Publications by authors named "Rajeshwari Subramaniam"

47 Publications

Preoperative planning for central venous cannulation in conjoint twins.

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):569-570. Epub 2021 Jan 18.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_596_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022058PMC
January 2021

Airway challenge in repaired tracheo-esophageal fistula patient.

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):563-564. Epub 2021 Jan 18.

Deptartment of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_139_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022062PMC
January 2021

Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock.

Indian J Crit Care Med 2021 Mar;25(3):310-316

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. : After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18-65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders." Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 ( = 0.016), 0.440 ( = 0.052), and 0.044 ( = 0.853) in control, sepsis, and septic shock patients, respectively. Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, . Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310-316. www.ctri.nic.in, CTRI/2017/11/010434.
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http://dx.doi.org/10.5005/jp-journals-10071-23764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7991757PMC
March 2021

A case of neglected hepatorenal dysfunction during the COVID pandemic.

Indian J Med Microbiol 2021 Mar 26. Epub 2021 Mar 26.

Department of Anaesthesia, AIIMS, 110029, New Delhi, India. Electronic address:

As the world fights with the Coronavirus, most of the hospitals are gearing up for the care of these patients. As most of the attention these days is being given on Coronavirus, the patients suffering from other clinical infections are being neglected. SARS-CoV-2 is being kept as the top differential in patients presenting with fever and respiratory distress. We hereby present a case of patient returning from Indonesia during the pandemic presenting with a history of hepatic, renal dysfunction with fever and cough. Due to the pandemic, the patient's fever and cough outweighed the hepatic and renal dysfunction, and the patient had to undergo dialysis before the final diagnosis of leptospirosis could be made.
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http://dx.doi.org/10.1016/j.ijmmb.2021.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997676PMC
March 2021

Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery.

Cochrane Database Syst Rev 2021 Feb 25;2:CD012968. Epub 2021 Feb 25.

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Background: Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia.

Objectives: To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality.

Search Methods: On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials.

Selection Criteria: We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia.

Data Collection And Analysis: Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome.

Main Results: Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias.

Authors' Conclusions: Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.
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http://dx.doi.org/10.1002/14651858.CD012968.pub2DOI Listing
February 2021

Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study.

Indian J Crit Care Med 2021 Jan;25(1):85-87

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Coronavirus disease 2019 (COVID-19) is a type of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 pneumonia has characteristic radiological features. Recent evidence indicates usefulness of chest X-ray and lung ultrasound (LUS) in detecting COVID-19 pneumonia.

Materials And Methods: In this prospective observational study, chest X-ray and LUS features of 50 adults with COVID-19 pneumonia at the time of presentation were described.

Results: Chest X-ray findings were present in 96% of patients, whereas all patients have ultrasound finding. Proportion (95% CI) of patients having bilateral opacities in chest X-ray was 96% (86.5-98.9%), ground glass opacity 74% (60.5-84.1%), and consolidation 50% (36.7-63.4%). In LUS, shred sign and thickened pleura was present in all patients recruited in this study. Air bronchogram was present in at least one area in 80% of all patients and B-lines score of more than 2 was present in at least one lung area in 84% patients. Number of lung areas with "shred sign" were higher in hypoxemic ( = 0.005) and tachypneic ( = 0.006) patients and pleura line abnormalities were present in more lung areas in hypoxemic patients ( = 0.03).

Conclusion: According to our study, LUS is a useful tool not only in diagnosing, but it also correlates with requirement of respiratory support in COVID-19 patients.

How To Cite This Article: Behera S, Maitra S, Anand RK, Baidya DK, Subramaniam R, Kayina CA, Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study. Indian J Crit Care Med 2021;25(1):85-87.
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http://dx.doi.org/10.5005/jp-journals-10071-23705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874276PMC
January 2021

SARS- CoV-2 infection presented as acute exacerbation of bronchial Asthma.

J Anaesthesiol Clin Pharmacol 2020 Jul-Sep;36(3):412-413. Epub 2020 Sep 15.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_414_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812949PMC
September 2020

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients.

Indian J Crit Care Med 2020 Nov;24(11):1143-1144

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Nair PR, Maitra S, Ray BR, Anand RK, Baidya DK, Subramaniam R. Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients. Indian J Crit Care Med 2020;24(11):1143-1144.
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http://dx.doi.org/10.5005/jp-journals-10071-23663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751036PMC
November 2020

SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients.

Indian J Crit Care Med 2020 Nov;24(11):1141-1142

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Kayina CA, Maitra S, Anand RK, Ray BR, Baidya DK, Subramaniam R. SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients. Indian J Crit Care Med 2020;24(11):1141-1142.
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http://dx.doi.org/10.5005/jp-journals-10071-23595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751029PMC
November 2020

Anaesthetic considerations in a child with methylmalonic acidemia and its literature review.

BMJ Case Rep 2020 Dec 9;13(12). Epub 2020 Dec 9.

Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, New Delhi, India.

Methyl malonyl coenzyme A mutase deficiency is a rare autosomal inherited inborn error in branched-chain amino acid metabolism characterised by the accumulation of methylmalonic acids. There is relative paucity of literature regarding anaesthetic management of these children presenting for incidental major abdominal surgery. Preoperative management includes goal-directed correction of dehydration, metabolic acidosis and hyperammonemia. Anaesthetic goals include avoidance of factors that can trigger metabolic crisis like hypercapnia, hypothermia, hypoxia, surgical stress, hypovolaemia, hypotension and so on. Herein, we are reporting the anaesthetic management of a 17-month-old child with methylmalonic acidemia (MMA) posted for a major upper abdominal surgery for excision of an adrenal mass, which was incidentally diagnosed during admission for an episode of metabolic crisis. We aim to highlight the specific nuances of pathophysiology of the disease, preoperative optimisation, anaesthetic considerations, role of advanced monitoring and regional anaesthesia and current literature on the management of patients with MMA.
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http://dx.doi.org/10.1136/bcr-2020-237270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733119PMC
December 2020

Epidemiological & clinical characteristics & early outcome of COVID-19 patients in a tertiary care teaching hospital in India: A preliminary analysis.

Indian J Med Res 2020 Jul & Aug;152(1 & 2):100-104

Department of Anesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: In this study we describe the epidemiological data, comorbidities, clinical symptoms, severity of illness and early outcome of patients with coronavirus disease 2019 (COVID-19) from a tertiary care teaching hospital in New Delhi, India.

Methods: In this preliminary analysis of a prospective observational study, all adult patients admitted to the screening intensive care unit (ICU) of the institute who fulfilled the WHO case definition of COVID-19 and confirmed to have SARS-CoV-2 infection by reverse transcription-polymerase chain reaction were included. Demographics, clinical data and 24 h outcome were assessed.

Results: The preliminary analysis of 235 patients revealed that the mean age was 50.7±15.1 yr and 68.1 per cent were male. Fever (68.1%), cough (59.6%) and shortness of breath (71.9%) were the most common presenting symptoms. Hypertension (28.1%) and diabetes mellitus (23.3%) were the most common associated comorbid illnesses. Patients with mild, moderate, severe and critical illness were 18.3, 32.3, 31.1 and 18.3 per cent, respectively, at the time of ICU admission. The proportions (95% confidence interval) of patients requiring any form of oxygen therapy, oxygen therapy by high-flow nasal cannula and invasive mechanical ventilation were 77, 21.7 and 25.5 per cent, respectively, within 24 h of hospital admission. The 24 h ICU mortality was 8.5 per cent, and non-survivors had higher respiratory rate (P <0.01, n=198) and lower baseline oxyhaemoglobin saturation (P <0.001, n=198) at presentation and higher baseline serum lactate (P <0.01, n=122), total leucocyte count (P <0.001, n=186), absolute neutrophil count (P <0.001, n=132), prothrombin time (P <0.05, n=54) and INR (P <0.05, n=54) compared to survivors.

Interpretation & Conclusions: Nearly half of the patients presented with severe and critical disease and required high-flow nasal oxygen or invasive mechanical ventilation at admission. Severity of the presenting respiratory illness, haematological parameters and lactate rather than age or presence of comorbidity predicted early death within 24 h.
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http://dx.doi.org/10.4103/ijmr.IJMR_2890_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853262PMC
September 2020

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial.

Indian J Anaesth 2020 Jun 1;64(6):507-512. Epub 2020 Jun 1.

Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background And Aims: Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures.

Methods: The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software.

Results: Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement ( = 0.01) and postoperative fentanyl requirement until 24 h ( = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment ( = 0.000).

Conclusion: ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.
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http://dx.doi.org/10.4103/ija.IJA_868_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398014PMC
June 2020

Anaesthetic management of a COVID-19 parturient for caesarean section - Case report and lessons learnt.

Indian J Anaesth 2020 May 23;64(Suppl 2):S141-S143. Epub 2020 May 23.

Department of Anaesthesiology Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

The corona virus disease 2019 (COVID-19) pandemic sweeping across the world has severely strained health care resources (equipment and personnel) forcing us to rethink strategies to provide obstetric care while judiciously using resources. We describe the anaesthetic management of a mildly symptomatic, COVID-19 positive, 28-year-old second gravida with term pregnancy who was taken up for an elective caesarean section under subarachnoid block in a standalone maternity facility. Challenges encountered and modifications of standard procedures so as to optimize patient care and minimize exposure of health care professionals are also discussed.
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http://dx.doi.org/10.4103/ija.IJA_509_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293367PMC
May 2020

Role of serial lactate measurement to predict 28-day mortality in patients undergoing emergency laparotomy for perforation peritonitis: prospective observational study.

J Intensive Care 2019 11;7:58. Epub 2019 Dec 11.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India.

Background: Serial lactate measurement is found to predict mortality in septic shock. Majority of patients with perforation peritonitis for emergency laparotomy are in sepsis and mortality rate is substantial. However, lactate dynamics has not been studied in this patient population.

Methods: After institutional ethics clearance and informed written consent, 113 patients with suspected or proven perforation peritonitis presenting for emergency laparotomy were recruited in this prospective observational trial. Baseline Mannheim peritonitis index (MPI), SOFA and APACHE II score were calculated. Lactate values were obtained at baseline, immediate and 24-h postoperative period. Primary outcome was 28-day mortality.

Results: Mortality was 15.04% at 28 days. Age, SOFA, qSOFA, APACHE, preoperative lactate, MPI and site of perforation were significantly different between survivors and non-survivors. Arterial lactate values at preoperative (cut off 2.75 mmol/L), immediate postoperative (cut off 2.8 mmol/L) and 24 h-postoperative period (cut off 2.45 mmol/L) independently predicted mortality at day 28. Combination of MPI and 24-h lactate value was best predictor of mortality with AUC 0.99.

Conclusion: Preoperative, immediate postoperative and 24-h postoperative lactate value independently predict 28-day mortality in perforation peritonitis patients undergoing emergency laparotomy. Combination of MPI and 24-h lactate value is the most accurate predictor of mortality.

Trial Registration: Clinical Trial Registry of India - CTRI/2018/01/011103.
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http://dx.doi.org/10.1186/s40560-019-0418-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907168PMC
December 2019

Recurrent syncope in a child and video assisted thoracoscopic surgery - The long and short of it.

Indian J Anaesth 2019 Oct 10;63(10):847-850. Epub 2019 Oct 10.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Long QT syndrome (LQTS) is a myocardial repolarisation disorder caused by cardiac ion channelopathy and one of its common presentations is recurrent syncope. This reduced repolarisation reserve in LQTS can be unmasked by perioperative factors like electrolyte imbalance, drugs, hypothermia and changes in cardiac autonomic tone. We report the anaesthetic management of left thoracoscopic sympathectomy in a 5-year-old child with LQTS and epicardial pacemaker in situ. It is very challenging to isolate the lung on one hand and prevent the predisposition to torsadogenic potential on the other.
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http://dx.doi.org/10.4103/ija.IJA_180_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6798626PMC
October 2019

Anesthetic Management of a Unique Case of Double-Outlet Right Ventricle With Glenn Shunt for Cesarean Delivery: A Case Report.

AANA J 2018 Oct;86(5):408-411

is a senior resident, in the Department of Anesthesiology, at AIIMS, in New Delhi, India.

Double-outlet right ventricle is a rare congenital cardiac anomaly resulting in intracardiac mixing of oxygenated and deoxygenated blood. Surgical palliation involves staged conversion to Fontan circulation, with an intermediate stage using a Glenn shunt. We report the case of a patient at 36 weeks of gestation, with a partially palliated double-outlet right ventricle and a Glenn shunt, who presented with severe dyspnea and worsening cyanosis. After preoperative optimization, a combined spinal-epidural technique was successfully used for cesarean delivery. The anesthetic concerns and perioperative management of patients with complex cardiac physiology are discussed in this report. Carefully titrated combined spinal-epidural technique can be safe and effective for such cases.
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October 2018

Comparison of ultrasound-guided versus conventional palpatory method of dorsalis pedis artery cannulation: A randomized controlled trial.

Saudi J Anaesth 2019 Oct-Dec;13(4):295-298

Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India.

Background: Whether use of ultrasound (USG) to cannulate dorsalis pedis artery (DPA) increases first pass successful cannulation, decreases the number of attempts and complications as compared to palpation technique was assessed in this study.

Design: Randomized controlled trial.

Setting: Operating room.

Patients: About 60 adult patients undergoing any head-neck or faciomaxillary surgery requiring arterial cannulation were enrolled.

Intervention: DPA was cannulated either by USG-guided technique (USG group) or by palpation technique (palpation group) with 30 patients in each group.

Measurement: Data were assessed for "first-attempt success" of cannulation, number of attempts, assessment time, cannulation time, cannulation failure, and incidence of complications.

Main Results: Successful first pass DPA cannulation was similar between the groups (ultrasound group vs. palpation group, 76.7% vs. 60%, respectively) [relative risk (95% confidence interval (CI) = 0.69 (0.43, 1.13), = 0.267)] as was the number of attempts required for successful cannulation [median (interquartile range (IQR) number of attempts 1 (1-2) in palpation group and USG group U 1 (1-1); = 0.376]. Median (IQR) assessment time was significantly less ( < 0.0004) in palpation group [palpation group 12 (9-17) vs. USG group U 19 (15-21)]. However, cannulation time was significantly higher ( = 0.0093) in Group [median (IQR) 17.5 (12-36 s) and 11.5 (9-15)]. Although the total procedure time (sum of both assessment time and cannulation time) remain statistically similar between two groups ( = 0.8882).

Conclusions: Use of USG for the cannulation of DPA is feasible, but it is not associated with significant increase in first-attempt success rate, decrease in total number of cannulation attempts or total procedure time.
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http://dx.doi.org/10.4103/sja.SJA_766_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753743PMC
October 2019

Anaesthetic concerns in preterm and term neonates.

Indian J Anaesth 2019 Sep;63(9):771-779

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for "Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia", as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.
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http://dx.doi.org/10.4103/ija.IJA_591_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761779PMC
September 2019

Perioperative management of patient with Conn's syndrome and severe hypokalaemia: How low is too low?

Indian J Anaesth 2019 Jan;63(1):67-68

Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

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http://dx.doi.org/10.4103/ija.IJA_562_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341878PMC
January 2019

Reply to Dr Woodham et al.

Reg Anesth Pain Med 2018 11;43(8):890-891

Department of Anesthesiology All India Institute of Medical Sciences New Delhi, India Department of Surgery All India Institute of Medical Sciences New Delhi, India.

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http://dx.doi.org/10.1097/AAP.0000000000000872DOI Listing
November 2018

Role of anesthesiologist in intrapartum treatment procedure: A case and review of anesthetic management.

J Anaesthesiol Clin Pharmacol 2018 Apr-Jun;34(2):148-154

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

The intrapartum treatment (EXIT) procedure is a rare form of perinatal resuscitation. It is basically a bridge therapy between partial delivery of the child and stabilization of its cardiorespiratory functions. This procedure has multiple anesthetic challenges including maternal anesthesia, maintenance of uteroplacental flow, tocolysis till the neonate is stabilized, management of postpartum hemorrhage, fetal, and neonatal anesthesia. This review also describes a case of cervical teratoma in fetus, for which the EXIT was performed in our institute. In addition to the case description, multiple concerns specific for EXIT procedure are discussed in this review.
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http://dx.doi.org/10.4103/joacp.JOACP_239_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066899PMC
August 2018

Comparison of Macintosh, McCoy, and Glidescope video laryngoscope for intubation in morbidly obese patients: Randomized controlled trial.

Saudi J Anaesth 2018 Jul-Sep;12(3):433-439

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Objectives: The aim of the study was to compare time to intubation and glottic visualization between Macintosh, McCoy, and Glidescope video laryngoscope (GVL) in morbidly obese patients.

Methodology: Forty-five American Society of Anesthesiologists I-III morbidly obese patients were randomized into three groups of 15 each and time to intubation, Cormack-Lehane grading, and Intubation Difficulty Score (IDS) were compared.

Results: GVL took more time to intubate (TTI) compared to Macintosh and McCoy laryngoscope ( = 0.0001). Overall IDS were similar between the groups.

Conclusion: To conclude, GVL takes longer TTI with no added advantage in IDS and hemodynamic response to intubation in morbidly obese patients. McCoy is only as effective as Macintosh and hence Macintosh laryngoscope should be laryngoscope of choice due to its widespread availability and familiarity.
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http://dx.doi.org/10.4103/sja.SJA_754_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044164PMC
August 2018

Low flow vascular malformations of cervico facial area: An airway challenge.

J Clin Anesth 2018 08 9;48:58-59. Epub 2018 May 9.

Dept. of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1016/j.jclinane.2018.04.016DOI Listing
August 2018

Comparison of Paravertebral Block by Anatomic Landmark Technique to Ultrasound-Guided Paravertebral Block for Breast Surgery Anesthesia: A Randomized Controlled Trial.

Reg Anesth Pain Med 2018 May;43(4):385-390

Background And Objectives: Paravertebral block (PVB) is an established technique for providing anesthesia for breast surgery. The primary objective was to compare anatomical landmark technique (ALT) to the ultrasound-guided (USG) PVB block for providing surgical anesthesia. Secondary objectives included comparison of perioperative analgesia and complications.

Methods: This randomized, controlled, observer-blinded study included 72 females, aged 18 to 65 years, American Society of Anesthesiologists physical status I or II, undergoing elective unilateral breast surgery. Study participants were randomized to the ALT group or USG group. Ipsilateral PVB was performed with the respective technique from T1 to T6. Five milliliters of local anesthetic mixture (0.5% ropivacaine, 5 μg/mL adrenaline, 1 μg/kg clonidine) was administered at each level. Paravertebral catheter was inserted at T4/T3 level. After confirming sensory loss, patients were taken up for surgery with propofol sedation (20-50 μg/kg per minute).

Results: More patients in the USG group (34/36 [94.44%]) had a successful block as compared with the ALT group (26/36 [72.22%]) (P = 0.024). Difference in proportion was 18.1 (95% confidence interval, 0.15-36.0) (P = 0.024) after adjustment for age. More dermatomes were blocked in the USG group (P = 0.0018) with less sparing of upper T2 and T3 dermatomes (P = 0.003, P = 0.006, respectively). Median time to first postoperative analgesic requirement was 502.5 minutes (range, 195-1440 minutes) in the USG group versus 377.5 minutes (range, 215-1440 minutes) in the ALT group. Pain at rest and movement 2 and 4 hours postoperatively and number of catheter top-ups in 24 hours postoperatively were lesser in the USG group (P = 0.012). Complications were comparable.

Conclusions: Ultrasound-guided PVB provided better anesthesia and perioperative analgesia than the landmark technique for breast surgery.

Clinical Trial Registration: The trial was registered retrospectively at the Clinical Trial Registry of India, CTRI/2015/05/005774.
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http://dx.doi.org/10.1097/AAP.0000000000000746DOI Listing
May 2018

Anesthetic Management for Prolonged Incidental Surgery in Advanced Liver Disease.

Anesth Essays Res 2017 Oct-Dec;11(4):1101-1104

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

In spite of advances in perioperative management, operative procedures in patients with chronic liver disease pose a significant challenge for the anesthesiologist due to multisystem involvement, high risk of postoperative hepatic decompensation, and mortality. We describe the anesthetic management of an elderly patient with advanced liver disease (model for end-stage liver disease 16) for prolonged abdominal surgery. The use of invasive hemodynamic monitoring, point-of-care biochemical, and hematological surveillance coupled with prompt correction of all abnormalities was responsible for good outcome. The patient's inguinal swellings turned out to be extensions of a large peritoneal mesothelioma, necessitating a large abdominal incision and blood loss. Analgesia was provided by bilateral transversus abdominis plane blocks, which helped to reduce opioid use and rapid extubation.
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http://dx.doi.org/10.4103/aer.AER_94_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5735460PMC
December 2017

Intravenous mishap following residual anesthetic drug in intravenous extension line.

Saudi J Anaesth 2017 Jul-Sep;11(3):375-376

Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, New Delhi, India.

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http://dx.doi.org/10.4103/sja.SJA_80_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516519PMC
August 2017

Comparison of Absorbable Versus Nonabsorbable Tackers in Terms of Long-term Outcomes, Chronic Pain, and Quality of Life After Laparoscopic Incisional Hernia Repair: A Randomized Study.

Surg Laparosc Endosc Percutan Tech 2016 Dec;26(6):476-483

Departments of *Surgical Disciplines †Anaesthesia ‡Psychiatry, All India Institute of Medical Sciences, New Delhi, India.

Background: Laparoscopic incisional and ventral hernia repair (LIVHR) has been associated with a high incidence acute and chronic pain due to use of nonabsorbable tackers. Several absorbable tackers have been introduced to overcome these complications. This randomized study was done to compare 2 techniques of mesh fixation, that is, nonabsorbable versus absorbable tackers for LIVHR.

Materials And Methods: Ninety patients admitted for LIVHR repair (defect size <15 cm) were randomized into 2 groups: nonabsorbable tacker fixation (NAT group, 45 patients) and absorbable tacker fixation (AT group, 45 patients). Intraoperative variables and postoperative outcomes were recorded and analyzed.

Results: Patients in both the groups were comparable in terms of demographic profile and hernia characteristics. Mesh fixation time and operation time were also comparable. There was no significant difference in the incidence of immediate postoperative and chronic pain over a mean follow-up of 8.8 months. However, cost of the procedure was significantly higher in AT group (P<0.01) and NAT fixation was more cost effective as compared with AT. Postoperative quality of life outcomes and patient satisfaction scores were also comparable.

Conclusions: NAT is a cost-effective method of mesh fixation in patients undergoing LIVHR with comparable early and late postoperative outcomes in terms of pain, quality of life, and patient satisfaction scores.
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http://dx.doi.org/10.1097/SLE.0000000000000347DOI Listing
December 2016

Outcomes of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography in Patients with Concomitant Gall Stones and Common Bile Duct Stones: A Prospective Study.

J Laparoendosc Adv Surg Tech A 2016 Dec 9;26(12):985-991. Epub 2016 Nov 9.

1 Department of Surgical Disciplines, All India Institute of Medical Sciences , New Delhi, India .

Introduction: The aim of the present study was to compare the outcomes of secondary laparoscopic CBD exploration (LCBDE) following failed endoscopic retrograde cholangiopancreatography (ERCP) and primary laparoscopic common bile duct (CBD) exploration.

Materials And Methods: One hundred eighty-five patients undergoing LCBDE were divided into Group I consisting of patients undergoing a primary LCBDE (n = 102) and Group II consisting of patients undergoing LCBDE after failure of ERCP to clear the CBD stones (n = 83). Primary outcome measure was successful laparoscopic CBD clearance. The secondary outcome measures were degree of difficulty, operative time, complications, hospital stay, and the cost of treatment.

Results: Success rate was similar in both groups (85.3% versus 80.7%). Mean operative time, degree of difficulty, hospital stay, and cost of procedure were significantly higher in Group II (P value <.05).

Conclusion: It may be prudent to consider ERCP failure patients for primary LCBDE than risk the complications of ERCP if they are suitable for primary surgery.
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http://dx.doi.org/10.1089/lap.2016.0272DOI Listing
December 2016

Transversus abdominis plane block for laparoscopic inguinal hernia repair: a randomized trial.

J Clin Anesth 2016 Sep 28;33:357-64. Epub 2016 May 28.

Department of Surgery, All India Institute of Medical Sciences, New Delhi, India.

Background: Pain after laparoscopic inguinal hernia surgery can be moderate to severe, interfering with return to normal activity. The study aimed to assess the efficacy of bilateral ultrasound-guided (USG) transversus abdominis plane (TAP) block for relieving acute pain after laparoscopic hernia repair as T10-L1 nerve endings are anesthetized with this block.

Methods: Seventy-one American Society of Anesthesiologists I to II patients, aged 18 to 65 years, undergoing unilateral/bilateral laparoscopic hernia repair were randomized to port site infiltration (control, 36) and TAP block groups (35). All patients received general anesthesia (fentanyl 2 μg/kg intravenously at induction, 0.5 μg/kg on 20% increase in heart rate or mean blood pressure) and paracetamol 6 hourly. Postintubation, TAP group received bilateral USG TAP block (15-20 mL 0.5% ropivacaine, maximum 3 mg/kg) with 18-G Tuohy needle. Control group had 20 to 30 mL 0.5% ropivacaine infiltrated preincision, at port sites from skin to peritoneum. Postoperative patient-controlled analgesia fentanyl was provided for 6 hours; pain was assessed using 0- to 100-mm visual analog scale (VAS) at 0, 1, 2, 4, 6, and 24 hours and telephonically at 1 week and 3 months.

Results: Demographic profile of the 2 groups was comparable. Significantly more number of patients required intraoperative fentanyl in the control group (24/36) than in the TAP group (13/35); VAS at rest was lower in TAP than control patients in postanesthesia care unit at 0, 2, 6, and 24 hours (median VAS TAP group: 0, 0, 0, and 0; control: 10, 20, 10, and 10; P= .002, P= .001, P= .001, and P= .006, respectively); P< .01 was considered statistically significant. TAP group had significantly lower VAS on deep breathing at 6 hours and on knee bending and walking at 24 hours and lesser patient-controlled analgesia fentanyl requirement. No significant difference in pain scores was observed at 1 week and 3 months.

Conclusion: TAP block reduced postoperative pain up to 24 hours after laparoscopic hernia repair.
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http://dx.doi.org/10.1016/j.jclinane.2016.04.047DOI Listing
September 2016

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs.

Surg Endosc 2017 03 5;31(3):1478-1486. Epub 2016 Aug 5.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

Methods: This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

Results: The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

Conclusions: Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.
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http://dx.doi.org/10.1007/s00464-016-5142-0DOI Listing
March 2017