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   Table of Contents - Current issue
Coverpage
September-December 2017
Volume 4 | Issue 3
Page Nos. 135-193

Online since Friday, September 8, 2017

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EDITORIAL  

Post-craniotomy pain: A neglected entity p. 135
Parmod K Bithal
DOI:10.4103/jnacc.jnacc_46_17  
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REVIEW ARTICLE Top

Understanding the physiological changes induced by mannitol: From the theory to the clinical practice in neuroanaesthesia Highly accessed article p. 138
Wilson Fandino
DOI:10.4103/jnacc.jnacc_31_17  
In this narrative review, the current evidence for the use of mannitol in neuroanaesthesia is presented, with focus on its pharmacokinetics and its main physiologic effects. Mannitol is a naturally occurring polyol that undergoes no biotransformation and is freely filtered in the kidney. Due to its strong osmotic effects, it induces key physiological changes, mainly in the cardiovascular system, the kidney and the brain. While it is clear that hypertonic solutions are effective in the treatment of intracranial hypertension in patients with acute brain injury, the role of mannitol in the context of intracranial haemorrhage, acute stroke and brain relaxation remains controversial. Furthermore, it possesses important side effects including acute kidney injury and electrolyte imbalances, particularly related to high doses in predisposing patients. Other aspects including the capability to modify neurological outcomes, the impact on mortality, the utility in patients with disrupted blood–brain barrier and the alternative use of hypertonic saline are also discussed. Further research is needed to make clear recommendations on these aspects.
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ORIGINAL ARTICLES Top

Assessment of the role of gabapentin in patients with supratentorial tumours undergoing craniotomy under general anaesthesia: A double-blind randomised study p. 147
Rabie Soliman, Gomaa Zohry
DOI:10.4103/jnacc.jnacc_36_16  
Background: Gabapentin attenuates the haemodynamics, decreases the catecholamine release and has a neuroprotective effect. The aim of the present study was to assess the effect of gabapentin in patients with supratentorial brain tumours undergoing craniotomy under general anaesthesia. Methods: A radial arterial line, central venous line and ventriculostomy catheters were inserted before surgery. Anaesthesia was induced with thiopental, fentanyl and atracurium and maintained with sevoflurane, fentanyl and atracurium infusion. The study included 160 patients classified randomly into two groups: Group G: The patients received gabapentin capsules 1200 mg orally 2 h before surgery. Group C: The patients received placebo capsules. Results: The heart rate, mean arterial blood pressure and intracranial pressure decreased significantly with gabapentin as compared to the control group (P < 0.05). The dose of fentanyl and end-tidal sevoflurane was lower with gabapentin than the control group (P < 0.05). The urine output was higher in the gabapentin group than the control group (P < 0.05). The Glasgow coma scale score was better in the gabapentin group as compared to the control group (P < 0.05). The incidence of nausea and vomiting was lower in the gabapentin group as compared to the control group (P < 0.05). Conclusions: Pre-operative administration of gabapentin in patients undergoing craniotomy under general anaesthesia minimised the fluctuations in haemodynamics, reduced the requirements for sevoflurane and fentanyl, decreased intracranial pressure and improved the outcomes. There were some side effects associated with gabapentin such as hypotension and bradycardia.
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Comparative evaluation of morphine and fentanyl for emergence following supratentorial craniotomy p. 155
Hemant Bhagat, Neeru Sahni, Ishwar Bhukal, Puneet Khanna, Priska Bastola, Parmod K Bithal, Hari H Dash
DOI:10.4103/jnacc.jnacc_53_16  
Background: The emergence from anaesthesia is a very crucial aspect in neurosurgical patients due to the need for evaluation of neurological status in the immediate post-operative period. The present study evaluates the emergence characteristics following administration of morphine as compared to shorter-acting opioid, fentanyl in patients undergoing supratentorial craniotomy. Methods: A total of 84 patients were included in the study. The patients either received morphine 0.1 mg/kg before induction or fentanyl 2 mcg/kg body weight at induction, 1 mcg/kg before skin incision and at the beginning of dural closure. Doses of both opioids were repeated as judged clinically during surgery. Following surgery, the trachea was extubated after reversal of residual neuromuscular blockade, and the emergence characteristics of patients in the two groups were compared. Results: The mean time to emergence was 8.5 ± 3.7 min in morphine group whereas it was 7.8 ± 5.1 min in fentanyl group (P = 0.11). Conclusions: Morphine appears similar to fentanyl for facilitating early emergence in patients undergoing an elective supratentorial craniotomy.
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The influence of anaesthesia on intraoperative neuromonitoring changes in high-risk spinal surgery p. 159
Nathan P Royan, Nancy Lu, Pirjo Manninen, Lakshmikumar Venkatraghavan
DOI:10.4103/jnacc.jnacc_10_17  
Background: The use of intraoperative neuromonitoring is a well-established method of detecting neurologic injuries during spine surgery. Anaesthesia, especially inhalational agents, influence motor evoked potential (MEP) monitoring. The aim of our study was to compare the effect of balanced anaesthesia (BA) (intravenous plus inhalational anaesthesia) and total intravenous anaesthesia (TIVA) on the incidence of intraoperative neuromonitoring changes, interventions performed and neurological outcomes of patients following high-risk spinal surgery. Methods: After Research and Ethics Board approval, a retrospective review of 155 patients who underwent spinal surgery with MEP was performed. Data were collected on changes in MEP and/or somatosensory evoked potential, interventions performed and neurological outcomes. Patients were divided into BA and TIVA groups and data were analysed. Results: A total of 152 patients were eligible for the study (mean age 54 ± 17, male: female 45:55). A BA technique was used in 62% and TIVA in 38%. Desflurane (<0.5 minimum alveolar concentration [MAC]) was used in 85% BA cases. Intraoperative neuromonitoring changes occurred in 11.8% (18/152) of cases. There was no statistical difference in the incidence of monitoring changes between BA (78%) and TIVA (22%) groups (P = 0.197). Anaesthetic or surgical interventions were performed in 12 patients, with a resolution of changes in 50% (P = 0.455). All 5 patients with persistent MEP changes had worsening of existing neurological deficits postoperatively; 8 had transient MEP changes, and 2 experienced worsening of existing neurological deficits. Conclusions: We found that intraoperative neurophysiological monitoring can be performed with both BA (MAC <0.5) and TIVA in high-risk spinal surgery with no statistical difference in the incidence of intraoperative monitoring changes.
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BRIEF REPORTS Top

Effect of intravenous midazolam on intracranial pressure during endotracheal suctioning in patients with severe head injury p. 167
Metilda Robin, Teenu Xavier, T Anjusha, Merin L Kuriakose, Deepak Agrawal
DOI:10.4103/jnacc.jnacc_78_16  
Background: Patients with severe traumatic brain injury (TBI) require elective ventilation and sedation to decrease intracranial pressure (ICP) and any increase in ICP may be detrimental for the outcome in these patients. Methods: This prospective study was done in a neurotrauma intensive care unit (ICU )of a level 1 trauma centre in India over a one month period. All adult male patients with severe TBI on mechanical ventilation and monitored for ICP were included in this study. Baseline ICP was measured before starting endotracheal (ET) suctioning and serial readings were taken during and after ET suctioning. Patients were divided into two groups (control and intervention) with intervention group receiving intravenous bolus dose of 2 mg of midazolam before ET suction. Results: A total of 20 patients were enrolled during the study period. Both groups were well matched with regards to age and admission Glasgow coma scale (GCS). There were 10 patients in the midazolam group and 10 patients in the control group. The mean rise of ICP following ET suctioning in control group was found to be 24.1mm Hg ±11.1 as compared to 18.25 mm Hg ±-9.29 in the midazolam group (P < 0.05). Conclusions: Significant rise in ICP from baseline occurs following ET suctioning in ventilated, severe TBI patients. Our study suggests that additional intravenous bolus of midazolam prior to suctioning may significantly reduce the rise in ICP and should be practiced by ICU nurses.
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Post-operative complications in patients undergoing anterior cervical discectomy and fusion: A retrospective review Highly accessed article p. 170
Rahul Yadav, Siddharth Chavali, Arvind Chaturvedi, Girija P Rath
DOI:10.4103/jnacc.jnacc_18_17  
Background: Anterior cervical discectomy and fusion (ACDF) is a surgical procedure used to manage various cervical spine disorders including spondylosis, prolapsed intervertebral disc, trauma and degenerative disc disease. However, this procedure may be associated with significant post-operative complications. In this study, we aimed to analyse the prevalence of post-operative complications following ACDF. Methods: Perioperative data of 128 patients who underwent ACDF surgery at our institute over a 3-year period was analysed. Patients who underwent previous neck surgeries were excluded. Results: Single level ACDF without cervical plating was observed to be the most commonly performed surgical procedure (53%). Dysphagia was the most common (16.4%) post-operative complaint, followed by neurological deterioration (7.9%). One patient suffered pharyngeal perforation and presented postoperatively with subcutaneous emphysema and haemoptysis. Conclusions: Post-operative dyphagia and worsening of pre-existing myelopathy were the most common complications following ACDF, and multilevel surgery was identified as the most significant risk factor. The early detection and prompt management may help reduce mortality and morbidity in such patients.
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CASE REPORTS Top

Iatrogenic neck mobility restriction due to stereotactic fixed-frame application: Implications of a 'non-laryngoscopic' airway management approach p. 175
Rachna Bhutani, Amitabh Dutta, Neelam Ganguly, Jayashree Sood
DOI:10.4103/jnacc.jnacc_14_17  
Stereotactic biopsy is a common minimal access neurosurgical procedure. It requires a stereotactic frame to be secured on the head, and thereafter, based on computerised tomography scan markings on the frame, precise biopsy is retrieved. For anaesthesiologists, the application of frame poses difficulty in accessing the upper airway with the conventional laryngoscopy-intubation methodology. The various airway-access limitations imposed by an 'in-place' frame can be problematic and should be addressed. This report elucidates the problems caused by the presence of stereotactic frame in the management of upper airway. The approach to upper airway can be variable on a case-to-case basis, depending on attending anaesthesiologists' decision-making and availability of equipments/devices. Here, the, recommendations on the problematic points and the suggested way thereof are presented.
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An unusual presentation of autonomic dysreflexia-autonomic dysreflexia due to pneumatic stockings p. 178
Ankita Madan, Saurabh Bhargava, Meenaxi Sharma, Karan Marwah
DOI:10.4103/jnacc.jnacc_19_17  
Autonomic dysreflexia is a potentially dangerous clinical emergency associated with spine injury at or above T6 level. Identification of triggering factor and its removal is a very important for the management of this condition. We hereby report a rare presentation of autonomic dysreflexia in a 57-year-old male, a case of D9–L1 arteriovenous malformation (AVM) with prolapsed intervertebral disc L3–L4 who underwent laminectomy from D6 to L4 level followed by excision of the AVM under general anaesthesia. He developed symptoms and signs suggestive of autonomic dysreflexia following application of intermittent compression pneumatic stockings which were reversed after the removal of the stimulus. Application of intermittent compression pneumatic stockings is an unusual cause of autonomic dysreflexia.
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CORRESPONDENCES Top

Unanticipated difficult airway in male hypogonadism p. 181
Pasupuleti Hemalatha, Bathanpalli Aparna, Aloka Samantaray, Mangu H Rao
DOI:10.4103/jnacc.jnacc_2_17  
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Uvular trauma caused by endotracheal tube p. 183
Saurabh Bhargava, Zara Wani, Meenaxi Sharma
DOI:10.4103/jnacc.jnacc_17_17  
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LETTER TO EDITOR Top

Correlation analysis in repeated measures design p. 185
Deepti Srinivas, Dhritiman Chakrabarti
DOI:10.4103/jnacc.jnacc_38_17  
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ISNACC/CONFERENCE/MEETING REPORT Top

Report on the 4th Neuroanaesthesia Symposium (2017) held at Kuching, Sarawak, Malaysia p. 187
Girija P Rath, Peter C Tan
DOI:10.4103/jnacc.jnacc_29_17  
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Report on Annual Scientific Meeting of Neuro Anaesthesia and Critical Care Society of Great Britain and Ireland, 2017 Held at London, UK p. 189
Barkha Bindu, Hemanshu Prabhakar
DOI:10.4103/jnacc.jnacc_39_17  
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Report of the 3rd Annual Medanta Neuro Critical Care conference held at Medanta - The Medicity, Gurgaon from 31st March 2017 to 2nd April 2017 p. 191
Harsh Sapra, Gaurav Kakkar
DOI:10.4103/jnacc.jnacc_36_17  
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