Hari Dash - Academia.edu (original) (raw)

Papers by Hari Dash

Journal of Anaesthesiology Clinical Pharmacology, 2013

Background: Communication failure is a risk factor for mishaps and complaints, which can be reduc... more Background: Communication failure is a risk factor for mishaps and complaints, which can be reduced by effective communication between operating room team members and patients. Aim: To conduct a survey among anesthesiologists regarding communications skills and related issues like stress in case of communication failure, need for training, music in operation theater, and language barrier at their work place. Materials and Methods: We conducted a survey among anesthesiologists coming for a neuroanesthesia conference in India (n = 110) in February 2011 by questionnaire sent by e-mail to them. Results: The response rate was 61.8% (68/110). Majority (95.5%) of the respondents agreed that good verbal communication leads to better patient outcome, better handling of crisis and is important between surgeons and anesthesiologists (98.5%). A total of 86% of the anesthesiologists felt that failure of communication caused stress to them. The idea of communication by e-mail or phone text messages instead of verbal communications was discouraged by 65.2%. A total of 82% of respondents felt that training of communication skills should be mandatory for all medical personnel and 77.6% were interested in participating in such course. Language barrier at work place was seen as hurdle by 62.7% of the respondents. A total of 80% of respondents felt that playing music in operating theater is appropriate. Conclusion: Results of the survey highlight the need for effective communication in the operating room between team members and need for formal training to improve it.

Seizure-european Journal of Epilepsy, Sep 1, 2012

The goals of epilepsy surgery are to identify the epileptogenic zone from which seizures originat... more The goals of epilepsy surgery are to identify the epileptogenic zone from which seizures originate and excise it completely without complications. Electrocorticography (ECoG) was first described by Penfield and Jasper, to map focal inter-ictal spiking and mark areas to be resected. 1,2 Although, over the years, many advantages and limitations of ECoG have been described, it is still used in many centers across the globe. 3,4 Intraoperatively, it is very important for neurosurgeon and neurologist to have optimal waveforms of ECoG, as decisions based on interpretations of this guide the surgeon to perform the resection. It is well known that general anesthetics suppress/alter ECoG activity. Anesthetic agent may interact with the background activity as well as epileptiform discharges. 4 Thus, role of the anesthesiologist becomes important in designing the anesthetic technique in such a way that optimal waveforms of ECoG may be recorded. General anesthetic techniques for epilepsy surgery remain largely empirical, typically institution specific and sparsely described in literature. 5,6 There are no randomized studies available, comparing various anesthetic techniques to demonstrate their effects on ECoG. Thus this study was conducted to design an optimal combination of anesthetic drugs for recording ECoG. The aim of the study was to compare the effects of isoflurane and propofol with or without nitrous oxide on electrocorticographic activity in patients undergoing epilepsy surgery in terms of satisfactory identification of epileptiform activity. 2. Materials and methods Institutional ethics committee approval and informed consent from all the patients were obtained before commencement of the

Indian Journal of Anaesthesia, 2015

Anesthesia for awake craniotomy: A retrospective study of 54 cases BACKGROUND: Awake craniotomy a... more Anesthesia for awake craniotomy: A retrospective study of 54 cases BACKGROUND: Awake craniotomy allows intraoperative neurological testing during resection of lesions located near the eloquent areas of brain. The anesthetic challenge is to maintain adequate sedation, analgesia, respiratory and hemodynamic stability in an awake and comfortable patient who should be able to cooperate during intraoperative neurological assessment. OBJECTIVE: To review and analyse the anesthetic management, perioperative complications and outcome at discharge in patients undergoing awake craniotomy at our institution METHODS: After obtaining the approval from Institute Ethics Committee, medical records of 54 patients who underwent awake craniotomy over a period of ten years were reviewed, retrospectively. Data regarding anesthetic management, intraoperative complications and postoperative course were recorded.

Current Opinion in Anesthesiology, Oct 1, 1997

Journal of Neurosurgical Anesthesiology, Oct 1, 2016

To JNA Readers: An intracranial space-occupying lesion is a strong contraindication to performing... more To JNA Readers: An intracranial space-occupying lesion is a strong contraindication to performing neuraxial block. The pressure gradient between cranial and spinal compartment increases due to drainage of cerebrospinal fluid after a spinal block which may cause brain stem herniation. 1 We performed an epidural block in a morbidly obese female aged 70 years posted for bilateral knee arthroplasty. She had a frontal space-occupying lesion that she had concealed during preoperative assessment. Her clinical and hematological investigations were normal. The anesthetic technique planned for her was subarachnoid block with 0.5% bupivacaine followed by postoperative analgesia with 0.375% ropivacaine via adductor canal catheter to be placed under ultrasound visualization and a single-shot tibial nerve block. Because of obese habitus, a subarachnoid block could not be placed despite attempts by a senior anesthesiologist proficient in regional blocks. Hence an epidural catheter was inserted and arthroplasty proceeded under analgesia with 0.5% bupivacaine via epidural route. She was sedated with intravenous dexmedtomidine during the surgery (loading dose 1 mg/kg, maintainence 1 mg/kg/h). Her perioperative period was uneventful. On postoperative day 2, she revealed a history of moderately severe holocranial headaches and bilateral hearing loss for the past 6 years. Considering them insignificant, she had concealed these symptoms during the preanesthetic work up. A neurosurgical opinion was sought and an magnetic resonance imaging of the brain revealed a space-occupying lesion in the right frontal region measuring approximately 6Â 7Â 6 cm (Fig. 1). There was no peritumor edema, midline shift, or hydrocephalus. She underwent right-sided frontal cra-niotomy with total excision of the lesion and cranioplasty under general anesthesia 20 days after the knee arthroplasty. Her perioperative course was FIGURE 1. MRI scan of brain revealing Space Occupying lesion in right frontal region.

A plethora of percutaneous procedures are available for the management of trigeminal neuralgia (T... more A plethora of percutaneous procedures are available for the management of trigeminal neuralgia (TGN). Percutaneous procedures are useful in patients with drug-refractory TGN, who either refuse surgery, or in those with significant medical risks to undergo invasive surgical procedures. Percutaneous retrogasserian glycerol rhizolysis (PRGR) is one of the most popular methods of treatment for TGN. PRGR is carried out by injecting glycerol into the Meckel’s cave and its safety has been established by several studies [1–4]. The major advantages of PRGR are: (1) long-term pain relief following single injection, (2) significant reduction in postoperative facial deafferentation compared to thermal rhizotomy, and (3) simple to perform with an image intensifier. Precise anatomic placement of anhydrous glycerol is achieved with the help of intraoperative trigeminal water-soluble contrast cisternography prior to drug injection [5–8].

Journal of Neurosurgical Anesthesiology, Oct 1, 2015

T he 4th Biennial Congress of Asian Society of Neuroanesthesia and Critical Care (ASNACC) was org... more T he 4th Biennial Congress of Asian Society of Neuroanesthesia and Critical Care (ASNACC) was organized on April 3 and 4, 2015 in conjunction with the 22nd annual meeting of the Korean Society of Neuroscience in Anesthesiology and Critical Care (KSNACC) at Busan, South Korea. The conference was held at the Haeundae Grand Hotel, located in Haeundae beach area, one of the most scenic and beautiful locality of Busan facing the East Sea (Pacific Ocean). A total of 289 delegates participated in this congress and their geographic distributions are: South Korea

Journal of Neuroanaesthesiology and Critical Care, Apr 1, 2016

Background: Atlantoaxial dislocation (AAD) is highly unstable and usually fatal injury resulting ... more Background: Atlantoaxial dislocation (AAD) is highly unstable and usually fatal injury resulting from osseoligamentous disruption between the C1 and C2 vertebrae, it is at high risk of life-threatening neurological injury so cervical spine management is essential, manual in-line stabilisation is used to decrease cervical spine injury. The major difficulty encountered is that of airway management. Intraoperative management should focus on maintaining adequate perfusion pressure and oxygenation of spinal cord. This study is to provide an update on airway management, intraoperative haemodynamics and post-operative complications in patients of AAD. Methodology: After Ethics Committee approval, we retrospectively analysed 105 patients operated for AAD at Neurosurgery Department of K.E.M. Hospital, Mumbai from March 2012 to March 2015. Difficult intubations were evaluated on basis of all 3 = MPC-III or IV, sternomental distance = <12.5 cm, mouth opening = <3 fingers. AirTraq, McGrath, Macintosh, McCoy, intubating laryngeal mask airway (ILMA) were compared, intraoperative haemodynamics and post-operative complications were analysed. Results: After analysis of data, 38 (36.2%) patients were difficult and 67 (63.8%) were not difficult intubations. 7 (6.67%) patients were intubated with AirTraq, 2 (1.90%) McGrath, 69 (65.71%) Macintosh, 13 (12.38%) McCoy, 14 (13.33%) ILMA, respectively. Successful intubation in first attempt among total was = AirTraq 6 (85.7%), McGrath 2 (100%), Macintosh 35 (50.7%), McCoy 4 (30.8%), ILMA 7 (50%). Moreover, among difficult intubation were = AirTraq 2 (66.7%), McGrath 2 (100%), Macintosh 5 (22.7%), McCoy 0 (0%), ILMA 2 (40%). Intubation requiring more than two attempts = AirTraq 1 (33.3%), McGrath 0 (0%), Macintosh 13 (59.1%), McCoy 5 (83.3%), ILMA 1 (20%). Major blood loss (>1500 ml) was in 24 (22.86%) patients. Five patients had bradycardia and hypotension intraoperatively, 3 of them had major blood loss. Four were recurrent AAD, 3 with rheumatoid arthritis, 2 with Down's syndrome. Post-operatively, 4 patients were neurologically same and 2 were deteriorated. Post-operative mortality recorded in 5 patients, of which 3 had major blood loss and 2 were pre-operatively bad (power = 0). Discussion: Indirect laryngoscopy-McGrath and AirTraq were better than other intubation techniques. Major blood loss had higher incidence of post-operative ventilator support and mortality. No overall correlation between post-operative ventilatory support and neurological deterioration with intubation technique. Being retrospective, missing data are major limitation Awake fibreoptic bronchoscope was not used for intubation. ISNACC-S-33 Effects of 20% mannitol and 3% hypertonic saline on intracranial pressure and systemic haemodynamics

Journal of Neuroanaesthesiology and Critical Care, Feb 1, 2017

Postoperative intracerebral vasospasm is one of the leading causes of morbidity and mortality fol... more Postoperative intracerebral vasospasm is one of the leading causes of morbidity and mortality following clipping of intra cranial aneurysm. Early diagnosis, prompt and effective management helps in salvaging these patients. Umpteen modalities of treatment strategies are available to achieve good neurologic recovery. Intraarterial nimodipine, nicardipine and milrinon provide good neurologic recovery. Stellate ganglion block on the affected side is also a treatment modality which needs to be investigated.

Journal of Neurosurgical Anesthesiology, Jul 1, 2003

For successful catheter placement, central venous cannulation (CVC) through internal jugular vein... more For successful catheter placement, central venous cannulation (CVC) through internal jugular vein and subclavian vein has been recommended in both adult and pediatric patients. But it carries a risk of serious complications, such as pneumothorax, carotid, or subclavian artery puncture, which can be life-threatening, particularly in critically ill children. So a prospective study was carried out to determine the success rate of correct catheter tip placement during CVC through antecubital veins in pediatric neurosurgical patients. A total of 200 pediatric patients (age 1-15 years) of either sex were studied. Basilic or cephalic veins of either arm were selected. All the patients were cannulated in the operation room under general anesthesia. Single lumen, proper size catheters (with stillete) were used for cannulation. The catheter was inserted in supine position with the arm abducted at right angle to the body and neck turned ipsilaterally. The length of insertion was determined from cubital fossa to the right second intercostal space. The exact position of the tip of the catheter was confirmed radiologically in ICU. Correct catheter tip placement was achieved in 98 (49%) patients. Multivariate logistic regression analysis of data shows that there was no statistically significant difference among correct and incorrect catheter tip placement in relation to factors including sex, side of cannulation (left or right), and type of vein (basilic or cephalic). The analysis of correct catheter tip placement in relation to age showed that the highest success rate was achieved in children of age group 6 to 10 years (60.2%) followed by 30.6% in the 11 to 15 year group. The lowest success rate of tip placement of only 9.2% was observed in younger children of age 1 to 5 years, which is statistically significant (P = 0.001). Of 102 incorrect placements reported, 37% were in 1 to 5 year age group versus 9.2% correct tip placements. The most common unsatisfactory placements were either in the ipsilateral internal jugular vein (N = 38, 37.2%) or in the ipsilateral subclavian vein (N = 27, 26.4%). In 10 patients the catheter crossed over to the opposite subclavian vein, in 16 patients the catheter tips were found in the axillary vein, and in 10 patients each the catheter tip was observed in right atrium and right ventricle. No major complication during and following CVC was observed. To conclude, CVC using single orifice catheter through arm veins in pediatric patients is easy to perform, but the proper catheter tip placement is highly unreliable, particularly in younger children 1 to 5 years of age.

Journal of Neurosurgical Anesthesiology, Apr 1, 2010

Background: There are numerous reports of difficult laryngoscopy and intubation in patients with ... more Background: There are numerous reports of difficult laryngoscopy and intubation in patients with acromegaly. To date, no study has assessed the application of extended Mallampati score (EMS) for predicting difficult intubation in acromegalics. The primary aim of this study was to compare EMS with modified Mallampati classification (MMP) in predicting difficult laryngoscopy in acromegalic patients. We hypothesized that since EMS has been reported to be more specific and better predictor than MMP, it may be superior to the MMP to predict difficult laryngoscopy in acromegalic patients. Materials and Methods: For this prospective cohort study with matched controls, acromegalic patients scheduled to undergo pituitary surgery over a period of 3 years (January 2008-December 2010) were enrolled. Preoperative airway assessment was performed by experienced anesthesiologists and involved a MMP and the EMS. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL) grading. MMP and CL grades of I and II were defined "easy" and III and IV as "difficult". EMS grade of I and II were defined "easy" and III as "difficult". Data were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MMP and EMS in predicting difficult laryngoscopy. Results: Seventy eight patients participated in the study (39 patients in each group). Both MMP and EMS failed to detect difficult laryngoscopy in seven patients. Only one laryngoscopy was predicted to be difficult by both tests which was in fact, difficult. Conclusion: We found that addition of neck extension did not improve the predictive value of MMP.

World Neurosurgery, May 1, 2016

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature, Jul 31, 2009

Journal of Neuroanaesthesiology and Critical Care, Dec 1, 2015

Tissue ischaemia can be a significant contributor to increased morbidity and mortality. Conventio... more Tissue ischaemia can be a significant contributor to increased morbidity and mortality. Conventional oxygenation monitoring modalities measure systemic oxygenation, but regional tissue oxygenation is not monitored. Near-infrared spectroscopy (NIRS) is a non-invasive monitor for measuring regional oxygen saturation which provides real-time information. There has been increased interest in the clinical application of NIRS following numerous studies that show improved outcome in various clinical situations especially cardiac surgery. Its use has shown improved neurological outcome and decreased postoperative stay in cardiac surgery. Its usefulness has been investigated in various high risk surgeries such as carotid endarterectomy, thoracic surgeries, paediatric population and has shown promising results. There is however, limited data supporting its role in neurosurgical population. We strongly feel, it might play a key role in future. It has significant advantages over other neuromonitoring modalities, but more technological advances are needed before it can be used more widely into clinical practice.

Saudi Journal of Anaesthesia, 2013

The current era has adopted many new innovations in nearly every aspect of management of subarach... more The current era has adopted many new innovations in nearly every aspect of management of subarachnoid hemorrhage (SAH); however, the neurological outcome has still not changed significantly. These major therapeutic advances mainly addressed the two most important sequels of the SAH-vasospasm and re-bleed. Thus, there is a possibility of some different pathophysiological mechanism that would be responsible for causing poor outcome in these patients. In this article, we have tried to compile the current role of this different yet potentially treatable pathophysiological mechanism in post-SAH patients. The main pathophysiological mechanism for the development of early brain injury (EBI) is the apoptotic pathways. The macro-mechanism includes increased intracranial pressure, disruption of the blood-brain barrier, and finally global ischemia. Most of the treatment strategies are still in the experimental phase. Although the role of EBI following SAH is now well established, the treatment modalities for human patients are yet to be testified.

Indian Journal of Anaesthesia, 2013

Through evolving research, recent years have witnessed remarkable achievements in neuromonitoring... more Through evolving research, recent years have witnessed remarkable achievements in neuromonitoring and neuroanesthetic techniques, with a huge body of literature consisting of excellent studies in neuroanaesthesiology. However, little of this work appears to be directly important to clinical practice. Many controversies still exist in care of patients with neurologic injury. This review discusses studies of great clinical importance carried out in the last five years, which have the potential of influencing our current clinical practice and also attempts to define areas in need of further research. Relevant literature was obtained through multiple sources that included professional websites, medical journals and textbooks using key words "neuroanaesthesiology," "traumatic brain injury," "aneurysmal subarachnoid haemorrhage," "carotid artery disease," "brain protection," "glycemic management" and "neurocritical care." In head injured patients, administration of colloid and pre-hospital hypertonic saline resuscitation have not been found beneficial while use of multimodality monitoring, individualized optimal cerebral perfusion pressure therapy, tranexamic acid and decompressive craniectomy needs further evaluation. Studies are underway for establishing cerebroprotective potential of therapeutic hypothermia. Local anaesthesia provides better neurocognitive outcome in patients undergoing carotid endarterectomy compared with general anaesthesia. In patients with aneurysmal subarachnoid haemorrhage, induced hypertension alone is currently recommended for treating suspected cerebral vasospasm in place of triple H therapy. Till date, nimodipine is the only drug with proven efficacy in preventing cerebral vasospasm. In neurocritically ill patients, intensive insulin therapy results in substantial increase in hypoglycemic episodes and mortality rate, with current emphasis on minimizing glucose variability. Results of ongoing multicentric trials are likely to further improvise our practice.

Acta neurochirurgica, Mar 1, 1995

The blink reflex was prospectively studied in 28 patients with trigeminal neuralgia, prior-to and... more The blink reflex was prospectively studied in 28 patients with trigeminal neuralgia, prior-to and following percutaneous glycerol rhizotomy to the Gasserian ganglion. Fifteen patients (54%) had varying degrees of sensory loss in the trigeminal nerve distribution already before glycerol injection. Three more patients developed sensory loss following glycerol injection. Thus following glycerol injection 18 patients had graded sensory loss. Pre-injection the blink reflex showed abnormal R1 wave in 57% patients, while direct and consensual R2 waves were abnormal in 43% and 48%, respectively. Post-injection R1 wave was abnormal in 64% patients. Direct R2 waves were abnormal in 33% patients. Thus clinical findings of sensory loss correlated well with pre-and post-injection blink reflex abnormality. Postoperatively R1 and ipsilateral R2 latencies from the side of the injection deteriorated and consensual R2 latency improved, thus, signifying better function on the contralateral side following relief of pain by glycerol rhizotomy.