (ISB) with the aid of nerve stimulator for surgical anaesthesia and analgesia using 20 mL 0.5% ropivacaine by extrafascial (Group E) or intrafascial (Group I) approach. The incidence of hemidiaphragmatic paresis was measured by M-mode ultrasound before and 30 min after the procedure. Secondary outcomes such as respiratory functions (forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate) were measured, and complications were recorded and compared. The statistics was obtained using SPSS Version 19. Levene's test and paired and unpaired t-test were used. P value <0.05 was considered significant. Results: The incidence of hemidiaphragmatic paresis was 17% and 46% in Group E and Group I, respectively (P < 0.0001). All other respiratory outcomes were preserved in Group E compared with Group I. Conclusion: Ultrasound-guided ISB with the aid of nerve stimulator through extrafascial approach reduces the incidence of hemidiaphragmatic paresis and also reduces respiratory function impairment when compared with intrafascial approach.

Post-operative analgesia for shoulder arthroscopic surgeries: A comparison between inter-scalene block and shoulder block Nibedita Pani, Sidharth S Routray, Soveena Pani, Soumyakanta Mallik, Santiswaroop Pattnaik, Amit Pradhan Indian Journal of Anaesthesia 2019 63(5):382-387 Background and Aims: Shoulder arthroscopic surgeries can produce intense post-operative pain. Inter-scalene block (ISB) provides good analgesia after shoulder surgery, but concerns over its associated risks have prompted the search for alternatives. Shoulder block (SHB), which includes suprascapular block along with axillary nerve (AN) block, was recently proposed as an alternative to ISB, but evidence of its efficacy is conflicting. The aim of our study was to compare SHB with ISB in shoulder surgery for post-operative analgesia. Methods: A total of 76 patients scheduled for shoulder arthroscopic surgery were equally divided into 2 groups of 38 patients each: ISB group and SHB group. Both the nerve blocks were achieved by using ultrasound and a nerve stimulator. Visual analogue scale (VAS) scores were evaluated at 1, 4, 6, 12 and 24 h post-operatively. The time to first analgesia request, total analgesic requirement for 24 h post-operatively, patient satisfaction and any complications were recorded. Results: SHB provided equivalent analgesia to ISB in terms of post-operative VAS scores. Time to first analgesic request was 6.2 ± 1.3 h in ISB group and 5.9 ± 1.2 h in SHB group, which was not statistically significant. Complications like subjective dyspnoea and weakness of arm were significantly higher in ISB group compared to SHB group. Patient satisfaction scores were also significantly higher in SHB group compared to ISB group. Conclusion: SHB is as effective as ISB for post-operative pain relief and with fewer complications due to selective blockade of suprascapular and axillary nerves.

Effect of immobilised cervical spine on oropharyngeal sealing pressure with Ambu AuraGain™ Supraglottic airway: A randomised crossover trial Duraiyarassu Uthaman, Suman Lata Gupta, Sandeep Kumar Mishra, Satyen Parida, Prasanna Udupi Bidkar, Muthupillai Senthilnathan Indian Journal of Anaesthesia 2019 63(5):388-393 Background and Aims: Ambu® AuraGain™ laryngeal airway (AuraGain) is one of the newer supraglottic airway device introduced in 2014. Cervical spine stabilisation with hard cervical collar makes insertion of supraglottic airways and tracheal intubation difficult. This study was conducted to investigate whether the presence of a cervical collar affects the oropharyngeal sealing pressure (OSP) and fibreoptic view of the glottis (Brimacombe score) in airways secured with the AuraGain. Methods: The study was a randomised crossover trial. Thirty five ASA 1-3 patients undergoing elective surgery under general anaesthesia were recruited for the study. In each patient AuraGain was inserted twice in a crossover manner once with and once without a hard cervical collar in situ, with the sequence of insertion randomised. During each insertion of AuraGain the OSP, fibreoptic view of the glottis, insertion parameters, ventilator data and complications were noted. Results: The mean OSPs in both the groups were similar with no significant difference (29.6 ± 3.7 cmH2O without collar and 30.1 ± 3.1 cmH2O with collar [P = 0.310]). The fibreoptic view of glottis was also similar in both groups. The insertion with collar was more difficult than without collar. The number of attempts for successful insertion was same in both the groups. The time taken for appropriate placement of LMA was significantly prolonged in patients with collar. Conclusions: We conclude that the Ambu AuraGain can be used to provide effective ventilation in patients whose cervical spine is immobilised with a hard cervical collar.

Development and validation of a questionnaire for a survey on perioperative fasting practices in India Pradeep A Dongare, S Bala Bhaskar, SS Harsoor, M Kalaivani, Rakesh Garg, K Sudheesh, Umesh Goneppanavar Indian Journal of Anaesthesia 2019 63(5):394-399 Background and Aims: Perioperative fasting guidelines have been published and updated to standardise practices. Hence, Indian Society of Anaesthesiologists decided to conduct a survey to assess the fasting practices and the food habits across India, which would be subsequently used for developing preoperative fasting guidelines for the Indian population. We detail and discuss herewith the content validity of the questionnaire developed for the survey. Methods: Thirty-six questions related to perioperative fasting practices were framed based on the collected evidence and relevance to regional diet and concerns. Subsequently, an information sheet was prepared and sent to 10 experts to grade each question. The responses were tabulated, and item-wise content validity index (I-CVI), scale-wise content validity index (S-CVI) and modified kappa statistic were calculated in Microsoft Excel™ sheet. Results: Seven of the 10 experts completed the assessment and grading as per the instructions provided and submitted a completed proforma. S-CVI for relevance, simplicity, clarity and ambiguity was 0.72, 0.86, 0.72 and 0.72, respectively. S-CVI/average or average congruency percentagewas 0.95, 0.97, 0.95 and 0.95 for relevance, simplicity, clarity and ambiguity, respectively. Question 2 received an I-CVI of 0.71 in terms of clarity and question 23 received an I-CVI of 0.71. They were modified as persuggestions of the experts. Conclusion: We conclude that our questionnaire designed to ascertain the preoperative fasting practices for a surveymet the content validity criteria both by qualitative and quantitative analyses.