Dr. Anurag Tewari, MD - Medical Director (Evokes LLc) Director of Education and Research (Medsurant Health)

Dr. Anurag Tewari


Medical Director (Evokes LLc) Director of Education and Research (Medsurant Health)

Ohio | United States

Main Specialties: Anesthesiology, Neurological Surgery, Pediatric Anesthesiology

Additional Specialties: Anesthesiology, Intraoperative Neurophysiological Monitoring, Deep Brain Stimulation

ORCID logohttps://orcid.org/0000-0002-4899-9533

Dr. Anurag Tewari, MD - Medical Director (Evokes LLc) Director of Education and Research (Medsurant Health)

Dr. Anurag Tewari





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315PubMed Central Citations

Intraoperative Neuromonitoring for Brachial Plexus Neurolysis During Delayed Fixation of a Clavicular Fracture Presenting as Thoracic Outlet Syndrome: A Case Report.

JBJS Case Connect 2018 Oct-Dec;8(4):e85

Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio.

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http://dx.doi.org/10.2106/JBJS.CC.18.00040DOI Listing
November 2019
88 Reads

[Medication errors in anesthesia: unacceptable or unavoidable?]

Rev Bras Anestesiol 2017 Mar - Apr;67(2):184-192. Epub 2016 Dec 27.

Drexel University College of Medicine, Anesthesiology and Perioperative Medicine, Philadelphia, PA, EUA.

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

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http://dx.doi.org/10.1016/j.bjan.2016.12.006DOI Listing
April 2019
62 Reads
6 Citations
0.415 Impact Factor

Intraoperative neurophysiological monitoring team's communiqué with anesthesia professionals.

J Anaesthesiol Clin Pharmacol 2018 Jan-Mar;34(1):84-93

Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.

Background And Aims: Intraoperative neurophysiological monitoring (IONM) is the standard of care during many spinal, vascular, and intracranial surgeries. High-quality perioperative care requires the communication and cooperation of several multidisciplinary teams. One of these multidisciplinary services is intraoperative neuromonitoring (IONM), while other teams represent anesthesia and surgery. Few studies have investigated the IONM team's objective communication with anesthesia providers. We conducted a retrospective review of IONM-related quality assurance data to identify how changes in the evoked potentials observed during the surgery were communicated within our IONM-anesthesia team and determined the resulting qualitative outcomes.

Material And Methods: Quality assurance records of 3,112 patients who underwent surgical procedures with IONM (from 2010 to 2015) were reviewed. We examined communications regarding perioperative evoked potential or electroencephalography (EEG) fluctuations that prompted neurophysiologists to alert/notify the anesthesia team to consider alteration of anesthetic depth/drug regimen or patient positioning and analyzed the outcomes of these interventions.

Results: Of the total of 1280 (41.13%) communications issued, there were 347 notifications and 11 alerts made by the neurophysiologist to the anesthesia team for various types of neuro/orthopedic surgeries. Prompt communication led to resolution of 90% of alerts and 80% of notifications after corrective measures were executed by the anesthesiologists. Notifications mainly related to limb malpositioning and extravasation of intravenous fluid.

Conclusion: Based on our institutions' protocol and algorithm for intervention during IONM-supported surgeries, our findings of resolution in alerts and notifications indicate that successful communications between the two teams could potentially lead to improved anesthetic care and patient safety.

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http://dx.doi.org/10.4103/joacp.JOACP_315_17DOI Listing
April 2018
462 Reads
1 Citation

Anesthetic and pharmacologic considerations in perioperative care of obese children.

J Clin Anesth 2018 03 21;45:39-50. Epub 2017 Dec 21.

Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. Electronic address:

Purpose: Anesthetic management of obese pediatric patients is challenging. With increasing prevalence of childhood obesity, more severely obese children with comorbidities present for surgery every day. The purpose of this review is to provide an up-to-date comprehensive narrative review on the impact of pathophysiological changes imposed by pediatric obesity on the perioperative management of obese children, especially drug dosing. This knowledge is necessary to provide safe delivery of anesthesia for severely obese children.

Source: MEDLINE and PubMed peer-reviewed manuscripts in obesity and pediatric anesthesia. When there was no information in pediatric literature, we included adult studies in our review.

Principal Findings: Defining obesity in a growing child is based on body mass index percentiles specific to age and sex. The precursors of adult obesity-related comorbidities are often seen in obese children. Respiratory and cardiovascular comorbidities increase perioperative risk in the severely obese child [>99th percentile]. Obstructive sleep apnea is highly prevalent and requires consideration of opioid sparing techniques and careful postoperative disposition. A detailed discussion on the effect of obesity on pharmacokinetics of different commonly used anesthetics and analgesics is presented, with current recommendations on dosing.

Conclusion: Optimal and safe anesthetic management of an obese child requires thoughtful pre-procedure assessment and meticulous perioperative management tailored to associated comorbidities, with heightened awareness of potential perioperative complications. There remains a need for improved guidelines for risk stratification, drug dosing and postoperative disposition in this patient population.

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http://dx.doi.org/10.1016/j.jclinane.2017.12.016DOI Listing
March 2018
69 Reads
4 Citations
1.210 Impact Factor

Intraoperative Neurophysiological Monitoring of the Laryngeal Nerves During Anterior Neck Surgery: A Review.

Ann Otol Rhinol Laryngol 2017 Jan 1;126(1):67-72. Epub 2016 Nov 1.

Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA.


Contributions to the literature on intraoperative neuro monitoring (IONM) during endocrine and head and neck surgery have increased over recent years. Organizational support for neural monitoring during surgery is becoming evident and is increasingly recognized as an adjunct to visual nerve identification. A comprehensive understanding of the role of IONM for prevention of nerve injuries is critical to maximize safety during surgery of the anterior compartment of the neck. This review will explore the potential advantages of IONM to improve the outcomes among patients undergoing anterior neck surgery.

Keywords intraoperative neurophysiological monitoring (IONM)nerve monitoringanterior neck surgerylaryngeal nerve monitoringrecurrent laryngeal nerve (RLN)superior laryngeal nerve (SLN)head and neck surgeryanterior spine surgeryvocal cord paralysisendocrine surgerythyroid and parathyroid surgery

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http://dx.doi.org/10.1177/0003489416675354DOI Listing
January 2017
47 Reads
7 Citations
1.054 Impact Factor

Insulin and the Brain: A Sweet Relationship With Intensive Care.

J Intensive Care Med 2017 Jan 12;32(1):48-58. Epub 2015 Jul 12.

Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Rome, Rome, Italy.

Background: Insulin receptors (IRs) in the brain have unique molecular features and a characteristic pattern of distribution. Their possible functions extend beyond glucose utilization. In this systematic review, we explore the interactions between insulin and the brain and its implications for anesthesiologists, critical care physicians, and other medical disciplines.

Methods: A literature search of published preclinical and clinical studies between 1978 and 2014 was conducted, yielding 5996 articles. After applying inclusion and exclusion criteria, 92 studies were selected for this systematic review.

Results: The IRs have unique molecular features, pattern of distribution, and mechanism of action. It has effects on neuronal function, metabolism, and neurotransmission. The IRs are involved in neuronal apoptosis and neurodegenerative processes.

Conclusion: In this systematic review, we present a close relationship between insulin and the brain, with discernible effects on memory, learning abilities, and motor functions. The potential therapeutic effects extend from acute brain insults such as traumatic brain injury, brain ischemia, and hemorrhage, to chronic neurodegenerative diseases such as Alzheimer and Parkinson disease. An understanding of the wider effects of insulin conveyed in this review will prompt anaesthesiologists and critical care physicians to consider its therapeutic potential and guide future studies.

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http://dx.doi.org/10.1177/0885066615594341DOI Listing
January 2017
15 Reads
13 Citations
3.262 Impact Factor

Comparison of the combination of dexmedetomidine and ketamine to propofol or propofol/sevoflurane for drug-induced sleep endoscopy in children.

Paediatr Anaesth 2016 Jul 23;26(7):742-51. Epub 2016 May 23.

Department of Anesthesia, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.

Aim: Examination of dynamic airway collapse in patients with obstructive sleep apnea (OSA) during drug-induced sleep endoscopy (DISE) can help identify the anatomic causes of airway obstruction. We hypothesized that a combination of dexmedetomidine and ketamine (Group DK) would result in fewer oxygen desaturations and a higher successful completion rate during DISE in children with OSA when compared to propofol (Group P) or sevoflurane/propofol (Group SP).

Methods: In this retrospective study, we reviewed the records of 59 children who presented for DISE between October 2013 and March 2015. Data analyzed included demographics, OSA severity, and hemodynamics (heart rate and blood pressure). The primary outcomes were airway desaturation during DISE to <85% and successful completion of DISE; these were compared between the three groups: DK, P, and SP.

Results: Preoperative polysomnography was available for 49 patients. There were significantly more patients with severe OSA in Group P as compared to the other two groups. The mean (±sd) bolus dose for ketamine, dexmedetomidine, and propofol were 2.0 ± 0.6 mg·kg(-1) , 1.9 ± 0.9 mcg·kg(-1) , and 1.8 ± 1.1 mg·kg(-1) , respectively. The mean (±sd) infusion rate for dexmedetomidine was 1.6 ± 0.7 mcg·kg(-1) ·h(-1) and for propofol was 248 ± 68 mcg·kg(-1) ·min(-1) in Group P and 192 ± 48 mcg·kg(-1) ·min(-1) in Group SP. Patients in Group DK had significantly fewer desaturations to <85% during DISE compared to Group P. Patients in Group DK had significantly more successful completion of DISE (100% Group DK, 92% Group P, and 79% Group SP) as compared to Group SP.

Conclusions: These results suggest that the described dose regimen of propofol used alone or in combination with sevoflurane appears to be associated with more oxygen desaturations and a lower rate of successful completion than a combination of dexmedetomidine and ketamine during DISE in children with OSA.

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http://dx.doi.org/10.1111/pan.12931DOI Listing
July 2016
41 Reads
17 Citations
1.742 Impact Factor

Effect of clonidine and/or fentanyl in combination with intrathecal bupivacaine for lower limb surgery.

J Anaesthesiol Clin Pharmacol 2015 Oct-Dec;31(4):485-90

Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background And Aims: Various adjuncts to local anesthetics have been used with the purpose of improving the quality of subarachnoid block. This randomized double-blind study was conducted to evaluate the efficacy of adding clonidine to bupivacaine and bupivacaine-fentanyl combination.

Material And Methods: A total of 100 patients scheduled for surgery under spinal anesthesia were randomly allocated into four groups (n = 25 each) to receive intrathecal bupivacaine 7.5 mg plus normal saline 0.5 ml (group BS), intrathecal bupivacaine 7.5 mg, and fentanyl 25 ?g (group BF), intrathecal bupivacaine 7.5 mg and clonidine 75 ?g (group BC), intrathecal bupivacaine 7.5 mg, clonidine 37.5 ?g, and fentanyl 12.5 ?g (group BCF). The time of onset and duration of sensory block, highest dermatome level of sensory block, time of onset of motor block, time to complete motor block recovery and duration of spinal anesthesia, intraoperative and postoperative hemodynamics and side effects if any were recorded. VAS, total number of patients who were administered supplemental analgesic in each group and the total amount of supplemental analgesic administered in the next 24 h was quantified and documented in all the groups.

Results: The time of onset of sensory block (min) in groups BS, BC, BCF, and BF was 10.80 ± 2.26, 10.20 ± 1.00, 10.00 ± 0.00, and 13.80 ± 2.61 respectively, thus onset of sensory block was significantly earlier in groups BC and BCF. Similarly, onset of motor block was also quicker in groups BC and BCF. Time of requirement of supplemental analgesia was 135.20 ± 12.70 min, 199.2 ± 21.92 min, 209.80 ± 26.32 min, and 208.00 ± 26.58 min in groups BS, BF, BC, and BCF respectively. Intraoperative and postoperative changes in heart rate, mean arterial blood pressure, oxygen saturation, and respiratory rate were comparable. Sedation scores were significantly higher in group BC. Pruritus was only observed in groups BF and BCF. Mean nausea vomiting scores were comparable in all groups.

Conclusion: We conclude that the addition of clonidine in doses of 75 ?g and 37.5 ?g to low-dose bupivacaine and bupivacaine-fentanyl prolongs the sensory and motor block while increasing the duration of postoperative analgesia without significant side-effects.

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http://dx.doi.org/10.4103/0970-9185.169069DOI Listing
December 2015
19 Reads
5 Citations

Effect of intravenous esmolol on analgesic requirements in laparoscopic cholecystectomy.

J Anaesthesiol Clin Pharmacol 2015 Jul-Sep;31(3):375-9

Department of Anaesthesiology, Fortis Hospital, Gurgaon, India.

Background And Aims: Perioperative beta blockers are also being advocated for modulation of acute pain and reduction of intraoperative anesthetic requirements. This study evaluated the effect of perioperative use of esmolol, an ultra short acting beta blocker, on anesthesia and modulation of post operative pain in patients of laproscopic cholecystectomy.

Material And Methods: Sixty adult ASA I & II grade patients of either sex, scheduled for laparoscopic cholecystectomy under general anesthesia, were enrolled in the study. The patients were randomly allocated to one of the two groups E or C according to computer generated numbers. Group E- Patients who received loading dose of injection esmolol 0.5 mg/kg in 30 ml isotonic saline, before induction of anesthesia, followed by an IV infusion of esmolol 0.05 ?g/kg/min till the completion of surgery and Group C- Patients who received 30 ml of isotonic saline as loading dose and continuous infusion of isotonic saline at the same rate as the esmolol group till the completion of surgery.

Results: The baseline MAP at 0 minute was almost similar in both the groups. At 8th minute (time of intubation), MAP increased significantly in group C as compared to group E and remained higher than group E till the end of procedure. Intraoperatively, 16.67% of patients in group C showed somatic signs as compared to none in group E. The difference was statistically significant. 73.33% of patients in group C required additional doses of Inj. Fentanyl as compared to 6.67% in group E.

Conclusions: We conclude that intravenous esmolol influences the analgesic requirements both intraoperatively as well as postoperatively by modulation of the sympathetic component of the pain i.e. heart rate and blood pressure.

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http://dx.doi.org/10.4103/0970-9185.161676DOI Listing
September 2015
73 Reads
8 Citations

Awake craniotomy: A qualitative review and future challenges.

Saudi J Anaesth 2014 Oct;8(4):529-39

Professor and Vice Chair (Research) Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, USA.

Neurosurgery in awake patients incorporates newer technologies that require the anesthesiologists to update their skills and evolve their methodologies. They need effective communication skills and knowledge of selecting the right anesthetic drugs to ensure adequate analgesia, akinesia, along with patient satisfaction with the anesthetic conduct throughout the procedure. The challenge of providing adequate anesthetic care to an awake patient for intracranial surgery requires more than routine vigilance about anesthetic management.

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http://dx.doi.org/10.4103/1658-354X.140890DOI Listing
October 2014
43 Reads
15 Citations

Anesthetic challenges for deep brain stimulation: a systematic approach.

N Am J Med Sci 2014 Aug;6(8):359-69

Department of Neuroanaesthesia, Cleveland Clinic Foundation, Ohio, USA.

Ablative intracranial surgery for Parkinson's disease has advanced to embedding electrodes into precise areas of the basal ganglia. Electrode implantation surgery, referred to as deep brain stimulation (DBS), is preferred in view of its reversibility, adjustability, and capability to be safely performed bilaterally. DBS is been increasingly used for other movement disorders, intractable tremors epilepsy, and sometimes chronic pain. Anesthesiologists need to amalgamate the knowledge of neuroanatomical structures and surgical techniques involved in placement of microelectrodes in defined cerebral target areas. Perioperative verbal communication with the patient during the procedure is quintessential and may attenuate the need for pharmacological agents. This review will endeavor to assimilate the present knowledge regarding the patient selection, available/practiced anesthesia regimens, and perioperative complications after our thorough search for literature published between 1991 and 2013.

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http://dx.doi.org/10.4103/1947-2714.139281DOI Listing
August 2014
73 Reads
26 Citations

Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery?

J Anaesthesiol Clin Pharmacol 2014 Jul;30(3):313-5

Deparment of Anaesthesiology, Dayanand Medical College, Ludhiana, Punjab, India.

Pre-operative echocardiography has been utilized in perioperative period for decades in patients with active cardiac conditions scheduled for non-cardiac surgery to aid in risk stratification. Echocardiography enables direct visualization of the various chambers of the heart, valves, adjacent structures and major connecting vessels like pulmonary artery and aorta. In the majority of patients, trans-thoracic echocardiography (TTE) has been used for screening with few exceptional clinical conditions such as endocarditis, severe calcific aortic stenosis, suspected intra cardiac thrombus etc., where trans esophageal echocardiography has been performed pre-operatively. TTE as a cardiac imaging offers safety, portability and repeatability in addition to high quality imaging. The pertinent question raised is “Is pre-operative resting or stress TTE evidence based?” This editorial scrutinizes if the pre-operative echocardiography utilization is based on the guidelines or individualistic expert opinion.

Cardiac disease is a potential source of perioperative complications in any non-cardiac surgery. Perioperative physicians and anesthesiologists realize the importance of risk stratification by evaluation of the nature and severity of cardiac disease prior to anesthesia. Major non-cardiac surgeries with prolonged hemodynamic and cardiac stress are associated with major cardiac complications (between 2.0% and 3.5%) and mortality (between 0.5% and 1.5%).[] This difference in the incidences is mainly explained by patient selection and the endpoints defined for myocardial infarction. The morbidity and mortality depends on various factors like the nature of the patient's pre-existing clinical condition (e.g., ischemic heart disease [IHD], left ventricular [LV] dysfunction and significant valvular heart disorders), its severity and the type of surgical procedure being performed.

Currently, British Society of Echocardiography (BSE) as well as American Society of Echocardiography (ASE) is establishing guidelines for Echocardiography in the pre-operative assessment with periodic revision. BSE recommends TTE in patients with documented IHD with reduced functional capacity (<4 metabolic equivalents [METS]), unexplained shortness of breath in the absence of clinical signs of heart failure, if electrocardiogram (ECG) and/or chest X-ray are abnormal, murmur in the presence of cardiac or respiratory symptoms, murmur in an asymptomatic individual in whom clinical features or other investigation suggest severe structural heart disease. TTE should not be used just to repeat the assessment of previous echocardiogram with no intervening change in clinical status within 12 months.[] ASE has no clearly defined indication for resting echocardiogram, except for high-risk vascular procedures in patients with reduced functional capacity (<4 METS) where only stress echocardiography is recommended.[]

Clinical evidence showing appropriate utilization of pre-operative echocardiography in non-cardiac surgery is scanty. The resting echocardiography has relatively weak evidence in predicting post-operative outcomes even in patients with active cardiac conditions and poor functional status.[] American Heart Association (AHA) guidelines for perioperative cardiac risk stratification state that cardiac evaluation in any form should help the perioperative care providers by doing more than just giving medical clearance for the surgery.[] It should rather fortify informed clinical judgment in terms of existing cardiac status, recommendations for managing of cardiac issues and collaborating with perioperative anesthesiology team for management that might affect short or long-term cardiac outcomes.

Few prospective and retrospective studies validate a positive correlation between LV dysfunction and post-operative morbidity or mortality.[,] Any degree of LV dysfunction has been found to be associated with perioperative myocardial infarction or cardiogenic pulmonary edema (odds ratio [OR] 2.1, 95% of the confidence interval 1-4.5, P < 0.05).[] This finding of predictive post-operative events had a very poor sensitivity (43%) and predictive value (13%) but at the same time had significant specificity (76%) and negative predictive value (94%). It was found that the overall greatest risk of complications was associated with ejection fraction <35%.[] Hence it makes cardiac risk stratification pertinent pre-operatively. Flu et al. in their prospective trial on more than 1000 vascular surgical patients found 40% asymptomatic LV failure of which majority had isolated diastolic dysfunction and this doubled the 30 day cardiovascular morbidity and quadrupled the long-term mortality more in open than endovascular procedures. They suggested including TTE routinely for asymptomatic open vascular procedures in the pre-operative risk stratification.[] Technology advancements with newer echocardiography features such as strain analysis and 3D echo helps to quantify diastolic function more precisely and thereby improve overall perioperative management.[,]

A meta-analysis of 25 echocardiography and 50 nuclear scanning in non-cardiac surgical patients, found out superior likelihood ratio (true positive to false positive rate) with stress echocardiography compared with thallium scanning (4.09 vs. 1.83) in predicting post-operative outcomes.[] In terms of cost effective analysis, Kertai et al.[] demonstrated a positive trend for dobutamine stress echo (DSE) to have better diagnostic performance than ambulatory ECG, exercise ECG, radionuclide ventriculography, myocardial perfusion scintigraphy and dipyridamole stress echo, in their meta-analysis of 8119 vascular patients. Mantha et al. suggested DSE is not an ideal test in predicting post-operative outcomes as suggested by the Kertai et al.[] by proposing two stage hierarchic model to combine information about likelihood ratio separately for positive and negative outcomes.[]

It has been seen that pre-operative echocardiography used based on the international guidelines in the targeted population influences perioperative management including the anesthesia technique. This information is predominantly from expert opinion and retrospective review.[] Unfortunately, till date there exists no objective evidence in terms of randomized control trial on utilization of pre-operative echocardiography on the perioperative outcome. In a large population based retrospective cohort review 2,64,823 patients were analyzed and echocardiography performed in 15.1% of these patients. They found the pre-operative echocardiography was not associated with improved outcomes or shorter hospital stay in major non-cardiac surgery, casting doubts on proper utilization of the very common pre-operative test.[]

Is there a better way to analyze if pre-operative echocardiography improves post-operative outcome? May be yes, with a large number of prospective cohort studies or with randomized control trials, but these studies are not devoid of their own inherent limitations. Cohort studies would be subjected to selection and information bias along with many confounding factors like severity of illness. Blinding is a pertinent concern even with a randomized trial leading to the observer and performance bias. Is there a way to optimize the pre-operative condition such as altering medications, fluid therapy etc. based on the echocardiography to assess the outcome? One should realize the ethical issues for the control group in these interventional trials. Thus, study designs in various forms for assessing the relationship between pre-operative echocardiography and post-operative outcome may have major clinical and logistical concerns.

Since multiple issues may be encountered while performing clinical trial on the utilization of the pre-operative echocardiography, perhaps a web-based survey may answer these issues. In a web-based survey on the simulated patients, Vigoda et al. found out that only 40% of responders follow the recommendations for patients without active cardiac conditions but 82% of responders followed the guidelines when faced with simulated patients with active cardiac issues.[] This observation casts doubt on the recommendations advised by AHA/American College of Cardiology including utilizing echocardiography. We (SS) are currently doing web based questionnaire study on the pre-operative utilization of TTE in non-cardiac and non-vascular simulated patients with varying cardiac conditions. Participants are asked to report in terms of anesthetic induction, invasive lines, cardiac output monitoring, planned post-operative care before and after reading the echocardiography. However, these types of surveys are handicapped due to a large selection prejudice.

Evolution of computer technology aids miniature of versatile echo probes such as Vscan thus facilitating bedside availability including pre-operative clinic. Authors are expecting significant progression in the usage of TTE for limited examination on ventricular function and assessment of the valves and major vessels as proposed by BSE and cardiac society of Australia and New Zealand, which has also suggested inclusion of hemodynamic assessment in addition to diagnostic screening.[] Canty and Royse audited echocardiography as point of care in the pre-operative clinic.[] Although there was no available data for change in the outcome, they realized major impact in these techniques in terms of newly diagnosed end stage cardiac disease, change in the anesthetic and hemodynamic management and avoiding postponement of the surgery.

In conclusion, appropriate utilization of the pre-operative echocardiography to improve over all perioperative outcomes is a challenging task, encountered by every perioperative physician during pre-operative assessment. With recent increase in echocardiography training amongst anesthesiologists, we envisage increased integration with conventional anesthetic assessment. Utilization of pre-operative echocardiography can be extended to intraoperative as well as post-operative period as a new standard in monitoring. Cardiologists, cardiac anesthesiologists and anesthesiologists need to formulate a new strategy for utilizing echocardiography in an assessment paradigm in peri-operative risk stratification of patients afflicted with cardiac pathology.

Adequate training for use is essential as these imaging technologies require both skills in acquisition of diagnostic quality images, as well as knowledge and experience in their interpretation. Every perioperative physician needs to understand that it might not affect outcomes directly though it influences perioperative anaesthetic and medical management, indirectly.


1. Poldermans D, Bax JJ, Boersma E, De Hert S, et al. Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery, European Society of Cardiology (ESC) Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J. 2009;30:2769–812. [PubMed]
2. British Society of Echocardiography. Clinical indications for echocardiography. [Last accessed on April 2013]. Available from:http://www.cdn1.cache.twofourdigitalnet/u/bsecho/media/10465/clinical_indications_forechocardiography.pdf .
3. American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011;24:229–67. [PubMed]
4. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007;116:1971–96.[PubMed]
5. Fleisher LA American College of Cardiology/American Heart Association. Cardiac risk stratification for noncardiac surgery: Update from the American College of Cardiology/American Heart Association 2007 guidelines. Cleve Clin J Med. 2009;76(Suppl 4):S9–15. [PubMed]
6. Pedersen T, Kelbaek H, Munck O. Cardiopulmonary complications in high-risk surgical patients: The value of preoperative radionuclide cardiography. Acta Anaesthesiol Scand. 1990;34:183–9. [PubMed]
7. Poldermans D, Fioretti PM, Forster T, Thomson IR, Boersma E, el-Said EM, et al. Dobutamine stress echocardiography for assessment of perioperative cardiac risk in patients undergoing major vascular surgery. Circulation. 1993;87:1506–12. [PubMed]
8. Rohde LE, Polanczyk CA, Goldman L, Cook EF, Lee RT, Lee TH. Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery. Am J Cardiol. 2001;87:505–9. [PubMed]
9. Halm EA, Browner WS, Tubau JF, Tateo IM, Mangano DT. Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Study of Perioperative Ischemia Research Group. Ann Intern Med. 1996;125:433–41. [PubMed]
10. Flu WJ, van Kuijk JP, Hoeks SE, Kuiper R, Schouten O, Goei D, et al. Prognostic implications of asymptomatic left ventricular dysfunction in patients undergoing vascular surgery. Anesthesiology. 2010;112:1316–24. [PubMed]
11. Hoffmann R, Altiok E, Nowak B, Kühl H, Kaiser HJ, Buell U, et al. Strain rate analysis allows detection of differences in diastolic function between viable and nonviable myocardial segments. J Am Soc Echocardiogr. 2005;18:330–5. [PubMed]
12. Monaghan MJ. Role of real time 3D echocardiography in evaluating the left ventricle. Heart. 2006;92:131–6. [PMC free article] [PubMed]
13. Beattie WS, Abdelnaem E, Wijeysundera DN, Buckley DN. A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging. Anesth Analg. 2006;102:8–16.[PubMed]
14. Kertai MD, Boersma E, Bax JJ, Heijenbrok-Kal MH, Hunink MG, L’talien GJ, et al. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart. 2003;89:1327–34. [PMC free article] [PubMed]
15. Mantha S, Mascha E, Foss JF, Ellis JE, Roizen MF. Meta-analysis of diagnositic tests: Two stage hierarchic model for combining likelihood ratios for positive and negative test results. Anesth Analg. 2007;104:S99.
16. O’Neill S, Danjoux G. Targeted pre-operative echocardiography using international guidelines may influence patients’ management and outcome Anaesthesia . 2007;62:426–7.
17. Wijeysundera DN, Beattie WS, Karkouti K, Neuman MD, Austin PC, Laupacis A. Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: Population based cohort study. BMJ. 2011;342:d3695. [PMC free article] [PubMed]
18. Vigoda MM, Behrens V, Miljkovic N, Arheart KL, Lubarsky DA, Dutton RP. Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines. J Clin Anesth. 2012;24:446–55. [PubMed]
19. Canty DJ, Royse CF, Kilpatrick D, Bowman L, Royse AG. The impact of focused transthoracic echocardiography in the pre-operative clinic. Anaesthesia. 2012;67:618–25. [PubMed]
20. Canty DJ, Royse CF. Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Br J Anaesth. 2009;103:352–8. [PubMed]

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http://dx.doi.org/10.4103/0970-9185.137258DOI Listing
July 2014
101 Reads
5 Citations

A comparative study evaluating the prophylactic efficacy of oral clonidine and tramadol for perioperative shivering in geriatric patients undergoing transurethral resection of prostate.

J Anaesthesiol Clin Pharmacol 2014 Jul;30(3):340-4

Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background And Aims: Perioperative shivering, in geriatric patients undergoing urological surgery under central neuraxial blockade is a common complication. Prophylactic measures to reduce shivering are quintessential to decrease the morbidity and mortality. Believing that oral formulation will bring down the cost of treatment, we decided to compare the efficacy of oral clonidine and tramadol, as premedication, in prevention of shivering in patients undergoing transurethral resection of prostate (TURP) under spinal anesthesia in a prospective and double-blind manner.

Materials And Methods: The patients were randomly allocated into three groups (40 patients each). Group I received oral clonidine 150 ?g, Group II received oral tramadol 50 mg, while Group III received a placebo. Number of patients having shivering, their grades and duration, hemodynamic changes, and side-effects in the form of sedation were recorded. Data were analyzed using analysis of variance, Student's t-test, Z test as and when appropriate.

Results: In group I and II, 38 patients (95%) and 37 patients (92.5%) did not shiver, respectively. Although in the group III, 24 patients (60%) exhibited no grade of shivering, the shivering was of significantly severe intensity and lasted for a longer duration. No, clinically significant collateral effects were observed in patients who were administered clonidine or tramadol.

Conclusions: Oral clonidine and tramadol were comparable in respect to their effect in decreasing the incidence, intensity, and duration of shivering when used prophylactically in patients who underwent TURP under subarachnoid blockade.

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http://dx.doi.org/10.4103/0970-9185.137264DOI Listing
July 2014
169 Reads
11 Citations

Antioxidants: The new frontier for translational research in cerebroprotection.

J Anaesthesiol Clin Pharmacol 2014 Apr;30(2):160-71

Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Rome, Rome, Italy.

It is important for the anesthesiologist to understand the etiology of free radical damage and how free-radical scavengers attenuate this, so that this knowledge can be applied to diverse neuro-pathological conditions. This review will concentrate on the role of reactive species of oxygen in the pathophysiology of organ dysfunction, specifically sub arachnoid hemorrhage (SAH), traumatic brain injury (TBI) as well as global central nervous system (CNS) hypoxic, ischemic and reperfusion states. We enumerate potential therapeutic modalities that are been currently investigated and of interest for future trials. Antioxidants are perhaps the next frontier of translational research, especially in neuro-anesthesiology.

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http://dx.doi.org/10.4103/0970-9185.130001DOI Listing
April 2014
61 Reads
30 Citations

VEINROM: A possible solution for erroneous intravenous drug administration.

J Anaesthesiol Clin Pharmacol 2014 Apr;30(2):263-6

Department of Bioengineering and Biomedical Engineering, University of Iowa, IA, USA.

Erroneous intravenous drug administration has a high probability of causing substantial financial consequences along with patient morbidity or mortality. Anesthesiologists and hospital administrators need to be cognizant of the problem. National and international anesthesiology bodies should be involved with the medical device manufacturing industry to alleviate this long standing enigma. We propose our concept Vassopressors, Emergency drugs, Induction agents, Reversal agents, Opioids and Miscellaneous (VEINROM) as a conceivable solution to this paradox.

The problem

We believe the key instigator of erroneous drug administration (EDA) is the adaptation of the universal Leur locking mechanism to intravenous drug delivery systems. All syringe ports on the fluid delivery system are able to interlock with any syringe nozzle by nature of the Leur design. This inherently provides the opportunity for an adverse event to occur especially in a situation of high duress.

Our solution

The development of a fluid intake manifold used for multiple intravenous drug delivery featuring specially designed syringe ports, which can only interlock with a predispositioned syringe. Hence we designed VEINROM.


An acronym which stands for Vassopressors, Emergency drugs, Induction agents, Reversal agents, Opioids, and Miscellaneous drugs. These seven categories encompass most of the intravenous drugs that are used frequently in anesthesia. The envisioned fluid delivery system, which we named VEINROM, shall harbor one syringe port for each of the seven drug class categories that are most commonly used drugs in anesthesiology and critical care.

Deterrents to prevent erroneous drug administration (EDA)

VEINROM is a unique drug delivery manifold and syringe assembly which has incorporated mechanical and electronic mechanisms that will make it very difficult to administer wrong drugs intravenously. These defense mechanisms are:

  1. VEINROM manifold: The fluid intake manifold shall have seven differently designed syringe ports which feature a lock-and-key interaction between the port and designated syringe. Through the improvised VEINROM lock-and-key mechanism, it is impossible to incorrectly administer one category of drug into any one of the other six ports. Incompatible syringes will not be able to enter the manifold ports, and thus the drug administrator will not be able to inject the drug [Figures ?[Figures11 and ?and22].
  2. VEINROM syringes: Preloaded syringes will further decrease the potential for human error when administering drugs instead of loading-labeling them perioperatively. The VEINROM syringes shall have following features
    • Specific male ports: Each syringe shall have uniquely designed tips that can only mate with their destined manifold ports [Figure 3].
    • Engraved labels: Acting as a visual reinforcement to the user, each syringe shall display what category it belongs to by being boldly engraved on to the syringe body, obviating the need for colored sticker labeling [Figure 3].
    • Color coded: Syringe pistons and bodies for each drug class shall be color coded per American Society for Testing and Materials standards. This feature promotes visual memory and obliterates the need to manually label the syringes.
    • Texture coded: Each syringe class shall have a specific external texture embedded within the syringe body, producing tactile stimuli which generates neurogenic memory rendering identification of syringes easier [Figure 3].
    • Scan able bar codes: Each syringe shall have a barcode at its distal end that identifies drug class and lot number. Before delivery, the drug administrator swipes the syringe in front of a barcode scanner which in turn enters the drug information and delivery time into patient specific electronic medical records [Figure 3].
    • Inherent electronic data collection: VEINROM shall incorporate a medical electrical system designed to identify and register the connection of a syringe to any port, thereby logging the port ID and time of delivery into the patient's medical records. Not only does this improve patient data logging practices, it implements practitioner accountability.


    A time for change in the field of anesthesiology is inevitable. As indicated previously, medical errors are prevalent within this field and current safety protocol has not been changed in over 60 years. Not only will the implementation of a device like VEINROM increase practitioner's accountability, update patient records in real time and improve the overall health care system, it will most importantly save lives. It is an obligation for standards committee members and medical device manufacturers to implement safeguards that prevent human error. The Institute of medicine estimates that at least 1.5 million Americans are injured each year as a result of EDA, costing the US healthcare field more than 3.5 billion USD annually. The global health care system is in the process of implementing improved standards and regulations that require syringes to be pre-filled by outside pharmacies rather than medical practitioners during the pre-operation period. To support this claim, Transparency Market Research estimates that the global pre-filled syringe market will grow by a 13.3% compound annual rate, reaching a market value of 4.98 billion USD by the year 2019[]. These trends point to an estimated 3 billion USD in profit opportunity within the next 7 years.

    It is our moral and Hippocratic duty to continue risk management processes that decrease the probability of iatrogenic morbidities. For a device such as VEINROM, the time is right and future, bright. Medical device innovation is continuous and safety measures are continually updated. VEINROM is the next step in making the art of anesthesia safer for all involved.

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    http://dx.doi.org/10.4103/0970-9185.130055DOI Listing
    April 2014
    110 Reads
    3 Citations

    Use of oral tramadol to prevent perianesthetic shivering in patients undergoing transurethral resection of prostate under subarachnoid blockade.

    Saudi J Anaesth 2014 Jan;8(1):11-6

    Department of Anesthesiology, Dayanand Medical College, Ludhiana, India.

    Context: Under regional anesthesia, geriatric patients are prone to shivering induced perioperative complications that Anesthesiologists should prevent rather than treat.

    Aim: We investigated the prophylactic efficacy of oral tramadol 50 mg to prevent the perioperative shivering after transurethral resection of prostate (TURP) surgery under subarachnoid blockade (SAB). Shivering is usually overlooked in patients undergoing urological surgery under spinal anesthesia and may result in morbidity, prolonged hospital stay and increased financial burden. Use of prophylactic measures to reduce shivering in geriatric patients who undergo urological procedures could circumvent this. Oral formulation of tramadol is a universally available cost-effective drug with the minimal side-effects.

    Settings And Design: Prospective, randomized, double-blinded, placebo-controlled study.

    Patients And Methods: A total of 80 patients who were scheduled for TURP surgery under subarachnoid block were randomly selected. Group I and II (n = 40 each) received oral tramadol 50 mg and placebo tablet respectively. After achieving subarachnoid block, the shivering, body temperature (tympanic membrane, axillary and forehead), hemodynamic parameters and arterial saturation were recorded at regular intervals.

    Statistical Analysis Used: T-test, analysis of variance test, Z-test and Fisher exact test were utilized while Statistical Product and Service Solutions, IBM, Chicago (SPSS statistics (version 16.0)), software was used for analysis.

    Results: Incidence of shivering was significantly less in patients who received tramadol (7.5% vs. 40%; P < 0.01). The use of tramadol was associated with clinically inconsequential side-effects.

    Conclusion: We conclude that the use of oral tramadol 50 mg is effective as a prophylactic agent to reduce the incidence, severity and duration of perioperative shivering in patients undergoing TURP surgery under SAB.

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    http://dx.doi.org/10.4103/1658-354X.125898DOI Listing
    January 2014
    6 Reads
    4 Citations

    A comparison of intrathecal dexmedetomidine, clonidine, and fentanyl as adjuvants to hyperbaric bupivacaine for lower limb surgery: A double blind controlled study.

    J Anaesthesiol Clin Pharmacol 2013 Oct;29(4):496-502

    Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

    Background: Various adjuvants are being used with local anesthetics for prolongation of intraoperative and postoperative analgesia. Dexmedetomidine, the highly selective 2 adrenergic agonist is a new neuraxial adjuvant gaining popularity.

    Settings And Design: The study was conducted in prospective, double blind manner. It included 120 American Society of Anesthesiology (ASA) class I and II patients undergoing lower limb surgery under spinal anesthesia after approval from hospital ethics committee with written and informed consent of patients.

    Materials And Methods: The patients were randomly allocated into four groups (30 patients each). Group BS received 12.5 mg hyperbaric bupivacaine with normal saline, group BF received 12.5 mg bupivacaine with 25 g fentanyl, group BC received 12.5 mg of bupivacaine supplemented 30 g clonidine, and group BD received 12.5 mg bupivacaine plus 5 g dexmedetomidine. The onset time to reach peak sensory and motor level, the regression time of sensory and motor block, hemodynamic changes, and side effects were recorded.

    Results: Patients in Group BD had significantly longer sensory and motor block times than patients in Groups BC, BF, and BS with Groups BC and BF having comparable duration of sensory and motor block. The mean time of two segment sensory block regression was 147 ± 21 min in Group BD, 117 ± 22 in Group BC, 119 ± 23 in Group BF, and 102 ± 17 in Group BS (P > 0.0001). The regression time of motor block to reach modified Bromage zero (0) was 275 ± 25, 199 ± 26, 196 ± 27, 161 ± 20 in Group BD, BC, BF, and BS, respectively (P > 0.0001). The onset times to reach T8 dermatome and modified Bromage 3 motor block were not significantly different between the groups. Dexmedetomidine group showed significantly less and delayed requirement of rescue analgesic.

    Conclusions: Intrathecal dexmedetomidine is associated with prolonged motor and sensory block, hemodynamic stability, and reduced demand of rescue analgesics in 24 h as compared to clonidine, fentanyl, or lone bupivacaine.

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    http://dx.doi.org/10.4103/0970-9185.119151DOI Listing
    October 2013
    17 Reads
    79 Citations

    Critical incident reporting: Why should we bother?

    J Anaesthesiol Clin Pharmacol 2013 Apr;29(2):147-8

    Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

    Quality assurance, self-reporting, near misses

    One of the key features of the patient safety ‘movement’ is the belief that safety can be improved by learning from incidents and near misses, rather than pretending they have not happened.[] Critical incident investigation was first used in the 1940s as a technique to improve safety and performance among military pilots.[] This focus on critical incidents enabled the researchers to investigate the differences between behaviors that led to success and those that led to failure, and to derive conclusions about how people should be encouraged to act, especially by redesigning their work environments to produce more desirable outcomes.

    In 1978, Cooper and colleagues described a ‘modified critical incident technique’ to interview anesthesiologists and obtain descriptions of preventable incidents.[] It is now common for departments of anesthesia to record and discuss adverse incidents and near misses with a view to learning from the problems encountered and preventing their re-occurrence[] in their mortality and morbidity (M and M) meetings. However, the knowledge of, and learning from, these incidents tends to be shared only at a local level, and any ensuing improvement in patient safety thus remains constrained locally. These do usher in a change of work settings, with many individual anesthesiologists citing such meetings to modification in their work practices. At departmental levels such meetings do bring in change in procurement policies of monitoring equipments or drugs after an unfortunate critical incident.[] Thus it becomes paramount in continuous quality improvement of work ethics, especially teamwork, communications, and organizational culture.

    Several countries are in the process of developing their national critical incident reporting systems. In Europe an online anesthesia-specific reporting system was initiated in Switzerland since the mid-1990s[] and, more recently, the German Society of Anesthesiology and Intensive Care set up its own Patient Safety Optimization System.[] The Australian Incident Monitoring Study began in the late 1980s as an anesthesia-specific venture and later culminated as the Australian Patient Safety Foundation which extended incident reporting beyond anesthesia.[] Patient Safety Database of Denmark allows uploading of incidents but it is not anesthesia-specific.[] The UK National Patient Safety Agency (NPSA), established in 2001, set up a Reporting and Learning System[] (RLS) to collect and learn from adverse incidents and near misses reported throughout the National Health Service in England and Wales. Various pertinent publications,[,] including an Australian manual for the management of critical situations in anesthesia[] are available for reference, but huge lacunae still persist. This warrants, further work on appreciating methodology to learn from incidents, wider propagation of such ideas, and measuring impact on standards, quality, research, and patient outcomes.

    Although developing countries are slowly starting to implement critical care reporting[,] to improve their patient care, it is time their national bodies endorsed critical incident reporting at state and national levels and developed a culture where incident reporting is a routine occurrence. Our community has to be convinced that it will lead an overall improvement in patient care. Turning the reported incidents into new learning points will expedite changes in clinical management, thus optimizing patient safety. The success of a critical incident reporting system will be contingent upon the enthusiasm among the anesthesiologists and the quality of incident reporting. Anesthesiologists anticipate seeing the incidents they report culminating in increased patient safety, and use of less risky techniques. Organizations will then need to ensure that they deliver on these expectations.

    An imperative facet of any reporting system is continuing feedback, which is ideal in keeping anesthesiologists involved.[] They have to be persuaded that their reporting of critical incidents would not be a wasted effort by showing functional improvements in patient safety. The realization of a critical incident reporting system hinges on it being user-friendly, intuitive, unambiguous[] and amenable to regular analysis, such that any learning points are promptly fed back to those concerned. The feedback or follow-up should be quick and not tenuous. It is important that the policy in place unmistakably designates ‘fair blame’ and ‘no disciplinary action’ on incident reporting with an assurance that they will be at no risk for retribution, unlike the aviation industry where not reporting is considered a matter for possible disciplinary action. The policy should have commitment to professional standards, training, curriculum, examinations, guidelines and recommendations, national audits, and research. The governing body should guarantee that the conveyed incidents are handled by professionals and independent experts, initiate speedy and suitable actions, reports, and recommendations, which can be circulated widely using prevailing channels (emails, websites, journals, and newsletters) within these organizations.

    An article in this issue,[] showed significant deficiencies in the adequacy of perioperative charting of records after analysis of 850 patients in an Australasia, especially in emergency and patients operated under regional anesthesia. Audits like these ensure uniformity, adequacy and accuracy in reporting. A detailed analysis of all the reported incidents and deficiencies in reporting should be generated every quarter or semi-annually and summary reports should be disseminated to all anesthesiologists and relevant specialist societies. Priority should be given to incidents of ‘severe harm’ or ‘death’ which can be scrutinized rapidly and, if considered appropriate, to even issue nation-wide rapid alerts. Guidelines should be formulated after audits, root cause analyses and modifiable circumstances surrounding recurrent incidents. Recommendation to professional bodies and specialist societies should be developed and research promoted in the areas of concern. Liaison with the professional bodies to modify training, education, professional standards, and curriculum is needed on priority, thus bringing greater integrity to our specialty. In our Department of Anesthesiology and Perioperative Medicine at Drexel University College of Medicine in Philadelphia, we have instituted mandatory critical care reporting and it is taken up on a monthly basis as cases in Morbidity and Mortality (M and M) Quality Assurance meetings. During these meetings incidents are analyzed and any changes, if required, in preexisting perioperative policies are contemplated to avoid repeat of the same incident. The major question to be addressed is: Was it ‘human error’, ‘organizational accident’ or ‘unsafe act’? Unsafe acts are divided into unintended action and intended action. Active errors of unintended action are either ‘slip’ (attention failure) or lapse (memory failure). Intended action can be ‘active’ as in ‘mistake’ which may further be rule- or knowledge-based. Intended action that is a ‘violation’ is the last group; ‘routine’, ‘optimizing’ and ‘necessary’ violations all fall in this subgroup.

    The transparent non-punitive collaboration will harness the passion of the profession for reporting threats to patient safety and acting to eliminate them. In conclusion, it will not be too optimistic to speculate that, as in many other areas, specialty-specific national incident reporting in anesthesia will be a model for future ingenuities in other specialties.

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    http://dx.doi.org/10.4103/0970-9185.111648DOI Listing
    April 2013
    26 Reads
    6 Citations

    The fatigued anesthesiologist: A threat to patient safety?

    J Anaesthesiol Clin Pharmacol 2013 Apr;29(2):151-9

    Professor and Vice Chairman for Research, Director of Clinical Research, Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, USA.

    Universally, anesthesiologists are expected to be knowledgeable, astutely responding to clinical challenges while maintaining a prolonged vigilance for administration of safe anesthesia and critical care. A fatigued anesthesiologist is the consequence of cumulative acuity, manifesting as decreased motor and cognitive powers. This results in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping. With rising expectations and increased medico-legal claims, anesthesiologists work round the clock to provide efficient and timely services, but are the "sleep provider" in a sleep debt them self? Is it the right time to promptly address these issues so that we prevent silent perpetuation of problems pertinent to anesthesiologist's health and the profession. The implications of sleep debt on patient safety are profound and preventive strategies are quintessential. Anesthesiology governing bodies must ensure requisite laws to prevent the adverse outcomes of sleep debt before patient care is compromised.

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    http://dx.doi.org/10.4103/0970-9185.111657DOI Listing
    April 2013
    29 Reads
    38 Citations

    Anesthetic considerations in pemphigus vulgaris: Case series and review of literature.

    Saudi J Anaesth 2012 Apr;6(2):165-8

    Department of Anaesthesia and Critical Care, Medanta-The Medicity, Gurgaon, Haryana, India.

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    http://dx.doi.org/10.4103/1658-354X.97032DOI Listing
    April 2012
    30 Reads

    Bier's block using lignocaine and butorphanol.

    J Anaesthesiol Clin Pharmacol 2011 Oct;27(4):465-9

    Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, India.

    Background: Opioids are most commonly used as adjuncts in intravenous regional anesthesia (IVRA) to improve the quality of intraoperative and postoperative analgesia. There is paucity of literature on the use of butorphanol in IVRA.

    Aims: The aim of this study was to evaluate the likely benefits of addition of butorphanol to lignocaine in Bier's block in terms of onset and duration of sensory block and also for analgesic requirement in postoperative period.

    Settings And Design: A randomized double blind study was conducted at Tertiary Care Educational Institute.

    Patients And Methods: A total of 40 adult ASA I or II patients scheduled to undergo upper limb surgery were randomized in two groups (n=20). Group I received 3 mg/kg of lignocaine alone and group II received 1 mg butorphanol in addition to 3 mg/kg lignocaine. Sensory block onset time and time to recovery from sensory block after tourniquet deflation were noted using the pin prick method. Duration of postoperative analgesia was noted using a visual analogue scale. All the patients were compared for the time to first rescue analgesic consumption and total analgesic consumption in first 24 hours postoperatively.

    Statistical Analysis Used: The statistical analysis was done using unpaired Student's t-test.

    Results: Our study showed significant prolongation of postoperative analgesia in group II as noted by the time to first analgesic requirement. Total analgesic consumption in first 24 hours postoperatively was less in group II. Sensory block onset time and time to recovery from sensory block after tourniquet deflation, did not show any significant difference between the two groups.

    Conclusions: Addition of butorphanol to lignocaine in IVRA significantly prolongs the duration of postoperative analgesia and 24 hours analgesic consumption is less in patients receiving butorphanol along with lignocaine in IVRA. However, there is no effect on sensory block onset time and time to recovery from sensory block.

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    http://dx.doi.org/10.4103/0970-9185.86580DOI Listing
    October 2011
    9 Reads
    11 Citations

    Does our sleep debt affect patients' safety?

    Indian J Anaesth 2011 Jan;55(1):12-7

    Department of Anesthesiology, Dayanand Medical College & Hospital, Ludhiana, India.

    The provision of anaesthesia requires a high level of knowledge, sound judgement, fast and accurate responses to clinical situations, and the capacity for extended periods of vigilance. With changing expectations and arising medico-legal issues, anaesthesiologists are working round the clock to provide efficient and timely health care services, but little is thought whether the "sleep provider" is having adequate sleep. Decreased performance of motor and cognitive functions in a fatigued anaesthesiologist may result in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping, all of which affect the patient safety, showing without doubt the association of sleep debt to the adverse events and critical incidents. Perhaps it is time that these issues be promptly addressed to prevent the silent perpetuation of a problem that is pertinent to our health and our profession. We endeavour to focus on the evidence that links patient safety to fatigue and sleepiness of health care workers and specifically on anaesthesiologists. The implications of sleep debt are deep on patient safety and strategies to prevent this are the need of the hour.

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    http://dx.doi.org/10.4103/0019-5049.76572DOI Listing
    January 2011
    27 Reads
    19 Citations

    Laryngoscope based lighted stylet for intubation: An innovation.

    Saudi J Anaesth 2010 Sep;4(3):209-10

    Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

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    http://dx.doi.org/10.4103/1658-354X.71575DOI Listing
    September 2010
    7 Reads

    U turn to venous air embolism.

    Indian J Crit Care Med 2009 Apr-Jun;13(2):92-3

    Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

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    http://dx.doi.org/10.4103/0972-5229.56055DOI Listing
    June 2010
    25 Reads
    1 Citation

    Placebo support: A possible weaning trial in ventilator dependency.

    Indian J Crit Care Med 2010 Apr;14(2):104-5

    Department of Anesthesiology and Resuscitation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

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    http://dx.doi.org/10.4103/0972-5229.68213DOI Listing
    April 2010
    8 Reads

    Anaesthetic consideration in macroglossia due to lymphangioma of tongue: a case report.

    Indian J Anaesth 2009 Feb;53(1):79-83

    Assistant Professor, Department of Anaesthesiology & Resuscitation., Institute: Dayanand Medical College & Hospital, Ludhiana, Punjab, India. PIN: 141001.

    Summary: Successful airway management of an infant or child with macroglossia prerequisites recognition of a potential airway problem. We describe our experience with a debilitated 13-year-old girl who presented with severe macroglossia, secondary to lymphangioma of the tongue. Along with the social discomfort she had inability to speak, eat or drink properly and exposure-induced dryness. Such patients are a challenge for the anaesthesiologists due to the anticipated difficult intubation associated with the oral mucosa occupying lesion. It also becomes pertinent to rule out any of the associated congenital anomalies. The importance of a thorough preoperative evaluation and attention to difficult intubation and maintenance of airway is emphasized. We endeavor to review the available literature regarding patient's perioperative management of such patients.

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    February 2009
    10 Reads
    5 Citations

    Let's broaden our surgical horizons.

    Anesth Analg 2007 Feb;104(2):452-3; author reply 453

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    http://dx.doi.org/10.1213/01.ane.0000253157.43751.28DOI Listing
    February 2007
    9 Reads
    1 Citation
    3.472 Impact Factor

    Surgical face mask as a nappy!

    Paediatr Anaesth 2005 Sep;15(9):793-4

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    http://dx.doi.org/10.1111/j.1460-9592.2005.01668.xDOI Listing
    September 2005
    20 Reads
    1.742 Impact Factor

    Anesthesiologists and perioperative antibiotic prophylaxis.

    Anesthesiology 2004 Jul;101(1):259; author reply 260

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    http://dx.doi.org/10.1097/00000542-200407000-00047DOI Listing
    July 2004
    7 Reads
    5.880 Impact Factor