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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
January-June 2021
Volume 11 | Issue 1
Page Nos. 1-52

Online since Friday, April 16, 2021

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Enigma of valid consent continues in 2021…… Highly accessed article p. 1
Aditi Tilak, Shilpa Kasodekar
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Conversion of labour epidural analgesia to anaesthesia for emergency caesarean section: A retrospective audit p. 5
Sunil Thakorbhai Pandya, Jyotsna Mikkilineni, Manokanth Madapu
Aim: to determine the rates of failed conversion of EA to surgical anaesthesia for patient and clinician information and benchmarking, and to develop an algorithmic approach for safe conversion of EA. Materials and Methods: A retrospective audit of parturients who had labour epidural analgesia (EA) at an advanced tertiary care institute for women and newborn health in south India. Information on EA, caesarean sections, conversion of EA, failure of regional anaesthesia, use of general anaesthesia, alternate techniques and supplemental medications were retrieved from electronic medical records. Results: Emergency cesarean section (CS) was performed for 4,259 (26.93%, 95% CI: 26.25, 27.63) of 15, 812 parturients that had EA at the study institute between Jan 2012 and December 2016. The EA was successful in 4,078 (95.75%, 95% CI: 95.11, 96.32) of these 4,259 women. Seventy three (1.71%, 95% CI: 1.37, 2.15) of the 4,259 women reported mild discomfort on the VAS for pain and required supplemental sedation for the emergency CS and 108 (2.53%, 95% CI: 2.11, 3.05) of the 4,259 women needed alternate techniques. The failure rate of EA was thus 4.25% (95% CI: 3.68, 4.89, n = 181) in this audit. Conclusions: The failure rates of EA at the study institute are well within the recommended standards of the RCA (Royal College of Anaesthesiologists – UK). This audit helped us to develop an algorithmic approach to further improve performance based on problems identified during the audit.
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Taurine as an adjunct therapy for early left ventricular recovery in peripartum cardiomyopathy p. 9
Hany V Zaki, Mohamed S Sweed, Rania M Ali, Mohamed A Abdelhafeez
Background and Aims: The pathophysiology of peripartum cardiomyopathy is not fully understood. Despite standard medical therapy, both morbidity and mortality remain high. Restoration of inflammatory cytokine balance may hold promise for therapy. Taurine has a powerful immune-modulatory and anti-inflammatory in addition to positive inotropic effect. This study evaluates the effect of taurine infusion on clinical status, left ventricular function, circulating plasma levels of N-terminal brain natriuretic peptide and C-reactive protein in women with peripartum cardiomyopathy. Methods: Forty women with peripartum cardiomyopathy admitted postpartum to the ICU were randomly assigned to one of two groups (20 in each group): Group T received taurine infusion and Group C received normal saline infusion over 24 hours for 5 days. Both groups received standard heart failure therapy according the institutional treatment protocol. Results: In the taurine group on day 5, there was a significant reduction in LVEDD and LVESD and significant increase in LVEF. All patients had an improvement in LVEF of at least 10% and 5 patients had recovery of LVEF to ≥50% on day 5 while the other 15 patients had LVEF 45- 50%. In the control group on day 5, there was non-significant change in LVEDD, LVESD and LVEF and no patient had recovery of LVEF to ≥50% or showed improvement in LVEF more than 10%. NYHA functional class showed significant increase on day 5 in the taurine group compared to the control group. Seventeen patients (85%) in the taurine group showed improvement of the NYHA functional class at day 5. In contrast, only 2 patients (10%) in the control group showed improvement of NYHA functional class at day 5. Conclusion: Early addition of taurine infusion to standard heart failure therapy improves both; echocardiographic parameters and laboratory parameters but without clinically significant changes in women with peripartum cardiomyopathy.
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Intravenous ondansetron to prevent hypotension during cesarean section under spinal anaesthesia p. 15
Anil Kumar Bhiwal, Kunal Chauhan, Savita Choudhary, Heena A Bhatt, Sunanda Gupta
Background: Spinal anesthesia for cesarean section (CS) is associated with common side effects like hypotension and bradycardia. Ondansetron, a 5HT3 receptor antagonist, inhibits Bezold-Jarish reflex and has been found to be effective for prevention of spinal-induced hypotension for elective cesarean section. Aims: The aim of this study was to evaluate the effect of two different doses of ondansetron as prophylaxis to prevent hypotension during spinal anesthesia for caesarean section. Materials and Methods: This prospective randomized double-blinded controlled study was conducted on 150 full-term parturients undergoing CS under spinal anesthesia, who were divided into three groups, receiving saline or different drug doses: Group C: 0.9% Normal Saline 10 ml; Group O4: 4 mg Ondansetron in 8 ml NS; or Group O8: 8 mg Ondansetron in 6 ml NS, 5 min before spinal anesthesia. All the patients were monitored for blood pressure, heart rate, vasopressor requirement, and side effects. Hemodynamic variables and demographic data were compared by analysis of variance (ANOVA) and Chi-square test was used for analyzing adverse effects and P value <0.05 was considered significant. Results: Intraoperative incidence of hypotension was significantly high (P < 0.001) in group C (58%) as compared to group O8 (16%) and group O4 (31.25%) but comparable between ondansetron groups (O8 vs. O4) (P = 0.074). Total requirement of ephedrine (mg) was significantly higher (P < 0.01) in group C (5.02 ± 4.95) as compared to group O8 (1.2 ± 3.20) and O4 (3.00 ± 4.88). It was found to be significantly higher (P = 0.034) in group O4 when compared with group O8. Mean HR, SBP, DBP, MAP was decreased more in group C at different time intervals. Conclusions: Prophylactic intravenous ondansetron reduced the incidence of hypotension and requirement of vasopressors in parturients undergoing CS under spinal anesthesia, with a further decrease in requirement of vasopressor in Group O8.
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Evaluating anesthesia practice for caesarean section: A prospective cross-sectional study from a tertiary care institution of low- and middle-income country p. 20
Samina Ismail, Malika Hameed
Background and Objective: In low and middle-income countries (LMICs), general anesthesia for cesarean section has shown to increase the odds of maternal mortality. Use of regional anesthesia for cesarean section is an indicator for safe practice of anesthesia; therefore, this study aims to evaluate the current practice of use of regional anesthesia and its failure rate for cesarean section. The current practice is analyzed in the light of previously published data from the same institution of LMIC. Methods: After hospital ethics committee approval, this prospective cross-sectional study was performed from January 1 to June 30, 2019. Prospective data collected on predesigned form included technique of anesthesia employed for different category of cesarean section, failure of regional anesthesia, and other related data. The cesarean section rate and trends of technique of anesthesia over last 10 years were collected from hospital record system. Results: Compared to the published data from the year 2012 from the same institution, the results from this prospective data have shown an increase rate of cesarean section rate from 31% to 52% with an overall decline in the use of general anesthesia from 49% to 12.3%. In addition, rate of regional anesthesia for category 1–3 cesarean section has increased from 46.4% to 79.8% and for category 1 from 37.1% to 63.4%. Decline in failure rate of regional technique was observed from 6.7% to 2.4%. Conclusion: Assessing and analyzing practices helps in taking initiative to implement safe practices which are needed to achieve the target for best practice.
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Methaemoglobinemia in pregnancy: Case series and literature review p. 25
Hari Kishan Boorugu, Makarand Anil Rane, G Usha, Hemamalini Vadlamani, Manokanth Madapu, Anisha Gala
Background: Methaemoglobinemia is a rare disease complicating pregnancy and often diagnosed for the first time in perioperative or peripartum setting. Aim: To analyse the type of methaemoglobinemia, clinical presentation and pregnancy outcomes in our series of pregnant women with methaemoglobinemia. Methods: This is a single centre retrospective study of patients with methaemoglobinemia admitted between 2003 and 2015. Results: We had six pregnant women with methaemoglobinemia during the study period. Three women had congenital methaemoglobinemia and three of them had acquired methaemoglobinemia. Obstetric and foetal outcomes were good. Conclusion: Congenital methaemoglobinemia is reasonably well tolerated in pregnancy. With proper counselling, follow-up, avoidance of drugs associated with methaemoglobinemia and prompt diagnosis and management especially in cases of acquired methaemoglobinemia, we can achieve good pregnancy outcomes.
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Complications of severe pre-eclampsia associated with acute intestinal intussusception—A case report p. 30
Jemea Bonaventure, Berinyuy Emelinda Nyuydzefon, Iroume Cristella Raissa Bifouna, Esiene Agnes
We present a challenging case of severe pre-eclampsia later complicated by eclampsia, severe renal failure, intestinal intussusception, septic shock, and stroke in a 26-year-old female primigravid patient in third trimester. We navigate through the diagnostic and therapeutic challenges faced in managing our patient to bring out lessons and proposals to prevent and manage similar cases in the future.
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Development of fast atrial fibrillation in an awake parturient undergoing elective caesarean section p. 33
Gregg James Baxter
A 25 year-old, fit and well, G2P1 woman presented for elective caesarean section under spinal anaesthesia for breech presentation. Following a straight forward spinal anaesthetic and initial progression of surgery, the patient developed atrial fibrillation with a fast ventricular response shortly after delivery and bolus of 5 units of oxytocin. Attempts to restore sinus rhythm with pharmacological methods were unsuccessful and ultimately the patient required electrical cardioversion. An RSI was performed as the patient was still within the first 48 hours post-delivery. Upon laryngoscopy, the patient reverted to sinus rhythm without the need for DC cardioversion. After a short stay in the hospital, the patient was discharged with outpatient ECHO and follow-up awaited. Blood, including thyroid function tests, were unremarkable pre-, intra- and post-operatively. This case report highlights the rarity of development of AF whilst also covering the management of this arrhythmia in the context of the awake parturient.
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Management of cesarean section in a patient with history of takotsubo cardiomyopathy-A case report p. 36
Aayush Kulshrestha, Ketan S Parikh
Takotsubo cardiomyopathy (TTCM), also known as stress-induced cardiomyopathy or “broken heart syndrome,” is a clinical entity characterized by acute left ventricular dysfunction and reversible cardiac failure in the absence of coronary artery disease. Obstetric patients with a history of peripartum TTCM pose a unique challenge to the anesthesiologist. With a multiplicity of issues to be considered and no recommendations for best practice, the management plan needs to be tailored for each parturient to minimize the stress associated with labor and delivery. We present the case of an apparently healthy parturient with a history of peripartum TTCM presenting for a subsequent cesarean section and outline the various issues an anesthesiologist might encounter.
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Bilateral subdural effusions and brainstem sagging following labor epidural—Case report and literature review p. 39
Joanna M Krawczyk, Jake Hartford-Beynon
Epidural analgesia is a technique commonly used in labor. Intracranial subdural hygromas are a rare complication of neuraxial techniques and have only been reported in a handful of patients. We report a case of a female with postpartum headache, presenting 5 days after delivery where epidural analgesia was used, who was found to have bilateral subdural effusions and brainstem sagging. Our literature review summarizes pathophysiology, imaging, and approach to treatment, as well as guidance on long-term outcomes and follow-up needed in this patient population.
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Magnesium sulfate toxicity – Are serum levels infallible? p. 43
Sendhil C Arumugam, Aanandini Takkellapati, Lopamudra B John
Since a century, we have been using magnesium sulfate for prophylaxis and treatment of eclamptic seizures. There are various regimens followed throughout the world. Although the efficacy is of no doubt, side effects remain a problem. Here, we present a rare case of magnesium toxicity with normal serum magnesium levels.
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Subdural injection: A possible cause of loss of consciousness during cesarean section p. 46
Mohamad Ali Barada, Saleh Kanawati, Omar Rajab, Zoher Naja
Spinal anesthesia is commonly used for cesarean section as it is safe and effective. However, subdural block can occur which might lead to loss of consciousness. We hereby report a parturient who received epidural analgesia for normal vaginal delivery followed by spinal anesthesia for emergency cesarean section and lost consciousness for 5 min after 10 min of spinal anesthesia induction.
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Anesthesia options for caesarean delivery of a paraplegic parturient with transverse myelitis: Past and present p. 48
Berrin Gunaydin, Didem T Akcali, Metin Alkan, Gozde Inan
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Anesthesia for cesarean section in a patient with von willebrand's disease p. 49
Nitu Puthenveettil, Juby Mathew, Sunil Rajan, Lakshmi Kumar
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Total intravenous anesthesia for anesthetic management of emergency caesarean section in a patient with moyamoya disease p. 50
Dimple Pande, Sakshi Gandotra, Anju Gupta
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Erratum: Impact of labor epidural analgesia on maternal and neonatal outcomes with trial of labor in previous caesarean delivery: A prospective, controlled, longitudinal study p. 52

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