Research & Innovation in Anesthesia

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2023 | July-December | Volume 8 | Issue 2

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Original Article

Nutan D Kharge, Yogita S Patil, Nirav M Kotak, Angha Pujari, Rajendra D Patel

Comparison of Laryngeal Mask Airway Cuff Pressure Changes with Nitrous Oxide and Oxygen vs Room Air Used for LMA Cuff Inflation: A Prospective Randomized Study

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:5] [Pages No:33 - 37]

Keywords: General anesthesia, Intracuff pressure, Laryngeal mask airway

   DOI: 10.5005/jp-journals-10049-2030  |  Open Access |  How to cite  | 


Introduction: Laryngeal mask airway (LMA) are devices that facilitate oxygenation and ventilation without endotracheal intubation. During general anesthesia (GA), nitrous oxide (N2O) can diffuse into the air-filled LMA cuff more rapidly than air. The increased cuff pressure may lead to malpositioning of the LMA, inadequate seal, ineffective ventilation, airway contamination, decreased mucosal capillary perfusion, and increased pharyngolaryngeal morbidity. The aim of this study was to compare cuff pressure changes and efficacy to maintain stable LMA intracuff pressures with air in one group and O2 (oxygen):N2O (50:50) mixture in the other and to study perioperative complications. Materials and methods: Study setting and design—a prospective randomized study conducted in a tertiary care institute. A total of 80 patients were divided into two groups, group I—LMA cuff inflated with air and group II—LMA cuff inflated with N2O + O2 mixture (50:50). Pressure gauge and transducer are attached to the pilot balloon using a three-way. LMA cuff pressure was monitored every 5 minutes for the first 15 minutes and then every 15 minutes for a duration of 2 hours. Postoperatively, patients were evaluated for complications like sore throat, dysphagia, and pharyngeal mucosal injury. Results: In group I—cuff pressure started rising from 5 minutes and reached 36.93 ± 5.75 at 10 minutes, whereas in group II, pressure recorded was 32.68 ± 3.12, with a p-value of 0.002 which is statistically significant. At 15 minutes, in group I, cuff pressures reached 41.15 ± 6.31; in group II, it reached 35.05 ± 3.65 (p-value of 0.05). Discussion: In this study, after evaluating and comparing the LMA cuff pressure variations with air and N2O + O2 mixture (50:50) during surgery, it can be concluded that continuous monitoring of cuff pressure and its maintenance within allowable limits is recommended. O2: N2O mixture provides a relatively stable cuff pressure in comparison to air during O2:N2O anesthesia.


Original Article

Shrividya Chellam, Pritee H Bhirud, Sandeep Satheesan, Pratibha V Toal

Comparison of Efficacy of Preoxygenation by Conventional Method vs Conventional Plus Supplementation via Nasal Prongs at Two Different Flow Rates

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:6] [Pages No:38 - 43]

Keywords: End-tidal oxygen, Nasal prongs, Preoxygenation

   DOI: 10.5005/jp-journals-10049-2035  |  Open Access |  How to cite  | 


Aim: To compare the efficacy of preoxygenation by a commonly used conventional method of preoxygenation, that is, tidal volume breathing of 100% oxygen (O2) for 3 minutes, with preoxygenation with the conventional method and supplementary O2 supply via nasal prongs at two different flow rates. Objectives: Primary objective evaluation of EtO2 following three different methods of preoxygenation, that is, • 3 minutes of tidal volume breathing through a closed circuit and a well-fitting anesthesia face mask with 100% O2 at a flow rate of 12 L/minutes. • 3 minutes of above plus supplementary O2 supply via nasal prongs at 3 L/minute. • 3 minutes of above plus supplementary O2 supply via nasal prongs at 10 L/minute. Secondary objective: To evaluate patient comfort using the three different preoxygenation techniques. Materials and methods: In this prospective, observational, comparative cross-over study 110 patients were included. Each participant fulfilling the inclusion criteria then underwent three different methods of preoxygenation, that is, • 3 minutes tidal volume breathing through a closed circle system with a well-fitted anesthesia face mask and valve completely open at a flow rate of 12 L/minute. • 3 minutes of the above plus supplementary O2 via nasal prongs at 3 L/minute. • 3 minutes of the above plus supplementary O2 via nasal prongs at 10 L/minute. • The patients were asked to assess the comfort levels associated with each method. Results: There was a statistically significant difference from baseline EtO2 with each of the methods (p < 0.001), implying all three methods increased the O2 reserve in the lung when compared with the baseline levels. Among the methods, method A produced 3.77 times higher EtO2 levels than method B [95% CI (2.54, 5.006) and p < 0.001]. Method C EtO2 levels are 10.26 times > method B [95% CI (11.22, 9.298) and p < 0.001] and 6.48 times higher than EtO2 of method A (95% CI (5.72, 7.24) and p < 0.001], implying method C produced best preoxygenation amongst all the methods. Conclusion: Preoxygenation with the conventional method at 12 L/minute and conventional method supplemented with the nasal cannula at 3 L/minutes and 10 L/minute is efficacious in providing preoxygenation. The use of a nasal cannula at a flow rate of 3 L/minute, along with conventional preoxygenation, can cause a reduction in EtO2 as compared to conventional method alone. Preoxygenation is enhanced by nasal cannula at 10 L/minute, but the same should be titrated against the comfort of the patient. Nasal prongs are available in most patient care areas; therefore, this simple, noninvasive, inexpensive technique could be routinely incorporated with airway management at a flow rate of 10/minute to enhance preoxygenation.



Vaishali P Chaskar, Rajshree Deopujari

Stereotactic Aspiration of Multiple Brain Abscesses in a Child with a Single Ventricle

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:3] [Pages No:44 - 46]

Keywords: Case report, Complex congenital heart disease with single ventricle, Neurocardiac anesthesia, Stereotactic frame

   DOI: 10.5005/jp-journals-10049-2029  |  Open Access |  How to cite  | 


One of the most frequent complications of congenital heart disease (CHD) is multiple brain abscesses. Prior to the palliative repair of CHD, these abscesses must be aspirated. The least invasive and least complicated method is stereotactic aspiration. The anesthesiologist should focus on patient-related and surgical-related issues when performing a case with complicated CHD for neurosurgery. Successful anesthetic management for the stereotactic aspiration of numerous abscesses in a 2-year-old child with a single ventricle is highlighted in this article.



Trupti S Pethkar, Minoti K Kamdar, Vaishali V Joshi

Anesthesia Management of Jehovah's Witness Undergoing Major Abdominal Surgery

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:4] [Pages No:47 - 50]

Keywords: Autologous blood transfusion, Case report, Jehovah's Witness, Operative cell salvage

   DOI: 10.5005/jp-journals-10049-2034  |  Open Access |  How to cite  | 


Aim and background: Jehovah's Witness (JW) religion is a proselytizing Christian movement. They have strong religious beliefs retrieved from a strictly literal interpretation of passages in the Bible forbidding the “eating” of blood as there is the fright of losing eternal life. They refuse to accept homologous or autologous whole blood and blood products, even in case of emergency, to prevent morbidity and mortality. Case description: We discuss the successful use of cell saver in JW patients presenting with multiple fibroids and heavy bleeding undergoing total abdominal hysterectomy with bilateral salpingectomy with expected blood loss of 1.5–2 L under general anesthesia with epidural analgesia. Proper consent and preoperative planning with an experienced team is essential. Conclusion: To work in the window of providing a bloodless surgery under the circumstances of the legal and ethical issues of JW is challenging. Proper planning is needed to handle the available limited options to manage intraoperative blood loss. Clinical significance: Preoperative counseling to discuss and understand JW's religious beliefs and accordingly tailoring the anesthesia plan and surgical interventions is of legal importance.



Reena Jindal

Inflammatory Fibromyalgia: A Diagnostic Dilemma

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:3] [Pages No:51 - 53]

Keywords: Case report, Creatine phosphokinase, Disease-modifying antirheumatic drugs, Inflammatory fibromyalgia, Polymyositis/Dermatomyositis

   DOI: 10.5005/jp-journals-10049-2032  |  Open Access |  How to cite  | 


Fibromyalgia in many ways remains a challenge for the medical profession. Patients are forced to give up work and become increasingly isolated, misunderstood and frustrated. The etiology and mechanisms of fibromyalgia are not well understood. One of the features distinguishing fibromyalgia from inflammatory conditions is the absence of elevated inflammatory markers. More recently, reports of inflammatory fibromyalgia are increasingly reported where patients have negative rheumatic serology but elevated inflammatory markers. They present a diagnostic dilemma and may receive unnecessary treatment. We aim to highlight association of inflammation and fibromyalgia and emphasize the importance of treating the patient and not focusing exclusively on abnormal laboratory results.



H. Sarin, Milin Shah, Akshat Dwivedi, Jyothis Manu, Dinesh A Lingam

Renal Transplant in Patient with Low Ejection Fraction and Diastolic Dysfunction Grade III: A Case Report

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:3] [Pages No:54 - 56]

Keywords: Case report, Diastolic dysfunction, Ejection fraction, Left ventricular, Renal transplantation, Ventricular

   DOI: 10.5005/jp-journals-10049-2033  |  Open Access |  How to cite  | 


Aim and background: Chronic kidney disease (CKD) patients on hemodialysis with ejection fraction (EF) <30% are reported to have a nine times higher risk of mortality rate than those with EF >60%. Patients with diastolic dysfunction also have an increased incidence of cardiac events. Kidney transplant provides better quality of life and prevents further deterioration of cardiac function as compared to dialysis. The intraoperative period is challenging in these patients as adequate renal perfusion has to be delivered to achieve good urine output while sustaining cardiac parameters within the optimal range. Case description: A 35-year-old male was posted for a live donor renal transplant. The two-dimensional (2D) echocardiography reported global hypokinesia of the left ventricle with severe left ventricular (LV) dysfunction. The EF was 25–30%. Diastolic dysfunction grade III with E/A 1.36, E/E 24.02, and DT 82 ms. Intraoperatively increased blood pressure was managed with nitroglycerine infusion, which was titrated to 0.4 mg/hour. The patient was hemodynamically stable throughout the procedure. The fluid infusion was guided by central venous pressure (CVP), which was maintained at 10–12 mm Hg at the time of declamping. The transplanted kidney functioned well immediately. Conclusion: Preoperative optimization of cardiac status, invasive monitoring for various cardiac parameters, carefully tailored anesthesia, and intense postoperative care are essential for successful transplants in such cases. Providing adequate renal perfusion while maintaining various cardiac parameters in optimal range is challenging but crucial. Clinical significance: Various studies have reported posttransplant normalization of lower EF due to uremic cardiomyopathy in the absence of cardiac ischemia. Increased incidence of major adverse cardiovascular events (MACE) has been reported in surgical patients having diastolic dysfunction; hence increased vigilance is required. Renal transplants can be carried out in patients with these parameters.



Kajal S Dalal, Shrividya Chellam, Pratibha V Toal, Shweta Panse

Scorpion Sting: A Reason for Failed Local Anesthetic Action

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:3] [Pages No:57 - 59]

Keywords: Case report, Failed local anesthesia, Local anesthesia resistance, Scorpion sting, Spinal anesthesia failure

   DOI: 10.5005/jp-journals-10049-2036  |  Open Access |  How to cite  | 


Failed action of local anesthetics can be due to technical errors, but resistance to local anesthetic agents can also be a reason. Scorpion venom has the potential to cause antibodies to local anesthetics and genetic mutations in the receptors resulting in local anesthesia resistance. We would like to report two cases with a history of scorpion stings in the past where resistance to local anesthetic agents was seen. Local anesthesia resistance can be manifested as inadequate block or block failure. In such cases, the anesthesiologist should keep a history of scorpion bite in mind in areas where scorpion sting is common. Eliciting the history of scorpion bites should be a part of the routine preoperative protocol in areas where scorpion bites are frequent.



Arun K Patra, Ipsita Choudhary, Aditya Sapra, Vikas Kulshrestha, Ankur Gupta, Chandrakant Reddy, Manimaran Pushparaj

Anesthetic Challenges in a Parkinson's Patient with Deep Brain Stimulation Undergoing Knee Replacement: A Case Report

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:3] [Pages No:60 - 62]

Keywords: Anesthesia management, Deep brain stimulation, Implantable pulse generator, Neurostimulators, Parkinson's disease, Partial knee replacement

   DOI: 10.5005/jp-journals-10049-2037  |  Open Access |  How to cite  | 


Deep brain stimulation (DBS) have progressively emerged as a crucial therapeutic option for those suffering from Parkinson's disease (PD), refractory to conventional pharmacological treatments. Although the therapeutic benefits of deep brain stimulation (DBS) have been recognized, the perioperative anesthetic challenges associated with DBS, especially in the setting of unrelated surgical procedures, remain a complex and intricate challenge. In the case under report, a female patient who had undergone DBS implantation was scheduled to undergo a partial knee replacement (PKR) procedure. The administration of anesthesia was complicated by additional challenges, particularly involuntary movements and rigidity, which presented significant challenges for conventional techniques of ventilation and intubation. The situation was made more complex by the possibility of unfavorable interactions occurring between electromedical devices and the DBS system. This case serves as a unique example of the importance of a multidisciplinary approach, where the collaboration of specialists from various fields like anesthesiology, neurophysician, and orthopedic surgeons was vital. The case study provides evidence of the paramount importance of collaborative decision-making, thorough comprehension, and rigorous perioperative planning in the effective management of patients undergoing deep brain stimulation (DBS) procedures.



Shrividya Chellam, Kajal Dalal, Pratibha V Toal

Anesthesia Management of a Morbidly Obese Patient in a Nonbariatric Setup Using HFNO: A Case Report

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:3] [Pages No:63 - 65]

Keywords: Case report, High-flow nasal oxygenation, Morbid obesity, Nonbariatric, Total intravenous anesthesia

   DOI: 10.5005/jp-journals-10049-2038  |  Open Access |  How to cite  | 


Anesthesia management in obese patients is often challenging due to associated comorbidities like hypertension, dyslipidemia, ischemic heart disease, diabetes mellitus, osteoarthritis, liver disease, asthma, obstructive sleep apnea (OSA), and obesity-hypoventilation syndrome. Obese patients may experience perioperative hypoxemia due to reduced functional residual capacity (FRC) and increased oxygen demand, emphasizing the importance of appropriate oxygenation in improving patient safety. High-flow nasal oxygenation (HFNO) is a relatively newer technique of oxygenation with rapidly increasing applications. It delivers high fraction of inspired oxygen (FiO2) compared to conventional oxygen delivery systems, with a flow rate of up to 70 L/minute, which matches or even exceeds patients’ peak inspiratory flow rate. A 66-year-old female, weighing 160 kg, 150 cm in height, body mass index (BMI) 71.1 kg/m2, morbidly obese, came with complaints of postmenopausal bleeding and was posted for hysteroscopy with dilatation and curettage. We describe the management of a morbidly obese patient for dilation and curettage (D&C) hysteroscopy in a nonbariatric setup to highlight the effective usage of HFNO and various other challenges faced.



Rohan Magoon, Varun Suresh

Perioperative Ketoacidosis with SGLT-2 Inhibitors: More Lessons to Learn

[Year:2023] [Month:July-December] [Volume:8] [Number:2] [Pages:1] [Pages No:66 - 66]

   DOI: 10.5005/jp-journals-10049-2031  |  Open Access |  How to cite  | 


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