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Papers by kusha nag

Sri Lankan Journal of Anaesthesiology

Background: Effective preoperative evaluation and communication with the patient is key to favour... more Background: Effective preoperative evaluation and communication with the patient is key to favourable perioperative outcome and patient satisfaction. This observational study aims to evaluate patient perspectives and satisfaction with communication at pre-anaesthetic evaluation clinic (PAC) of a tertiary care hospital. Methodology: All patients attending PAC during a period of three months were encouraged to fill a questionnaire and submit it in a drop box at the time of leaving the clinic. Responses were entered on a Microsoft excel sheet and analysed at the end of three months. Results: Out of 600 questionnaires distributed, with a response rate of 78.8%, 443 were subjected to statistical analysis after excluding the incompletely filled questionnaires. 44.9% patients had difficulty in locating PAC. 11.2% patients reported a waiting period of more than 20 minutes. Purpose of PAC was known to only 19.38% of patients prior to attending PAC. Only 38.83% patients were given an option to choose an anaesthetic technique. While 51.91% patients were explained the anaesthetic risk, 62.75% and 42.59% patients were explained surgical risk and risk associated with their comorbid condition respectively. 57% patients were explained about postoperative pain relief and given fasting instructions. 70.65% patients felt less anxious after visiting an anaesthesiologist while 73% patients felt that all their questions were adequately answered by the attending anaesthesiologist. 43.3% patients were not accepted as fit for anaesthesia in first PAC visit. Conclusion: Patients presenting in PAC had poor prior knowledge about the purpose of PAC. Fewer patients were provided information on anaesthetic techniques available to choose from. Overall satisfaction in terms of reduction in anxiety and being adequately answered by anaesthesiologist at PAC was found to be good in our hospital.

Journal of anaesthesiology, clinical pharmacology

Anesthesia: Essays and Researches

Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthes... more Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthesia. Adjuvants are added to improve the duration of analgesia. Randomized controlled trial was conducted in the Department of Anesthesiology in a tertiary care hospital. The objective of this study was to evaluate the efficacy of low-dose tramadol as an intrathecal adjuvant to levobupivacaine in terms of duration of analgesia, onset of sensory blockade, onset of motor blockade, and duration of motor blockade. After obtaining the Institutional Ethics Committee approval and informed consent, sixty patients posted for infraumbilical surgeries were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups: LT received 3 ml of 0.5% isobaric levobupivacaine with tramadol 10 mg (0.2 ml) and LS received 3 ml of 0.5% isobaric levobupivacaine with 0.2 ml of normal saline. Duration of analgesia, onset of sensory blockade, and onset and duration of motor blockade were recorded. There was no statistical difference in demographic data between the two groups. The mean onset time of sensory blockade in Group LS was 12.7 ± 9.81 min and for Group LT was 12.9 ± 0.81 min, which was not statistically significant between two groups (P = 0.93). The mean onset time of motor blockade in Group LS was 13.4 ± 10 min and for Group LT was 14.4 ± 10 min, which was no statistically significant between the two groups (P = 0.71). The mean time duration of analgesia in Group LS was 170.3 ± 59 min and for LT was 198.9 ± 57.33 min. There was mild prolongation of analgesia in Group LT, but it was not statistically significant (P = 0.0615). The mean duration of motor blockade in Group LS was 170.23 ± 58 min and Group LT was 190.76 ± 4 min, which was not statistically significant between the two groups (P = 0.14). Low-dose tramadol as an adjuvant to isobaric intrathecal levobupivacaine does not prolong analgesia significantly.

Anesthesia, essays and researches

There is increasing evidence to include sedation as an integral part of regional anesthesia to en... more There is increasing evidence to include sedation as an integral part of regional anesthesia to ensure patient comfort. This may compromise patient cooperation, an important component of regional anesthesia. We decided to determine the efficacy of dexmedetomidine (0.3 μg/kg/h and 0.5 μg/kg/h) for allaying procedural discomfort and ensuring their cooperation in patients undergoing surgery with subarachnoid block. Tertiary care center. Sixty patients with the American Society of Anesthesiologists physical status Class I and II posted for surgeries under subarachnoid block were randomized into two groups of 30 each to receive dexmedetomidine in a loading dose of 1 μg/kg in both groups followed by continuous infusion of 0.3 μg/kg/h in Group D 0.3 and 0.5 μg/kg/h in Group D 0.5. Observer assessment sedation score, ease of positioning score, response to spinal needle insertion, hemodynamic parameters, patient satisfaction (PS) score, and surgeon satisfaction (SS) score were evaluated. Medi...

Anesthesia, essays and researches

Visualization of vocal cords following extubation after thyroid and major neck surgeries is highl... more Visualization of vocal cords following extubation after thyroid and major neck surgeries is highly desirable for the surgeon as well as the anaesthesiologist to rule out vocal cord palsy or oedema. As the patient is emerging from general anaesthesia, it may be challenging for the anaesthesiologist to optimally visualise and grade vocal cord movement following extubation. Randomized clinical trial at a tertiary care centre. After obtaining institutional ethics committee approval, 60 patients posted for thyroid and major neck surgeries under American Society of Anesthesiologists (ASA) grade I and II were recruited for the study. Written informed consent was obtained. Pre-operatively indirect laryngoscopy was performed in all the patients to assess baseline vocal cord function. All patients were premedicated and induced and maintained as per standardized anaesthesia protocol. Patients were randomized using a sealed envelope technique to either Group K where intubation was performed usi...

Anesthesia: Essays and Researches, 2016

It is not uncommon to see in developing and underdeveloped countries, where the anesthesiologist ... more It is not uncommon to see in developing and underdeveloped countries, where the anesthesiologist who is untrained in cardiac specialty takes care of cardiac catheterization centers. The service in cardiac catheterization laboratories (CCL) in developed countries and some of the developing countries is mainly provided by the cardiac anesthesiologists. The scenario is not same in some part of developing countries or in underdeveloped countries which are mainly due to increase in number of CCL (catheterization laboratory) when compared to the number of cardiac anesthesiologists working outside the operation theater. It is also important for training the postgraduate in this field as to make them capable and competitive in managing such cases during emergency situation as it may save the life of a patient. Many a times, CCL is built as per the need of cardiologist ignoring the basic needs of cardiac anesthesiologist. It is important to note that anesthesiologist should be competent enough to provide complete, integrated anesthetic care outside the operation theater with available resources. It is challenging for the anesthesiologist to provide sedation or general anesthesia in such critical area where he/she will be dealing with life-threatening situations. In the modern era, the interventional techniques are advancing and treating complex heart diseases is more often. Days are not far where the CCL procedures may reduce the requirement of major surgeries. A careful and dedicated approach by the anesthesiologist with thorough knowledge and skills decreases morbidity and mortality rate. This article helps both cardiac and noncardiac anesthesiologists to improve their knowledge and to approach the patient systematically.

Anesthesia: Essays and Researches, 2015

A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to ... more A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to have a history of hypertension and ischemic heart disease from past 6 months on regular treatment. Pulse rate was irregularly irregular in a range of 56-60/min, unresponsive to atropine, with a sinus pause on the electrocardiogram. Although the patient was asymptomatic, anticipating unmasking of the sick sinus syndrome during general anesthesia in the prone position, a temporary pacemaker was implanted at right ventricular outflow tract (RVOT) septum before the scheduled surgery. A balanced anesthesia technique with endotracheal intubation was administered. There were several episodes of continuous pacing by the temporary pacemaker intraoperatively, which may be attributed to unmasking of the sinus node dysfunction due to general anesthesia. At the end of surgery, patient was extubated after adequate reversal from neuromuscular blockade. Postoperative period remained uneventful, and the pacemaker wires were removed on the 2(nd) postoperative day. With this case report, we highlight the importance of inserting a temporary pacemaker prior to anesthesia even in an asymptomatic patient if a sinus node dysfunction is suspected preoperatively and if intraoperative access to transvenous pacing is difficult such as in prone position. Pacing at RVOT septum minimizes ventricular dyssynchrony and improves hemodynamic parameters.

Open Access HTML Format For entire Editorial Board visit : Abstract Many anti‑emetics are used in... more Open Access HTML Format For entire Editorial Board visit : Abstract Many anti‑emetics are used in clinical practice. Palonosetron hydrochloride is one of them. It is a novel, centrally acting antiemetic, and anti‑nausea agent. This drug is an antagonist of serotonin receptor subtype 3 (5‑HT3). This drug has longer duration of action which makes it useful in the prevention and treatment of acute and delayed onset of nausea and vomiting. This drug was initially used for chemotherapy induced nausea and vomiting. Federal drug agency (FDA) has approved it for prevention and treatment of post‑operative nausea and vomiting. The literature search for this article was done using Google scholar and Pubmed using the terms ''Palonosetron,'' ''longer duration of action,'' ''nausea,'' ''vomiting,'' and ''postoperative''.

Anesthesia: Essays and Researches, 2014

Saudi Journal of Anaesthesia, 2013

strategy aimed at improving the compliance of mu-opioid receptor (MOR) agonists is to combine MOR... more strategy aimed at improving the compliance of mu-opioid receptor (MOR) agonists is to combine MOR agonism with monoamine reuptake inhibition. Tapentadol is a novel, next generation, centrally acting analgesic with dual mechanism of action that offers analgesic efficacy that is similar to that provided by a pure MOR agonist, but with an improved side-effect profile. [7] Literature search for the article was done using PubMed and Google Scholar using the terms "Tapentadol," "extended release," and "immediate release." CHEMISTRY Tapentadol (3-((1R,2R)-3-(dimethylamino)-1-ethyl-2methylpropyl) phenol hydrochloride) is a non-racemic molecule [Figure 1]. The molecular formula of Tapentadol Access this article online Quick Response Code:

Indian journal of anaesthesia, 2015

Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides j... more Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC50) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant. Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 μg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 μg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was...

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. ... more These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video-or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team. † This Article is accompanied by Editorials aev298 and aev404.

Sri Lankan Journal of Anaesthesiology

Background: Effective preoperative evaluation and communication with the patient is key to favour... more Background: Effective preoperative evaluation and communication with the patient is key to favourable perioperative outcome and patient satisfaction. This observational study aims to evaluate patient perspectives and satisfaction with communication at pre-anaesthetic evaluation clinic (PAC) of a tertiary care hospital. Methodology: All patients attending PAC during a period of three months were encouraged to fill a questionnaire and submit it in a drop box at the time of leaving the clinic. Responses were entered on a Microsoft excel sheet and analysed at the end of three months. Results: Out of 600 questionnaires distributed, with a response rate of 78.8%, 443 were subjected to statistical analysis after excluding the incompletely filled questionnaires. 44.9% patients had difficulty in locating PAC. 11.2% patients reported a waiting period of more than 20 minutes. Purpose of PAC was known to only 19.38% of patients prior to attending PAC. Only 38.83% patients were given an option to choose an anaesthetic technique. While 51.91% patients were explained the anaesthetic risk, 62.75% and 42.59% patients were explained surgical risk and risk associated with their comorbid condition respectively. 57% patients were explained about postoperative pain relief and given fasting instructions. 70.65% patients felt less anxious after visiting an anaesthesiologist while 73% patients felt that all their questions were adequately answered by the attending anaesthesiologist. 43.3% patients were not accepted as fit for anaesthesia in first PAC visit. Conclusion: Patients presenting in PAC had poor prior knowledge about the purpose of PAC. Fewer patients were provided information on anaesthetic techniques available to choose from. Overall satisfaction in terms of reduction in anxiety and being adequately answered by anaesthesiologist at PAC was found to be good in our hospital.

Journal of anaesthesiology, clinical pharmacology

Anesthesia: Essays and Researches

Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthes... more Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthesia. Adjuvants are added to improve the duration of analgesia. Randomized controlled trial was conducted in the Department of Anesthesiology in a tertiary care hospital. The objective of this study was to evaluate the efficacy of low-dose tramadol as an intrathecal adjuvant to levobupivacaine in terms of duration of analgesia, onset of sensory blockade, onset of motor blockade, and duration of motor blockade. After obtaining the Institutional Ethics Committee approval and informed consent, sixty patients posted for infraumbilical surgeries were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups: LT received 3 ml of 0.5% isobaric levobupivacaine with tramadol 10 mg (0.2 ml) and LS received 3 ml of 0.5% isobaric levobupivacaine with 0.2 ml of normal saline. Duration of analgesia, onset of sensory blockade, and onset and duration of motor blockade were recorded. There was no statistical difference in demographic data between the two groups. The mean onset time of sensory blockade in Group LS was 12.7 ± 9.81 min and for Group LT was 12.9 ± 0.81 min, which was not statistically significant between two groups (P = 0.93). The mean onset time of motor blockade in Group LS was 13.4 ± 10 min and for Group LT was 14.4 ± 10 min, which was no statistically significant between the two groups (P = 0.71). The mean time duration of analgesia in Group LS was 170.3 ± 59 min and for LT was 198.9 ± 57.33 min. There was mild prolongation of analgesia in Group LT, but it was not statistically significant (P = 0.0615). The mean duration of motor blockade in Group LS was 170.23 ± 58 min and Group LT was 190.76 ± 4 min, which was not statistically significant between the two groups (P = 0.14). Low-dose tramadol as an adjuvant to isobaric intrathecal levobupivacaine does not prolong analgesia significantly.

Anesthesia, essays and researches

There is increasing evidence to include sedation as an integral part of regional anesthesia to en... more There is increasing evidence to include sedation as an integral part of regional anesthesia to ensure patient comfort. This may compromise patient cooperation, an important component of regional anesthesia. We decided to determine the efficacy of dexmedetomidine (0.3 μg/kg/h and 0.5 μg/kg/h) for allaying procedural discomfort and ensuring their cooperation in patients undergoing surgery with subarachnoid block. Tertiary care center. Sixty patients with the American Society of Anesthesiologists physical status Class I and II posted for surgeries under subarachnoid block were randomized into two groups of 30 each to receive dexmedetomidine in a loading dose of 1 μg/kg in both groups followed by continuous infusion of 0.3 μg/kg/h in Group D 0.3 and 0.5 μg/kg/h in Group D 0.5. Observer assessment sedation score, ease of positioning score, response to spinal needle insertion, hemodynamic parameters, patient satisfaction (PS) score, and surgeon satisfaction (SS) score were evaluated. Medi...

Anesthesia, essays and researches

Visualization of vocal cords following extubation after thyroid and major neck surgeries is highl... more Visualization of vocal cords following extubation after thyroid and major neck surgeries is highly desirable for the surgeon as well as the anaesthesiologist to rule out vocal cord palsy or oedema. As the patient is emerging from general anaesthesia, it may be challenging for the anaesthesiologist to optimally visualise and grade vocal cord movement following extubation. Randomized clinical trial at a tertiary care centre. After obtaining institutional ethics committee approval, 60 patients posted for thyroid and major neck surgeries under American Society of Anesthesiologists (ASA) grade I and II were recruited for the study. Written informed consent was obtained. Pre-operatively indirect laryngoscopy was performed in all the patients to assess baseline vocal cord function. All patients were premedicated and induced and maintained as per standardized anaesthesia protocol. Patients were randomized using a sealed envelope technique to either Group K where intubation was performed usi...

Anesthesia: Essays and Researches, 2016

It is not uncommon to see in developing and underdeveloped countries, where the anesthesiologist ... more It is not uncommon to see in developing and underdeveloped countries, where the anesthesiologist who is untrained in cardiac specialty takes care of cardiac catheterization centers. The service in cardiac catheterization laboratories (CCL) in developed countries and some of the developing countries is mainly provided by the cardiac anesthesiologists. The scenario is not same in some part of developing countries or in underdeveloped countries which are mainly due to increase in number of CCL (catheterization laboratory) when compared to the number of cardiac anesthesiologists working outside the operation theater. It is also important for training the postgraduate in this field as to make them capable and competitive in managing such cases during emergency situation as it may save the life of a patient. Many a times, CCL is built as per the need of cardiologist ignoring the basic needs of cardiac anesthesiologist. It is important to note that anesthesiologist should be competent enough to provide complete, integrated anesthetic care outside the operation theater with available resources. It is challenging for the anesthesiologist to provide sedation or general anesthesia in such critical area where he/she will be dealing with life-threatening situations. In the modern era, the interventional techniques are advancing and treating complex heart diseases is more often. Days are not far where the CCL procedures may reduce the requirement of major surgeries. A careful and dedicated approach by the anesthesiologist with thorough knowledge and skills decreases morbidity and mortality rate. This article helps both cardiac and noncardiac anesthesiologists to improve their knowledge and to approach the patient systematically.

Anesthesia: Essays and Researches, 2015

A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to ... more A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to have a history of hypertension and ischemic heart disease from past 6 months on regular treatment. Pulse rate was irregularly irregular in a range of 56-60/min, unresponsive to atropine, with a sinus pause on the electrocardiogram. Although the patient was asymptomatic, anticipating unmasking of the sick sinus syndrome during general anesthesia in the prone position, a temporary pacemaker was implanted at right ventricular outflow tract (RVOT) septum before the scheduled surgery. A balanced anesthesia technique with endotracheal intubation was administered. There were several episodes of continuous pacing by the temporary pacemaker intraoperatively, which may be attributed to unmasking of the sinus node dysfunction due to general anesthesia. At the end of surgery, patient was extubated after adequate reversal from neuromuscular blockade. Postoperative period remained uneventful, and the pacemaker wires were removed on the 2(nd) postoperative day. With this case report, we highlight the importance of inserting a temporary pacemaker prior to anesthesia even in an asymptomatic patient if a sinus node dysfunction is suspected preoperatively and if intraoperative access to transvenous pacing is difficult such as in prone position. Pacing at RVOT septum minimizes ventricular dyssynchrony and improves hemodynamic parameters.

Open Access HTML Format For entire Editorial Board visit : Abstract Many anti‑emetics are used in... more Open Access HTML Format For entire Editorial Board visit : Abstract Many anti‑emetics are used in clinical practice. Palonosetron hydrochloride is one of them. It is a novel, centrally acting antiemetic, and anti‑nausea agent. This drug is an antagonist of serotonin receptor subtype 3 (5‑HT3). This drug has longer duration of action which makes it useful in the prevention and treatment of acute and delayed onset of nausea and vomiting. This drug was initially used for chemotherapy induced nausea and vomiting. Federal drug agency (FDA) has approved it for prevention and treatment of post‑operative nausea and vomiting. The literature search for this article was done using Google scholar and Pubmed using the terms ''Palonosetron,'' ''longer duration of action,'' ''nausea,'' ''vomiting,'' and ''postoperative''.

Anesthesia: Essays and Researches, 2014

Saudi Journal of Anaesthesia, 2013

strategy aimed at improving the compliance of mu-opioid receptor (MOR) agonists is to combine MOR... more strategy aimed at improving the compliance of mu-opioid receptor (MOR) agonists is to combine MOR agonism with monoamine reuptake inhibition. Tapentadol is a novel, next generation, centrally acting analgesic with dual mechanism of action that offers analgesic efficacy that is similar to that provided by a pure MOR agonist, but with an improved side-effect profile. [7] Literature search for the article was done using PubMed and Google Scholar using the terms "Tapentadol," "extended release," and "immediate release." CHEMISTRY Tapentadol (3-((1R,2R)-3-(dimethylamino)-1-ethyl-2methylpropyl) phenol hydrochloride) is a non-racemic molecule [Figure 1]. The molecular formula of Tapentadol Access this article online Quick Response Code:

Indian journal of anaesthesia, 2015

Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides j... more Insertion of laryngeal mask airway (LMA) requires adequate depth of anaesthesia, which provides jaw relaxation and suppression of upper airway reflexes. Propofol can provide these conditions especially when combined with narcotics. This study had been designed to find out the effect-site concentration (EC50) of propofol using target controlled infusion (TCI) when fentanyl or morphine is added as an adjuvant. Patients satisfying inclusion criteria were divided into fentanyl and morphine groups. Intravenous glycopyrrolate 0.2 mg was given 15 min before induction. Patients were given either intravenous fentanyl (1 μg/kg) or morphine (0.1 mg/kg) before propofol infusion depending on the group. Patients in either groups were induced by continuous infusion of propofol at an EC of 6 μg/mL by TCI with Schneider pharmacokinetic model. The LMA supreme of appropriate size was inserted 1 min after achieving target concentration. Patient movement at LMA insertion or within 1 min of insertion was...

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. ... more These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video-or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team. † This Article is accompanied by Editorials aev298 and aev404.