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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
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July-December 2019
Volume 9 | Issue 2
Page Nos. 53-115

Online since Friday, September 6, 2019

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EDITORIAL  

Critically ill obstetric patients in resource-limited settings Highly accessed article p. 53
Samina Ismail, Muhammad Sohaib
DOI:10.4103/joacc.JOACC_32_19  
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ORIGINAL ARTICLES Top

Obstetric patients requiring critical care: Retrospective study in a tertiary care institute of Pakistan p. 56
Samina Ismail, Muhammad Sohaib
DOI:10.4103/joacc.JOACC_33_19  
Background: The outcome of obstetric patients admitted to the intensive care unit (ICU) depends on the number of factors. The objective of this study is to review the outcomes of these patients with regard to pregnancy status, source of admission, and their presenting illness at time of admission to ICU. Materials and Methods: A retrospective study was undertaken for all obstetric patients admitted to the ICU of a private tertiary care hospital of Pakistan from 2014 to 2018. The data were reviewed thorough ICU log sheet, electronic medical records, and online laboratory data. The data included patient demographics, pregnancy status, mode of admission, length of stay, laboratory investigation, presenting disease, and outcomes in terms of death or survival. Results: Obstetric patients accounted for 3.8% for all ICU admission with overall mortality of 11.1%. There was no statistically significant difference in the mortality rate with respect to presenting illness; however, morality was highest (37.5%) in patients with pre-eclampsia. A majority (54.2%) of the ICU admission were due to hemorrhagic/hematological causes followed by cardiovascular causes (33.1%). A statistically significant increase in mortality rate was observed in patients admitted through emergency compared with patients from within hospital (P < 0.0005). Conclusion: Patients coming through emergency as referral patients were found to have the highest mortality. There is dire need to uplift the primary and secondary tertiary care centers in developing countries, where early treatment can be provided and high-risk cases can be picked up with early referral to tertiary care center.
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Comparison of levobupivacaine alone versus levobupivacaine with ketamine in subcutaneous infiltration for postoperative analgesia in lower segment cesarean section p. 60
Paridhi Kaler, Indu Verma, Anju Grewal, Ashima Taneja, Dinesh Sood
DOI:10.4103/joacc.JOACC_25_19  
Context: Local anesthetic wound infiltration is employed as a part of multimodal analgesia to reduce opiate consumption and pain after lower segment cesarean section (LSCS). Additional blockade of pain pathway at spinal level by ketamine prolongs the duration of analgesia. Aims: To compare analgesic efficacy of subcutaneous wound infiltration of levobupivacaine or levobupivacaine plus ketamine following LSCS. Material and Methods: Randomized double blind study was conducted on 60 parturients undergoing LSCS under spinal anesthesia. Group A received surgical wound infiltration with 0.5% levobupivacaine 2 mg/kg body weight and Group B parturients were infiltrated with 0.5% levobupivacaine plus ketamine 1 mg/kg body weight diluted with normal saline. Postoperative pain scores, time to first rescue analgesia (FRA), hemodynamic parameters, and total opioid analgesic consumption were assessed. Results: Pain free period and time to FRA was 1.5 hours later in group B, which also had reduced mean VAS scores. In addition, the overall pain scores and total opioid consumption were significantly less (P = 0.003) in Group B. Only 50% in Group B and 97% parturients in Group A needed rescue analgesia. Patient satisfaction score was statistically superior in Group B (P = 0.009). Incidence of nausea and vomiting was comparable between the groups (P = 0.554). Conclusions: Addition of ketamine to levobupivacaine for surgical wound infiltration prolongs the analgesia duration, improves patient satisfaction, and decreases 24-hour opioid consumption.
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Optic nerve sheath diameter measured using ocular sonography is raised in patients with eclampsia p. 65
Renu Bala, Arnab Banerjee, Susheela Taxak, Rajesh Kumar
DOI:10.4103/joacc.JOACC_1_19  
Introduction: Eclampsia is one of the leading causes of maternal morbidity. Neurological sequelae are quite common and contribute to poor prognosis in these patients. Ultrasonographic measurement of optic nerve sheath diameter (ONSD) as noninvasive monitor of raised intracranial pressure (ICP) might aid in management of these patients. Based on these facts, this study intended to study the difference between ONSD in eclampsia versus noneclamptic parturients admitted to intensive care unit (ICU). The trends in ONSD were followed in patients with eclampsia to assess the association between ONSD and resolution of neurological symptoms. Materials and Methods: The present observational study comprised 46 patients and was conducted in our ICU from January 2015 to June 2015. Postpartum eclamptic patients requiring ventilatory support in the ICU were enrolled in group E (n = 24), while postpartum patients admitted for some other causes but requiring ventilatory support were enrolled in group C (n = 22). Transorbital ultrasound was done to measure ONSD using SonoSite M-Turbo machine. It was repeated daily in both the groups till patients were extubated or expired. The vital parameters, treatment, and investigations were also noted. Results: The ONSD in group E was 0.64 ± 0.02 cm, while in group C it was 0.45 ± 0.03 cm (P < 0.0001). Blood pressure was much higher in group E (P < 0.001). ONSD had positive correlation with systolic blood pressure than diastolic blood pressure. In group E, 22 patients were extubated, and following extubation ONSD decreased to normal value in 16 patients while in 6 patients it was still raised. Overall mortality was 6 (13%); 2 (8.3%) in group E and 4 (18.2%) in group C. Conclusion: ONSD was higher in patients with eclampsia suggesting raised ICP, and with subsidence of disease process it decreased. Thus, it may be adopted as a routine monitoring in these patients to guide management and predict prognosis, although further studies are required to support our findings.
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Anesthetic management of idiopathic pulmonary arterial hypertension for cesarean section – experiences from a tertiary care center p. 70
Nitu Puthenveettil, Jerry Paul, Sumana Moorthy, Lakshmi Kumar
DOI:10.4103/joacc.JOACC_4_19  
Introduction: Idiopathic pulmonary arterial hypertension (IPAH) is a rare cardiac disease. Recent studies have shown a decline in mortality due to the incorporation of PAH-specific therapy. Objective: The aim of our study was to examine the anesthetic management of patients with IPAH, who presented for cesarean section and to know the outcome of pregnancy. Materials and Methods: This is a retrospective observational review, where we have studied the maternal and fetal outcome and anesthetic management of IPAH who underwent elective cesarean section in a tertiary care center from 2010 to 2018. The demographic variables of the patient, details of pregnancy, maternal, and fetal outcome were analyzed. Results: All five patients studied had severe pulmonary arterial hypertension. Our maternal mortality rate was 20%. Except for one patient, all others received regional anesthesia. All patients went on inotropic support following induction, which was gradually tapered. Pulmonary artery catheter was not used in any of our patients. None of the patients required postoperative ventilation. Two babies were shifted to neonatal the intensive care unit in view of poor Apgar scores. Conclusion: Multidisciplinary approach involving cardiologist, obstetrician, and anesthetist is required in planning and management of these high-risk obstetric patients. Epidural anesthesia seems to be an alternative to general anesthesia for cesarean section. The risks versus benefit of pulmonary arterial catheter should be considered before its insertion. Despite all treatment efforts, maternal mortality is high. Hence, pregnancy should be discouraged, and preconceptional counseling and medical abortion should be offered if patient presents early or shows signs of deterioration.
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Prophylactic ephedrine to prevent postspinal hypotension following spinal anesthesia in elective cesarean section: A prospective cohort study in ethiopia p. 75
Tewoderos Shitemaw, Adugna Aregawi, Fissiha Fentie, Bedru Jemal
DOI:10.4103/joacc.JOACC_49_18  
Introduction: Spinal anesthesia is commonly used for cesarean section (CS); however, hypotension is a common clinical problem after spinal anesthesia. Prophylaxis ephedrine can safely be administered by bolus intravenous (IV) route which is simple and cheap, because of its longer duration of action than other vasopressors. Methods: A sample size of 88 consecutive parturients scheduled for elective CS under spinal anesthesia was recruited for this study. Based on the responsible anesthetist's management plan, prophylactic group (Group 1) received IV prophylaxis ephedrine (10 mg) with fluid co-loading, while the nonprophylactic group (Group 2) received fluid co-loading only. The drug norepinephrine was used intraoperatively for the treatment of hypotension in both groups. The primary outcome was the incidence of hypotension. Secondary outcomes were blood pressure (BP), first hypotension incidence time, vasopressor for hypotension treatment, and pulse rate (PR). Results: Hypotension occurred in 22 [50.0% (95% confidence interval, CI, 35%–65%)] of patients in nonprophylactic group (Group 2) and 10 [22.7% (95% CI, 10%–36%)] of the patients in prophylactic group (Group 1) [X2 (1, N = 88) = 7.07,P= 0.008]. Mean values of systolic and diastolic BP were significantly different between groups from 5th min until the 20th min [P < 0.05]. The first hypotension incidence time was significantly different between groups with log rank test [P = 0.003]. Number of patient that required rescue vasopressor and total dose of rescue vasopressor were significantly different between the groups [19 (43.2%) vs. 6 (13.6%) and 7.5(5) vs. 15(15)], respectively. Differences in heart rate and Apgar score between groups were not statistically different. Conclusion: Prophylaxis IV bolus 10 mg ephedrine reduced the incidence of hypotension and greater arterial pressure stability was achieved following spinal anesthesia in parturient undergoing elective CS.
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Prophylactic administration of two different bolus doses of phenylephrine for prevention of spinal-induced hypotension during cesarean section: A prospective double-blinded clinical study p. 81
Sawai Singh Jaitawat, Seema Partani, Venus Sharma, Karishma Johri, Sunanda Gupta
DOI:10.4103/joacc.JOACC_20_19  
Background: Hypotension following spinal anesthesia during cesarean delivery can cause adverse maternal and fetal effects. Phenylephrine has been found to be a potent vasopressor in preventing spinal-induced hypotension during cesarean section (CS) without fetal acidosis. Material and Methods: In this prospective double-blinded study, 120 parturients of ASA grade I and II posted for CS under spinal anesthesia were randomized into three groups of 40 each: group P0, group P75, and group P100. The primary objective was to study the influence of two different doses of phenylephrine on the incidence of spinal-induced hypotension during cesarean section. Corelation of postural variations in baseline hemodynamic data with observed degree of orthostatic hypotension to predict intraoperative hypotension, requirement of rescue vasopressors, and incidence of side effects and neonatal outcome were the secondary outcome measures. Statistical analysis was done with SPSS version 16 using student t test, ANOVA, and Chi-square test. Results: Incidence of hypotension was 70%, 25%, and 17.50% in P0, P75, and P100 groups (P < 0.001), respectively. Maximum change in systolic blood pressure paralleled the increasing doses of prophylactic phenylephrine which was highest in P100 group as compared to P75 and P0 groups. Incidence of bradycardia was higher in group P100 than groups P75 and P0. There were no other significant differences among the three groups. Conclusion: Prophylactic bolus dose of phenylephrine 75 mcg was found to be effective for the management of spinal-induced hypotension and should be preferred over 100 mcg which causes significant bradycardia and reactive hypertension.
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Sub-anaesthetic bolus dose of intravenous ketamine for postoperative pain following caesarean section p. 88
Anil Kumar Bhiwal, Vartika Sharma, Karuna Sharma, Anuj Tripathi, Sunanda Gupta
DOI:10.4103/joacc.JOACC_21_19  
Background: Effective postoperative analgesia following Caesarean Section is important because parturients are at a higher risk for thromboembolic events due to immobility, increased likelihood of developing postpartum depression (PPD) following inadequate pain control which also can interrupt breastfeeding. Ketamine at sub anesthetic doses has been considered to reduce postoperative pain and analgesic consumption following caesarean section. Aims: The aim of this study was to evaluate the efficacy of sub anesthetic doses of ketamine on post caesarean analgesia. Material and Methods: This randomized double blind, placebo controlled study was conducted on 108 parturients, divided into three groups (36 in each group);Group C- received 2 ml of 0.9% normal saline; Group Ka- received 0.15 mg/kg of ketamine (2 ml) and Group Kb- 0.3 mg/kg of ketamine (2 ml) after 5 min of delivery. Postoperatively VAS score, consumption of rescue analgesic in 24 h and adverse effects were recorded. Statistical analysis was done with Analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical scale. P values less than 0.05 were considered significant. Results: Postoperative VAS scores were significantly higher in control group while the time to the first analgesic requirement was significantly prolonged in Ka group (5.44 ± 1.45 h) and Kb group (6.18 ± 1.61 h) as compared to the control group (4.97 ± 1.48 h). The total number of doses and total dose of rescue analgesic (tramadol) required in 24 hours was significantly less in the Ka group (194.44 ± 53.15 mg) and Kb group (152.78 ± 50.63 mg) as compared to group C (136.11 ± 48.71 mg. Conclusion: Administration of sub-anesthetic doses (0.15 mg/kg and 0.3 mg/kg) of intravenous ketamine enhanced postoperative analgesia and reduced the total rescue analgesic consumption in first 24 h following CS. Ketamine 0.3 mg/kg also increased the time to first postoperative rescue analgesic request.
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Effect of intravenous ondansetron on maternal hemodynamics during elective caesarean section under subarachnoid block p. 94
Ankita Attri, Namrata Sharma, Mirley R Singh, Kamya Bansal, Sahil Singh
DOI:10.4103/joacc.JOACC_27_19  
Background and Aims: The Bezold–Jarisch reflex (BJR) is considered to contribute to subarachnoid block (SAB)-induced hypotension and bradycardia and is mediated by serotonin receptors (5-HT3 subtype). Ondansetron, a 5-HT3 receptor antagonist, is assumed to block the effect of serotonin and inhibit BJR. The aim was to study the effect of intravenous ondansetron on maternal hemodynamics. Materials and Methods: The study was conducted on 150 healthy parturients scheduled for elective caesarean section under SAB who were randomly allocated into two groups of 75 each to receive either 4 mg ondansetron or 0.9% normal saline 10 min before initiation of SAB. Hemodynamic parameters were studied from the time of administration of the study drug upto the time of delivery of baby. Results: Both the groups were comparable to each other with respect to baseline hemodynamic parameters. SAB-induced fall in systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) was significantly less in the ondansetron group when compared with placebo from the time of initiation of SAB upto 12 min of surgery time (P < 0.05). However, the difference in heart rate between both groups was not statistically significant. The total use of vasopressors was significantly low in ondansetron group when compared with placebo (P < 0.05). Better neonatal outcomes were observed in the ondansetron group. Conclusion: Intravenous ondansetron premedication can successfully attenuate SAB-induced fall in SBP, DBP, and MAP in parturients undergoing elective caesarean sections.
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CASE REPORTS Top

Anesthetic management of an obstetric patient with idiopathic transverse myelitis: A unique approach! p. 99
Kirti N Saxena, Amrita Kaul, Mohammad Shakir
DOI:10.4103/joacc.JOACC_24_19  
Transverse myelitis (TM) is a rare neurological disorder characterized by acute or subacute bilateral inflammation and myelin destruction in the spinal cord. A 14-year-old, primigravida with idiopathic TM presented to us with 38 weeks gestation for emergency cesarean section. There are potential anesthetic concerns with general anesthesia in the form of hyperkalemia following succinylcholine and delayed reversal from nondepolarizing muscle relaxants. Taking into consideration, the above-mentioned facts and level of sensory deficit of our patient; we successfully conducted the case under monitored anesthesia care with minimal analgesic support keeping our conventional anesthetic techniques as standby.
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Transfusion-Related acute lung injury in a patient with hellp syndrome: A case report p. 102
Ranjana S Kale, Priyanka D Gorjelwar
DOI:10.4103/joacc.JOACC_17_19  
Transfusion-related acute lung injury (TRALI) is a serious adverse reaction associated with the transfusion of plasma-containing blood components, and presents as hypoxemia and non-cardiogenic pulmonary oedema within 6 hrs of transfusion. Here we are reporting a case of TRALI in 24-year-old pregnant Female presented with HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome, an emergency caesarean section delivery was performed, and blood was transfused. In such cases, clinicians should strictly monitor the patient's condition at least during the 6 hrs while the patient receives blood transfusion, and should suspect TRALI. The patient's rapid clinical deterioration with falling O2 saturation and other respiratory symptoms after transfusion supports the diagnosis of TRALI.
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Anesthetic management of a case of wolf-parkinson-white syndrome with rheumatic mitral stenosis presenting for cesarean section p. 105
Amit Jain, Indu Bala
DOI:10.4103/joacc.JOACC_6_19  
The occurrence of Wolff-Parkinson-White syndrome with rheumatic mitral stenosis is not only an uncommon entity, but also a complex scenario. Although anesthetic concerns in a parturient with Wolff-Parkinson-White syndrome have been addressed previously, to the best of our knowledge, hemodynamic consequences and anesthetic implications of Wolff-Parkinson-White syndrome with coexisting mitral stenosis have not been reported so far. We describe the successful use of a modified low-dose, low-concentration, sequential combined spinal-epidural technique for emergency cesarean section in a parturient with Wolff-Parkinson-White syndrome and severe mitral stenosis.
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Anesthetic management in a super obese parturient undergoing elective caesarean section: A case report p. 109
Kavita Jain, Beena Thada, Surendra K Sethi
DOI:10.4103/joacc.JOACC_3_19  
Obesity has become a global epidemic nowadays with a considerable rise in prevalence among reproductive age group. In obese parturients, the perinatal and maternal morbidity are more common, so it is more likely to plan for elective caesarean section. Morbidly obese parturients along with physiological and pharmacological variations pose significant challenges such as patient positioning, difficult intravenous cannulation, anticipated difficult airway, risk of aspiration, associated comorbidities, postoperative ventilatory support, and risk of thromboembolism under general anesthesia. Hence, regional anesthesia is the preferred technique; however, it can also be challenging with factors such as identification of midline and epidural space, number of attempts, accidental dural puncture, and correct placement of catheter. Here, we report a case of a 34-year-old super obese parturient with gestational hypertension and hypothyroidism who underwent elective caesarean section under combined spinal epidural anesthesia.
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Wernicke korsakoff syndrome as a rare complication of hyperemesis gravidarum: A case report p. 113
Khalil Malki, Mohammed Aabdi, Moussa Lezreg, Brahim Housni
DOI:10.4103/joacc.JOACC_16_18  
Wernicke Korsakoff Syndrome is a rare brain disorder secondary to Thiamine deficiency. We report here a rare case 40-year-old Gravida3 Para 2, at 12 weeks of gestational age with severe hyperemesis gravidarum. The symptomatology was aggravated by acute installation of drowsiness, a diplopia, and a progressive change in the state of Consciousness; symptoms suggesting Wernicke Korakoff syndrome. The diagnosis was confirmed with MRI imaging and later by thiamine level dosage. The patient conditions improved after High dosage Thiamine supplementation therapy. Wernicke's encephalopathy is a rare complication of hyperemesis gravidarum. EARLY Diagnosis and thiamine supplementation are the main keys to prevent long-term neurological sequela or death. Prevention with Thiamine supplementation should be initiated in all pregnant women with prolonged vomiting.
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