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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
Coverpage
July-December 2017
Volume 7 | Issue 2
Page Nos. 65-120

Online since Tuesday, November 7, 2017

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EDITORIAL  

Interventional radiology: A disruptive innovation which is transforming management of post-partum haemorrhage Highly accessed article p. 65
Subramanyam S Mahankali
DOI:10.4103/joacc.JOACC_47_17  
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ORIGINAL ARTICLES Top

Effect of ondansetron in attenuation of post-spinal hypotension in caesarean section: A comparison of two different doses with placebo p. 69
Meenoti P Potdar, Laxmi L Kamat, Tanya R Jha, Aditi S Talnikar, Zakera M Mahevi, Manjeet P Save
DOI:10.4103/joacc.JOACC_7_16  
Context: Spinal anaesthesia (SA) is the preferred anaesthesia for Caesarean section. Hypotension and bradycardia are the most common side effects caused by sympathetic blockade with a parasympathetic overdrive, aortocaval compression, and the Bezold Jarisch reflex (BJR) which is mediated by serotonin (5 HT3) receptors. Ondansetron is a 5HT3 antagonist commonly used as an anti-emetic. The present study evaluated the effects of two different doses of ondansetron on the haemodynamic changes associated with SA for Caesarean section and the advantage of higher dose over the other. Aims: To study the effect of ondansetron in two different doses on the haemodynamic changes associated with spinal blocks. To compare the need of vasopressors if required and the incidence of nausea and vomiting with the two different doses of ondansetron in comparison with placebo in these patients. Settings and Design: Prospective, comparative, randomized, double-blinded placebo controlled study. Materials and Methods: After hospital ethics clearance 180 parturients undergoing Caesarean section were randomly divided into 3 groups before administration of SA. Group C received 10 ml of normal saline. Group F received 4 mg ondansetron with 8 ml normal saline. Group E received 8 mg ondansetron with 6 ml normal saline. All the patients were monitored for haemodynamics, vasopressor requirement and side effects and the results were compared. Three groups were compared using one-way analysis of variance with Tukey's multiple comparison post hoc test; the results were considered significant when P < 0.05. Adverse events were analysed with Chi-square test and was significant at P < 0.01. Results: The change in the heart rate (HR) was not significant statistically. The fall of systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) was statistically significant at all time intervals intraoperatively after administration of SA (P value <0.001) when compared to pre-operative values. The fall of SBP when compared between groups was significant after administration of SA, 111.92 ± 17.36 mmHg for Group C, group F was 122.16 ± 18.68 mm Hg and group E was119.29 ± 16.88 mmHg (P value = 0.04). The incidence of hypotension in patients was lesser in the group that received ondansetron, Group C (6, 14), Group F (3, 4) and Group E (1, 6) after administration of SA and at 5 minutes after administration of SA (P value = 0.03) but comparable between the ondansetron groups. Conclusions: Intravenous ondansetron reduced the incidence of hypotension, nausea and vomiting after administration of SA but there was no added advantage of 8 mg ondansetron over 4 mg.
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A study to determine minimum effective dose of oxytocin infusion during caesarean delivery in parturients at high risk of uterine atony p. 75
Shashikiran , Harsimran Kaur, Renu Bala, Neha Gupta
DOI:10.4103/joacc.JOACC_42_16  
Background: Oxytocin, a commonly used drug to prevent uterine atony after caesarean section, should be administered as dilute rapid infusion rather than as a bolus. This study was conducted to calculate ED90 of oxytocin infusion during caesarean delivery in parturients at high risk of postpartum haemorrhage (PPH). Materials and Methods: One hundred and twenty parturients having one or more risk factors for PPH received a blinded infusion of oxytocin following emergency caesarean delivery. The initial dose of oxytocin infusion was started as 0.4 IU min−1. The dose of oxytocin infusion for the next parturient was based on the response of preceding patient in increments or decrements of 0.1 IU min−1 as per a biased-coin design up-down sequential method (UDM). Measurements of non-invasive blood pressure and heart rate were taken at 2 min intervals from the time of oxytocin infusion. Intraoperative blood loss was noted. Side effects such as tachycardia, hypotension, nausea, vomiting, chest pain, headache and flushing were also recorded. Results: The ED90 of oxytocin infusion was found to be 0.405 IU min−1 (95% confidence interval 0.3864–0.4125) as calculated by Firth's penalised likelihood estimation using a biased-coin design UDM. Hypotension was observed for brief period of time in 25.6% of parturients and brief period of tachycardia was observed in 9.4% of parturients. No headache, flushing, chest pain and vomiting were observed in any parturients in our study. The estimated blood loss was within the normal limits. Conclusion: Our study showed that ED90 of oxytocin infusion required to achieve adequate uterine tone (UT) after an emergency caesarean delivery in parturients at high risk of uterine atony was 0.405 IU min−1. The higher doses of oxytocin did not result in further improvement of UT. Therefore, early use of alternative uterotonic therapy is preferable to achieve adequate UT.
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Ultrasound-guided transversus abdominis plane block: An evaluation of its efficacy in reducing post-operative opioid requirements in caesarean section p. 81
Shahid Adeel, Priti Narayan, Mahesh M Chandrashekaraiah, Khadija A Abuhassan, Rahma M Elsemeen, Sharon Skowronski
DOI:10.4103/joacc.JOACC_46_16  
Background: Different volumes of local anaesthetic are employed in transversus abdominis plane (TAP) block to provide analgesia for lower abdominal surgeries. Our aim was to compare the efficacy of high versus low volume of bupivacaine TAP block in providing postoperative analgesia for caesarean sections. Settings and Design: Prospective, single-blind, randomized comparative study was performed during post-operative period. Materials and Methods: Sixty patients who had received spinal anaesthesia for caesarean section were randomly allocated to one of three groups: Group A received 20 ml of 0.25% bupivacaine, Group B received 30 ml of 0.166% bupivacaine on each side TAP block under ultrasound guidance, respectively, and Group C did not receive TAP block. Multi-modal analgesia comprising paracetamol, diclofenac and patient-controlled analgesia (PCA) morphine was administered to all patients. The primary outcome measure in our study was 24-h post-operative morphine consumption through intravenous (IV) PCA. Other secondary outcome measures were pain scores, nausea, sedation and patient satisfaction scores. Statistical Analysis: Statistical analysis done using analysis of variance, Fisher's Exact test and Kruskal–Wallis test. Results: Our primary outcome measure of 24-h cumulative PCA morphine consumption was 18.2 ± 6.5, 17.9 ± 8.6 and 19.4 ± 8.4 mg in groups A, B and C, respectively (P = 0.819). In the secondary outcome measures, 100% of study population in group A & B and 95% of group C had pain score of 0-3 on Numerical Rating Scale (P = 1.000) at 24 hr. 19, 15 and17 patients in group A, B and C, respectively, agreed and 1, 5 and 3 patients in group A, B and C, respectively, very strongly agreed with patient satisfaction survey for pain management (P = 0.265). Conclusion: TAP block as a part of multi-modal analgesia is debatable in the context of reducing the need of post-operative opioids. The present study was unequivocal in that two different volumes of same dose of local anaesthetic failed to demonstrate any clinical or statistical significance in decreasing post-operative opioid consumption following caesarean section.
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Comparison of analgesic efficacy of wound infiltration with bupivacaine versus mixture of bupivacaine and tramadol for postoperative pain relief in caesarean section under spinal anaesthesia: A double-blind randomized trial p. 85
Roopa Sachidananda, Vikas Joshi, Safiya I Shaikh, G Umesh, T Mrudula, M Marutheesh
DOI:10.4103/joacc.JOACC_20_17  
Background: Caesarean section is one of the most frequently performed surgeries in obstetrics. Optimal pain relief of the mother is possible with multimodal methods. Wound infiltration is one of the simplest and safe methods. The aim of the study was to compare the analgesic efficacy of wound infiltration of bupivacaine, with tramadol and bupivacaine mixture for postoperative pain. Materials and Methods: After obtaining Institutional Ethical Committee approval, 60 pregnant women of age group 18–35 years, undergoing elective caesarean section under spinal anaesthesia were included in the study. The patients were randomized into two groups of 30 each. Patients belonging to group B received bupivacaine 0.25% 0.7 mg/kg (diluted to 20 mL with normal saline), while those belonging to group T received tramadol 2 mg/kg mixed in bupivacaine 0.25% 0.7 mg/kg (diluted to 20 mL with normal saline). The time for first request of analgesia, numerical rating scale score, and cumulative consumption of diclofenac and tramadol in 24 h were compared. Results: The time for first request of analgesia in group T was 386.17 ± 233.84 min compared to group B which was 192.50 ± 134.77 (P < 0.0002). The total diclofenac consumption in the first 24 h was significantly reduced in group T when compared to group B (P < 0.0068). Conclusions: Subcutaneous wound infiltration with tramadol and bupivacaine prolongs the pain-free period and analgesic consumption after caesarean section, while it also enhances the patient satisfaction.
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Epidural analgesia in hispanic parturients: A single-blinded prospective cohort study on the effects of an educational intervention on epidural analgesia utilization p. 90
Daniel A Hansen, Reuel J Measom, Barbara Scott
DOI:10.4103/joacc.JOACC_22_17  
Introduction: Epidural analgesia for the management of labour pain in pregnant women is a common intervention. In the United States, Hispanic parturients underutilize epidural anaesthesia when compared to other ethnic groups. Data suggest that misinformation deters many women from epidural analgesia while in labour. We hypothesized that education regarding epidural analgesia provided during a prenatal visit would normalize the utilization rates of Hispanic women while in labour. Materials and Methods: We performed a prospective, single-blinded cohort study with participants of self-described Hispanic origin in the second or third trimester. Participants (n = 45) were randomly assigned to receive an educational pamphlet on epidural anaesthesia or a control pamphlet. Following completion of their pregnancy, medical records were reviewed and participants were contacted for subjective information regarding their birth experience. Results: 38.9% of the control group was compared with 34.8% of the epidural group that received epidurals for labour analgesia (P value = 0.83), with no statistically significant differences noted between the two groups. Collection of subjective comments was notable for repeated concerns regarding complications due to neuraxial analgesia. Conclusions: A passively delivered educational pamphlet on epidural analgesia is unlikely to significantly influence Hispanic parturients' utilization of epidural analgesia. Cultural differences and values should be considered when addressing epidural analgesia to Hispanic patients. Additionally, in this patient population preemptively addressing concerns of chronic back pain may help alleviate reservations regarding epidural use.
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CASE REPORTS Top

Impetigo herpetiformis and pregnancy: Anesthetic management for caesarean delivery p. 95
Susmita Bhattacharyya, Debojyoti Das, Kalyan B Mandal
DOI:10.4103/joacc.JOACC_11_16  
The case report presented here is of a primigravida who was admitted with impetigo herpetiformis and was planned for an emergency caesarean section due to fetal distress. General anesthesia was administered. Immediately after extubation, she developed severe laryngospasm, which was relieved by administration of intravenous calcium gluconate. Rest of the postoperative period was uneventful.
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Anesthesia for combined cesarean section and pheochromocytoma resection p. 97
Sadhana Kulkarni, Sudhir Kulkarni, Savani Futane, Prashant Pachore
DOI:10.4103/joacc.JOACC_41_16  
Pheochromocytoma (PCC) is a rare cause of hypertension during pregnancy [1:54000 pregnancies]. Fetomaternal morbidity and mortality is about 58% if the diagnosis is missed. Administration of anesthesia to patients with PCC is challenging. Associated pregnancy adds to the problems. This is a case report of a patient having PCC diagnosed at 26 weeks of gestation. With medical management pregnancy was continued till 34 weeks. She was posted for cesarean section and resection of PCC. Patient underwent surgery lasting for 7 h due to inferior vena cava tear and had stormy intra as well as postoperative course. Mother and baby had uneventful recovery due to continuous invasive monitoring and a good teamwork, despite limited anesthetic resources.
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Minimally invasive cardiovascular monitoring in patient with severe pulmonary hypertension for caesarean delivery p. 100
Rakesh Singla, Deep Arora, Hari H Dash
DOI:10.4103/joacc.JOACC_13_17  
Management of severe pulmonary hypertension in pregnancy poses a multitude of problems. This report presents a case of severe primary pulmonary hypertension for elective caesarean section managed successfully under combined spinal epidural anaesthesia with newer minimally invasive cardiac output monitoring.
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Anaesthetic management of a patient with hypertrophic obstructive cardiomyopathy posted for emergency lower segment caesarean section p. 103
Pradnya M Bhalerao, Pritam B Adsule, Radhika M Marathe
DOI:10.4103/joacc.JOACC_19_17  
Hypertrophic cardiomyopathy is characterised by asymmetric hypertrophy of the interventricular septum causing intermittent obstruction of the left ventricular outflow tract. This disease may present to the anaesthesiologist in an undiagnosed form during routine pre-operative visit. Surgery and anaesthesia often complicate the peri-operative outcome in this group of patients. A 22-year-old patient was brought in for emergency lower segment caesarean section. She was a diagnosed case of hypertrophic obstructive cardiomyopathy (HOCM) with severe left ventricular outflow tract obstruction and moderate subaortic stenosis. Factors such as tachycardia, hypovolemia, vasodilatation, and increased cardiac contractility leads to exacerbation of this obstruction. We managed this case successfully considering the pathological issues caused by the disease and pregnancy.
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Spontaneous pneumothorax in pregnancy: A challenge for anaesthesiologist p. 106
RM Pinto, S Mahankali, BS Prasanna, MM Ramkumar
DOI:10.4103/joacc.JOACC_29_17  
Spontaneous primary pneumothorax (SPP) in pregnancy, though rare, can be a life threatening but easily treatable cause of pneumothorax. Only few cases have been reported till date. Early recognition and prompt treatment are keystones for preventing maternal and foetal complications. We report a case of a 32-year-old pregnant lady who developed right-sided large SPP in the third trimester. This case highlights the limitations of diagnostic aids in pneumothorax, challenges posed to an anaesthesiologist (for operative delivery and definitive lung surgery), and the importance of using multimodal pain management plan to improve the outcome.
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Peri-operative management of severe pre-eclampsia with kyphoscoliosis and poliomyelitis for emergency caesarean section p. 109
Anil K Bhiwal, Seema Partani, Preeti Saini
DOI:10.4103/joacc.JOACC_36_17  
A 37 years old primigravida, 31 weeks gestation with severe preeclampsia [BP = 180/120 mm Hg] with severe kyphoscoliosis and polio affecting right lower limb was admitted in emergency with complaint of blurring of vision and pedal edema. An emergency caesarean section was conducted under general anaesthesia because of a failed spinal anaesthesia. Perioperative anaesthetic management and her postoperative course are discussed.
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Wheeze in pregnancy: Sometimes a pain in the neck to diagnose p. 112
Nikki Higgins, Tasneem Pirani, Stefan Braunecker
DOI:10.4103/joacc.JOACC_46_17  
Background: Upper airway obstruction can present with stridor or wheeze and is sometimes misdiagnosed as asthma. As asthma is common amongst pregnant women, upper airway obstruction can remain hidden. Case: We describe the case of goitre-related life threatening upper airway obstruction which was initially thought to be poorly controlled asthma in a pregnant woman. Careful history, high clinical suspicion and directed imaging was required to make the diagnosis. A multi-disciplinary team and meticulous planning was required to safely treat the parturient. Conclusion: As asthma has an incidence of 3%-12% among pregnant woman; wheezing is likely to be diagnosed as asthma. Our case illustrates the importance of detailed history, examination and imaging in the parturient who presents with wheeze. It also highlights the added complexity of managing a patient with a life threatening airway problem while she is pregnant.
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ABSTRACTS Top

Selected abstracts of free papers presented during 10th national conference of association of obstetric anaesthesiologists held in Bengaluru on October 1st and 2nd 2017 p. 115

DOI:10.4103/2249-4472.217780  
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