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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
Coverpage
January-June 2022
Volume 12 | Issue 1
Page Nos. 1-78

Online since Monday, March 14, 2022

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EDITORIAL  

High flow nasal cannula (HFNC) and video laryngoscope (VL) as essential adjuncts in management of obstetric difficult airway: Efficacious tools or simply an industry push! p. 1
Anjan Trikha, Manpreet Kaur
DOI:10.4103/JOACC.JOACC_108_21  
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REVIEW ARTICLE Top

Anaesthesia for assisted reproductive technology (ART): A narrative review Highly accessed article p. 5
Ranjana Khetarpal, Veena Chatrath, Puneetpal Kaur, Anjan Trikha
DOI:10.4103/JOACC.JOACC_63_21  
Assisted reproductive technology (ART) is used primarily to address the treatment of infertility which includes medical procedures such as in vitro fertilisation (IVF), intra-cytoplasmic sperm injection (ICSI), gamete intra-fallopian transfer (GIFT) or zygote intra-fallopian transfer (ZIFT). IVF has revolutionised infertility treatment and is nowadays widely accepted all over the world. The IVF is carried out as a daycare procedure and many anaesthetic regimens have been studied, tried and tested so far. An anaesthesiologist's role mainly comes into play during trans- vaginal oocyte retrieval and embryo transfer (ET) process of IVF. Various techniques of anaesthesia are practised which include general or regional anaesthesia, conscious sedation or monitored anaesthesia care, patient-controlled analgesia, acupuncture and transcutaneous electrical nerve stimulation (TENS). The anaesthetic management needs careful consideration of the effect of drugs on the maturation of oocytes or embryonic development, fertilisation and pregnancy rates. In view of the Coronavirus disease-19 (COVID-19) pandemic, ART clinics have been affected and due to the ambiguity of its effects on the reproductive outcome, anaesthesiologists need to be vigilant and cautious with anaesthetic management during pandemic times. This review includes a discussion of various anaesthetic options and agents along with their advantages or disadvantages if any. The literature sources for this review were obtained via PubMed, Medline, Cochrane Library and Google Scholar. The results of 82 out of 110 articles discussing different methods of anaesthesia for ART procedures over 25 years were compiled.
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ORIGINAL ARTICLES Top

Evaluation of 0.25% bupivacaine vs. 0.375% ropivacaine for postoperative analgesia using ultrasound guided transversus abdominis plane block for caesarean section: A comparative study p. 17
Damodar Puchakala, Vidya Sagar Joshi, Avanish Bhardwaj
DOI:10.4103/JOACC.JOACC_28_21  
Background: Pain after Caesarean section is described as moderate to severe by most patients. Ultrasound guided transversus abdominis plane (TAP) block is now increasingly being used for postoperative analgesia in lower abdominal surgeries. Hence this study was undertaken to compare 0.25% Bupivacaine with 0.375% Ropivacaine for postoperative analgesia using TAP block in caesarean section. Methods: Seventy patients were randomized into Group B (n = 35) and Group R (n = 35). TAP block was administered after completion of surgery under ultrasound guidance using 15 mL of 0.25% Bupivacaine in Group B and 15 mL of 0.375% Ropivacaine in Group R on each side of the abdomen. Time to requirement of first analgesic dosage was observed in both the groups. Total analgesic requirement in the first 24 h, visual analogue scale (VAS) scores at 2, 4, 6, 8, 12 and 24 h, patient satisfaction and complications were also noted. Results: Mean time for the first dose of rescue analgesia after completion of surgery was 298.2 ± 93.6 min in Group B and 447.6 ± 85.2 min in Group R (P = 0.0001). Total requirement of Diclofenac Sodium injection was 162.86 ± 46.88 mg in Group B whereas it was only 130.71 ± 44.49 mg in Group R (P = 0.003). VAS at 4,6 and 8 h after surgery were significantly lower in the Ropivacaine group. Conclusion: 0.375% Ropivacaine provided longer duration of analgesia and resulted in lesser analgesic requirement than 0.25% Bupivacaine when used in TAP block after caesarean section.
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Comparison of intravenous infusion versus bolus dose of oxytocin in elective caesarean delivery: A prospective, randomised study p. 22
Jigisha P Badheka, Vrinda P Oza, Nitin S Manat, Mayur B Patel
DOI:10.4103/JOACC.JOACC_33_21  
Background: Oxytocin (OT) is routinely administered during caesarean delivery to prevent and treat postpartum haemorrhage (PPH). The common adverse effects of intravenous OT are tachycardia, hypotension, chest pain, Electrocardiogram (ECG) changes, nausea and vomiting. We aimed to compare the uterine contractility, haemodynamic changes, need for other uterotonics and adverse effects by comparing the intravenous bolus dose versus infusion dose of OT while retaining its benefits. Methods: Sixty patients undergoing elective caesarean delivery under spinal anaesthesia were randomised to receive OT 3 IU as a bolus (repeat 3 IU at an interval of 3 min) in group B (Bolus) or as an infusion 1 IU per minute in group I (infusion). The uterine tone was assessed by a blinded obstetrician as either adequate or inadequate. The intraoperative heart rate, blood pressure, blood loss and any other adverse events were recorded. Results: The adequacy of uterine tone was more sustained and the requirement of other uterotonics was less in group I. The heart rate increased to 20–25 beats/min at 3–5 min in group B and 8–10 beats/min at 2–4 mins and reached the baseline at 8–9 min in group B as well as in group I. Also, a significant fall in the mean blood pressure was observed at 3–5 min in group B. The ECG changes (ST-T changes) were more common in group B compared to group I. There was no significant difference in the estimated blood loss between the two groups. Conclusion: The infusion dose of OT provides more haemodynamic stability, better uterine tone and fewer adverse effects compared to the bolus dose.
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Enhanced recovery after cesarean protocol versus traditional protocol in elective cesarean section: A prospective observational study p. 28
Sunanda Gupta, Apoorva Gupta, Aditi S Baghel, Karuna Sharma, Savita Choudhary, Vidhu Choudhary
DOI:10.4103/JOACC.JOACC_16_22  
Background: Enhanced recovery programs result in reduced morbidity in terms of effective pain control, reduced length of stay (LOS), and an earlier return to normal activities. This study has been conducted to compare Enhanced recovery after caesarean (ERAC) protocol to traditional care of cesarean section (CS) in our institute. Materials and Methods: Patients undergoing elective CS were subjected to ERAC protocol (Group A; n = 100) for first six months and traditional protocol (Group B; n = 100) for next six months. Primary outcome was comparison of total duration of stay (readiness to discharge) in the hospital, whereas secondary objectives were intraoperative hemodynamic control and requirement of vasopressor, comparison of Visual Analogue Scale (VAS) scores and requirement of analgesics in 24 hrs, barriers to implementation of ERAC components, urinary retention and need of recatheterization and any adverse events perioperatively. Results: Significant reduction in LOS or readiness for discharge was found in Group A; 2.85 ± 0.5 vs 5.25 ± 0.61 hrs in Group B (p < 0.0001). Episodes of hypotension and requirement of phenylephrine was significantly more in Group B. (p < 0.0001) VAS scores in Group A were significantly less postoperatively with significant reduction in consumption of rescue analgesic in 24 hrs. (p < 0.001) Components of ERAC protocol were implemented successfully with significant difference in time of ambulation, decatheterization, and resumption of oral feed postoperatively. Conclusion: Implementation of ERAC results in significant reduction in LOS in hospital with better pain relief and reduced postoperative opioid requirement following cesarean delivery.
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Lung involvement in COVID-19 positive pregnant women and their outcomes – A clinical and imaging based retrospective case study p. 34
Mangal S Venkataraman, N Basker, Lakshmi Prakash
DOI:10.4103/JOACC.JOACC_32_21  
Background and Aims: COVID-19 has been a globally concerning pandemic affecting more than 20 million people worldwide. Due to physiological and anatomical changes, pregnant women are more susceptible to viral respiratory infections. Although the clinical and radiological features of COVID positive pregnant and non-pregnant women are comparable, literature pertaining to the clinical presentation and the outcomes in COVID positive pregnant women are being researched upon. Aims and Objectives: The main objective is to assess the lung involvement in COVID-19 positive pregnant women based on their clinical presentation and CT imaging features. The secondary aim is to study their clinical outcomes based on the above findings. Methods: This was a retrospective study carried out on COVID-19 positive pregnant women admitted to our hospital over 6 months (from May 2020 to October 2020). The collected data were analyzed with IBM.SPSS statistics software 23.0 Version. Results: There were a total of 480 COVID positive antenatal women detected Out of 480 patients 75.8% (364) were asymptomatic, one hundred and two patients (21.3%) presented with mild symptoms such as fever, dry cough, runny nose, loss of taste/smell without any breathing difficulty. Fourteen patients (2.9%) were identified in the moderate to severe symptomatic category with lung involvement with a 95% Confidence Intervals between 1.41 and 4.42. Three patients sustained mortality, the overall Mortality rate being 0.6%. Conclusion: The majority of the COVID positive antenatal women are asymptomatic or present with mild symptoms as detected from this study. Only a small proportion (2.9%) were identified with respiratory compromise. Although their infectivity rate is quite high, 99.4% of the population were cured and discharged.
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Anaesthetic complications during elective caesarean delivery and outcomes: A nigerian multi-centre cohort study p. 39
Simeon O Olateju, Babatunde B Osinaike, Omotayo F Salami, Adedapo O Adetoye, Oluwabunmi M Fatungase, Olurotimi I Aaron, Aramide F Faponle, on behalf of NiSOS
DOI:10.4103/JOACC.JOACC_62_21  
Background: Elective caesarean deliveries are planned procedures which are not without complications and unfavorable outcomes. We aimed to assess anaesthetic complications, risk factors and outcomes during caesarean delivery in Nigerian hospitals. Materials and Methods: Using a standardized template, we conducted a multi-centre prospective cohort study of parturients presenting for elective caesarean deliveries over a seven-day period in 49 hospitals. Demographic data of enrolled parturients, anaesthetic and surgical characteristics, complications; maternal and neonatal outcomes; ICU admissions and indications were collected. Results: A total of 237 parturients were studied. Previous caesarean section 50 (21%) and preeclampsia 25 (10.5%) were the most common indications for surgery. Regional technique was the most frequently used anaesthetic technique 221 (93.2%). Hypotension was more common with regional technique 29 (13%) than with general anaesthesia 6 (1%). The vast majority (71.8%) of those that developed complications had co-morbidities. Six patients were admitted to the ICU. Obstetric haemorrhage and severe preeclampsia were the most common indications for ICU admissions, 50% and 33% respectively. Two intraoperative cardiac arrests occurred with one survivor. There was one fresh stillbirth, three neonatal admissions and no neonatal death. Conclusion: Hypotension was the most common intraoperative complication during elective caesarean section whilst obstetric haemorrhage remained the major indication for ICU admissions with good outcomes.
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Pleth variability index measured in the sitting position before anesthesia can predict spinal anesthesia-induced hypotension in cesarean section: An observational study p. 47
Erhan Ozyurt
DOI:10.4103/JOACC.JOACC_97_21  
Background: Hypotension induced by spinal anaesthesia during caesarean section can have devastating effects on the parturient and foetus. This study investigated the ability to predict spinal anaesthesia-induced hypotension via the perfusion index and pleth variability index in the sitting position caesarean section. Materials and Methods: We enrolled 46 patients undergoing elective caesarean section in this study and used standard anaesthetic management in all patients. The haemodynamic parameters, perfusion index and pleth variability index of the patients were recorded at specific time points. Results: Hypotension occurred in 61.4% of the patients. There was a difference in the pleth variability index values between patients with and without hypotension at baseline as well as in the sitting position and after spinal anaesthesia (P = 0.023, 0.001, and 0.040, respectively). According to the receiver operating characteristic curve analysis, the pleth variability index value of the patients in the sitting position was a predictor of spinal anaesthesia-induced hypotension (area under the curve = 0.780, 95% confidence interval [CI]: 0.633–0.927, P = 0.001). The cut-off value of the pleth variability index (in the sitting position) for predicting hypotension was 20.5% (sensitivity: 76.5%, specificity: 70.4%). Multivariate logistic regression analysis revealed that an increased pleth variability index in the sitting position before spinal anaesthesia was an independent risk factor of spinal anaesthesia-induced hypotension (odds ratio: 0.78, 95% CI: 0.62–0.98, P = 0.034). Conclusion: The pleth variability index in the sitting position before spinal anaesthesia is a useful tool for predicting spinal anaesthesia-induced hypotension during caesarean section.
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CASE REPORTS Top

Anaesthetic considerations for the parturient with myogenic differentiation-1 gene-related congenital myopathy and pre-eclampsia: A case report p. 53
Hafiza B Misran, David W Hoppe, Andrew J Colls, Yayoi Ohashi
DOI:10.4103/JOACC.JOACC_71_21  
We present the anaesthetic management of a parturient with myogenic differentiation-1 gene-related congenital myopathy who presented for urgent caesarean section due to pre-eclampsia and respiratory failure. The challenges we faced include chronic respiratory failure with diaphragmatic dysfunction, difficulties with neuraxial anaesthesia, potential risk of triggering malignant hyperthermia in an unknown myopathy, and the complexities of multidisciplinary team involvement. As there is limited medical literature regarding this condition, we believe this is the first case report describing the anaesthetic care of a pregnant patient with this rare congenital myopathy.
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Case report: Utilisation of the paramedian approach to epidural insertion in a case of klippel-feil syndrome p. 56
James R Skelly, Siaghal MacColgáin
DOI:10.4103/JOACC.JOACC_72_21  
Klippel–Feil Syndrome (KFS) is a complex heterogeneous entity that can result in cervical spondylosis and thoracolumbar vertebral fusion. Combined, these features contribute to both a difficult airway and neuraxial anaesthesia. Previously, these patients required general anaesthesia in the obstetric setting, incorporating advanced airway techniques as the first line. Herein, we describe the novel use of the paramedian approach to epidural anaesthesia in a primigravid woman, with a background of KFS. The patient had a vaginal septum and double cervix and was considered at higher risk of obstetric complications. Antenatal assessment and forward planning within the multidisciplinary team setting were vital in the formulation and provision of safe care for this patient. Neuraxial ultrasound (US), undertaken at preassessment, yielded adequate views of the posterior complex in the paramedian sagittal oblique plane only. An anaesthetic plan with emphasis on early paramedian epidural insertion was thus formulated. The patient was admitted to early labour by the obstetric team. Neuraxial US replicated the previously attained windows and in keeping with the plan, the paramedian approach was utilised with successful insertion on the first attempt. Patient-controlled epidural anaesthesia infusion was utilised over her 6-hour labour with instrumental delivery. Epidural analgesia was maintained with a bilateral T6 sensory block with the patient comfortable throughout. This case study outlines the novel use of the paramedian approach to epidural anaesthesia in a patient with KFS. We also believe it exemplifies the need to pre-assess patients with abnormal spinal anatomy and utilises the neuraxial US to formulate an anaesthetic plan.
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Spontaneous postpartum intracranial haemorrhage: A case report p. 59
Matthew D Smith, James L Walker, Sukruta Pradhan, Felecia A Newton
DOI:10.4103/JOACC.JOACC_81_21  
Pregnancy-associated strokes are rare but can have detrimental effects on both mother and baby. A young female patient, 6 days postpartum, suffered a spontaneous intraparenchymal haemorrhage (IPH) and subarachnoid haemorrhage (SAH). The patient exhibited aphasia, right facial droop and right hemiparesis. Serial imaging showed no vascular malformation or other cause of her haemorrhages. Our pregnant patient presented with concurrent IPH and SAH. Given the timing of her stroke and the absence of underlying vascular lesion, it is possible her stroke was a case of IPH and SAH due to reversible cerebral vasoconstriction syndrome (RCVS). More specifically, it may reflect postpartum angiopathy, a subtype of RCVS presenting around 5 days postpartum. Alternatively, this could simply be a subarachnoid extension of a primary IPH.
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Neuraxial anesthesia for a laboring patient with hereditary spastic paraplegia: A case report p. 62
Joshua Falescky, Madina Gerasimov, Judith Aronsohn, Gregory Palleschi
DOI:10.4103/JOACC.JOACC_79_21  
Hereditary spastic paraplegia (HSP) is a rare, inherited condition affecting the corticospinal tract, typically characterized by bilateral lower extremity weakness and stiffness. HSP presents challenges to anesthetic management, particularly in the obstetric population due to the paucity of existing recommendations in the literature. Although case reports exist regarding the successful use of general and neuraxial anesthesia for cesarean section, none currently exist with regard to labor analgesia. Here, we report the use of labor epidural anesthesia in a 29-year-old woman with HSP. She delivered via cesarean delivery after laboring for 27 h with an epidural catheter in place. The patient tolerated epidural placement well with no adverse neurologic sequelae. The utilization of neuraxial techniques avoids the risks associated with airway manipulation in a parturient and obviates the need for the use of muscle relaxants in the setting of upper motor neuron disease. Epidural anesthesia appears to be a safe approach to the management of labor and cesarean delivery in a parturient with HSP.
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Successful anesthesia case of emergency cesarean section complicated with pregnancy-related group: A streptococcus sepsis p. 64
Yuta Kawatsu, Mitsunori Miyazu, Taiki Kojima
DOI:10.4103/JOACC.JOACC_66_21  
Pregnancy-related Group A streptococcus (GAS) sepsis is a rare, rapidly progressing life-threatening disease. Previous reports described the clinical features of pregnancy-related GAS sepsis, however, the evidence regarding general anesthesia is extremely limited. This report aims to alert anesthesiologists that pregnancy-related GAS sepsis is an emerging life-threatening disease and to describe the clinical issues when performing general anesthesia in the emergency cesarian section. We describe the case of a 37-year-old pregnant woman with undiagnosed pregnancy-related GAS sepsis who exhibited rapid, progressive circulatory collapse. Attentive anesthesia management and smooth transition to the cesarean section resulted in saving both the mother and baby without any complications. The evidence regarding anesthesia management in pregnancy-related GAS sepsis is extremely lacking. To make the diagnosis of GAS sepsis before initiating the emergency cesarean section was challenging under rapid deterioration. Anesthesiologists should consider GAS sepsis in pregnancy with aggressive septic features and prepare for the fatal intraoperative complications during general anesthesia.
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Spinal anaesthesia, a special consideration in antiphospholipid antibody syndrome in pregnancy: A case series p. 67
Eesha Banerjee, Suravi Samanta, Soumya Samal
DOI:10.4103/JOACC.JOACC_74_21  
Antiphospholipid syndrome (APLA) is an acquired autoimmune disorder, clinically characterised by the development of thrombosis and obstetric morbidities comprising recurrent miscarriages, fetal deaths and premature births resulting from placental insufficiency such as intrauterine growth restriction and pre-eclampsia. It is the most common acquired hypercoagulable state where the focus of management is anticoagulation for the prevention of thrombosis.We report three cases of primary APLA syndrome in parturients at term with history of multiple abortions, being managed with oral aspirin and low molecular weight heparin posted for elective caesarian section. All three parturients were given single shot atraumatic spinal anaesthesia achieving a level of sensory blockade up to T6 since their coagulation profile showed no abnormalities. Antiphospholipid-antibody syndrome requires a multidisciplinary approach during pregnancy where use of anticoagulants may lead to dilemma of their perioperative continuation. Discontinuation of anticoagulants is a double-edged sword requiring careful deliberation on the part of anaesthetist to reduce the risk of perioperative bleeding.
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A rare case of fetal gas gangrene following premature rupture of membranes in the second trimester diagnosed with the aid of computed tomography p. 70
K V. Venkatesha Gupta, AK Ajith Kumar, Modhulika Bhattacharya, Pooja R Murthy, K Sarath
DOI:10.4103/JOACC.JOACC_85_21  
Introduction: To report a rare case of foetal gas gangrene following premature rupture of membranes in the second trimester diagnosed with the aid of computed tomography. Case Report: A 33-year-old lady, with G4A2L1, booked and vaccinated, developed premature rupture of membranes at 25 weeks of gestation. She developed severe abdominal pain with high-grade fever on the fourth night after expectant management with intravenous antibiotics and close monitoring. As there was a new-onset shock, she was referred to the higher centre from the obstetric care unit. The ultrasound of the abdomen and pelvis in the emergency room ruled out other causes of shock but confirmed intrauterine death. After planning for vaginal delivery, she had further deterioration requiring intubation and vasopressors. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis was performed which showed foetal gas gangrene and bilateral acute cortical necrosis. Emergency hysterotomy, performed under high-risk consent delivered macerated foetus. She had atonic uterus and required obstetric hysterectomy under general anaesthesia (GA). Her post-partum course was complicated by disseminated intravascular coagulopathy (DIC), acute respiratory distress syndrome (ARDS) and multiorgan dysfunction syndrome requiring multiple transfusions, prone ventilation and multiorgan support. However, she could not be salvaged and died on the 2nd day of surgery. Conclusion: We describe a rare fatal case of foetal gas gangrene in the second trimester following premature rupture of membranes which was diagnosed by a computed tomography (CT) scan of the abdomen and pelvis. The CT scan reliably identifies emphysematous changes in the amniotic cavity and foetal parts which helps in decision-making from the induction of labour to early surgical approach to prevent peritonitis and multiorgan failure. We recommend early CT scan in pregnancies complicated by intrauterine infections with shock which can change the line of management.
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Anaesthetic management of a patient with sub-valvular aortic stenosis for emergency lower segment caesarean section: A case report p. 74
Anita R Chhabra, Prajakta D Shinde, Vijay L Shetty, Atul M Ganatra
DOI:10.4103/JOACC.JOACC_48_21  
Sub-valvular aortic stenosis (SAS) occurs due to a fibrous membrane or a muscular narrowing causing left ventricular outflow tract obstruction. The physiological changes of pregnancy may exacerbate the cardiac condition posing significant challenges for anaesthesia and surgery. A 34 years primigravida, with 32 weeks gestation, a known case of sub-valvular aortic stenosis presented in the emergency room in view of leaking/bleeding per-vagina. Risk factors such as tachycardia, decrease in afterload, preload and increased left ventricle contractility lead to exacerbation of the obstruction and should be avoided. We report a successful anaesthetic management of her lower segment cesarean section while balancing the physiological changes of pregnancy superimposed by pathology of the disease.
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LETTER TO EDITOR Top

Pregnancy in thalassemia: Correspondence p. 78
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/JOACC.JOACC_106_21  
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