Goal-directed fluid therapy guided by plethysmographic variability index versus conventional liberal fluid therapy in neonates undergoing abdominal surgery: A prospective randomized controlled trial.

BACKGROUND: Intraoperative fluid therapy maintains normovolemia, normal tissue perfusion, normal metabolic function, normal electrolytes, and acid-base status. Plethysmographic variability index has been shown to predict fluid responsiveness but its role in guiding intraoperative fluid therapy is still elusive. AIMS: The aim of the present study was to compare intraoperative goal-directed fluid therapy based on plethysmographic variability index with liberal fluid therapy in term neonates undergoing abdominal surgeries. METHODS: A prospective randomized controlled study was conducted in a tertiary care centre, over a period of 18 months. A total of 30 neonates completed the study out of 132 neonates screened. Neonates with tracheoesophageal fistula, congenital diaphragmatic hernia, congenital heart disease, respiratory disorders, creatinine clearance <90 mL/min and who were hemodynamically unstable were excluded. Neonates were randomized to goal-directed fluid therapy group where the plethysmographic variability index was targeted at <18 or liberal fluid therapy group. Primary outcome was comparison of total amount of fluid infused intraoperatively in both the groups. Secondary outcomes included intraoperative and postoperative arterial blood gas parameters, biochemical parameters, use of vasopressors, number of fluid boluses, complications and duration of hospital stay. RESULTS: There was no significant difference in total intraoperative fluid infused [90 (84-117.5 mL) in goal-directed fluid therapy and 105 (85.5-144.5 mL) in liberal fluid therapy group (p = .406)], median difference (95% CI) -15 (-49.1 to 19.1). There was a decrease in serum lactate levels in both groups from preoperative to postoperative 24 h. The amount of fluid infused before dopamine administration was significantly higher in liberal fluid therapy group (58 [50.25-65 mL]) compared to goal-directed fluid therapy group (36 [22-44 mL], p = .008), median difference (95% CI) -22 (-46 to 2). In postoperative period, the total amount of fluid intake over 24 h was comparable in two groups (222 [204-253 mL] in goal-directed fluid therapy group and 224 [179.5-289.5 mL] in liberal fluid therapy group, p = .917) median difference (95% CI) cutoff -2 (-65.3 to 61.2). CONCLUSION: Intraoperative plethysmographic variability index-guided goal-directed fluid therapy was comparable to liberal fluid therapy in terms of total volume of fluid infused in neonates during perioperative period. More randomized controlled trials with higher sample size are required. TRIAL REGISTRATION: Central Trial Registry of India (CTRI/2020/02/023561).

Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study.

AIMS: Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality. METHODS: This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed. RESULTS: Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced. CONCLUSION: Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.

Neonatal perioperative resuscitation (NePOR) protocol-An update.

Unexpected cardiac arrest in the perioperative period is a devastating complication. Owing to immaturity of organ systems, and presence of congenital malformations, morbidity and mortality are higher in neonates. There is abundant literature about early recognition and management of perioperative adverse events in children, but similar data and guidelines for surgical neonates is lacking. The current neonatal resuscitation guidelines cater to a newborn requiring resuscitation at the time of birth in the delivery room. The concerns in a newborn undergoing transition from intrauterine to extra uterine life is significantly different from a neonate undergoing surgery. This review highlights the causes and factors responsible for peri-arrest situations in neonates in the perioperative period, suggests preoperative surveillance for prevention of these conditions, and finally presents the resuscitation protocol of the surgical neonate. All these are comprehensively proposed as Neonatal Peri-operative Resuscitation (NePOR) protocol.

A noninferiority trial on information-based video versus self-selected video distraction technique for preoperative anxiety reduction in school children: Prepare trial.

BACKGROUND: Distraction techniques using smartphones to watch cartoon videos and play videogames have been successfully used to reduce preoperative anxiety in school children. However, the literature about the use of video-based preoperative information technique for anxiety reduction in that age group still remains understudied with conflicting results. We hypothesized that there would be no meaningful difference in anxiety score at induction period between the information-based video versus self-selected video distraction technique. METHODS: Eighty-two children between 6 and 12 years undergoing surgery were randomized to self-selected video (n = 41) and information-based video (n = 41) distraction group in this prospective, randomized, noninferiority trial. Children in self-selected video group were shown video of their choice using smart phones, while children in the information-based video group were shown video of operation theater (OT) set up and induction procedure. The children were taken inside operating room along with parents watching the respective videos. Modified Yale Preoperative Anxiety Scale (m-YPAS), just before induction of anesthesia was recorded as the primary outcome. Induction compliance checklist score, anxiety of the parents, and short-term postoperative outcomes in 15 days (telephonically) were recorded as secondary outcomes. RESULTS: The mean difference in the baseline mYPAS score (95% CI) between the two groups was -2.7 (-8.2 to 2.8, p = .33) and -6.39 (-12.74 to -0.44, p = .05) just before the induction period. The upper bound of the 95% CI did not cross the value of 8, which was the noninferiority margin decided prior to study commencement. 70.73% cases had perfect induction in the self-selected video distraction group, compared to 68.29% in the information-based video group. After 15 days of postoperative follow-up, participants in the self-selected video group had a larger proportion of negative outcomes (53.7%) compared to information-based video group (31.7%), p = .044. CONCLUSION: Information-based technique using smart phone is non inferior to self-selected video-based distraction-based technique in decreasing PA with an additional advantage of decreasing postoperative short-term negative outcomes. TRIAL REGISTRATION: CTRI identifier: CTRI/2020/03/023884.

Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial.

BACKGROUND: PVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery. METHODS: 42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either 'conventional liberal intraoperative fluids' (liberal group) or 'goal-directed intraoperative fluids' (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes. RESULTS: The mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001). CONCLUSION: Intraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy. TYPE OF STUDY: Randomized Clinical Trial. LEVEL OF EVIDENCE: Treatment Study (LEVEL 1).

Ultrasound Evaluation to Predict Difficult Laryngoscopy in Children below 2 Years.

OBJECTIVE: To evaluate the feasibility of sonography as a tool to predict difficult airway in children less than 2 y of age. METHODS: Airway ultrasound was performed in 90 children below the age of 2 y to measure airway dimensions preoperatively. Hyomental distance ratio in predicting difficult laryngoscopy was recorded as the primary outcome. Secondary outcomes included tongue thickness/oral cavity thickness ratio and tongue thickness/thyromental distance ratio in predicting difficult laryngoscopy and difficult intubation, time taken for intubation, and any complications. The sensitivity, specificity, positive predictive value, and negative predictive value with 95% CI of all the parameters were recorded. RESULTS: Six out of 90 (6.7%) patients had difficult laryngoscopy. HMDR was significantly different between children with easy and difficult laryngoscopy (1.15 ± 0.11 vs. 1.03 ± 0.016, p = 0.001). The optimal cutoff points for HMDR, TT/OCT, and TT/TMD to predict difficult laryngoscopy (CL grade III, IV) were > 1.055 (sensitivity 100%, specificity 86.9%), 0.755 (sensitivity 100%, specificity 57%), and 0.445 (sensitivity 53.5%, specificity 66.7%), respectively, the AUC being highest for HMDR (0.959). The cutoff value of ≥ 1.055 of HMDR to predict difficult laryngoscopy had the highest AUC of 0.959, p < 0.001. Fifty-two children had IDS = 0, while 38 had IDS between 1 and 4. None of the patients had IDS > 5. CONCLUSIONS: Ultrasound-guided airway assessment is a feasible option in children less than 2 y. Hyomental distance ratio can form a useful tool for predicting difficult airway in this age group. TRIAL REGISTRATION: The trial has been registered in Clinical trial Registry of India (CTRI/2019/05/019014) before enrollment of the first patient.

Effect of two different levels of positive end-expiratory pressure (PEEP) on oxygenation and ventilation during pneumoperitoneum for laparoscopic surgery in children: A randomized controlled study.

Background: Positive end-expiratory pressure (PEEP) is used to attenuate the changes in respiratory parameters because of pneumoperitoneum during laparoscopic (LAP) surgery. As the ideal level of PEEP during LAP in children is not known, this study compared the effect of 5- and 10-cm H2O of PEEP on oxygenation, ventilator, and hemodynamic parameters during pediatric LAP. Method: After obtaining approval from the Institute Ethics Committee and written informed parental consent, 30 American Society of Anesthesiologists (ASA) I and II children aged 2-10 years, undergoing LAP were randomized to receive PEEP of 5- or 10-cm H2O during pneumoperitoneum. Baseline hemodynamic and ventilatory parameters, PaO2, and PaCO2 were measured 2 min after tracheal intubation, 2 min and 1 h after pneumoperitoneum, and after deflation of pneumoperitoneum. Oxygenation index, dynamic compliance, and alveolar-arterial oxygen gradient (D (A-a) O2) were calculated at the above-mentioned time points. Data were analyzed using Student's t-test and repeated measures ANOVA with Bonferroni correction. Results: The oxygenation index and D(A-a)O2 decreased in PEEP 5 Group and increased in PEEP 10 Group after pneumoperitoneum, the difference between the two groups being statistically significant (P = 0.001). The dynamic compliance decreased in PEEP 5 Group and increased or remained the same in PEEP 10 Group after pneumoperitoneum, the difference between the two groups being significant (P = 0.001). There were no significant changes in the hemodynamic parameters in the two groups. Conclusion: Use of 10-cm H2O PEEP during pneumoperitoneum in children improves ventilation and oxygenation, without significant hemodynamic changes.

Videolaryngoscopic versus direct laryngoscopic paraglossal intubation for cleft lip/palate reconstructive surgeries: A randomised controlled trial.

BACKGROUND AND AIMS: In the cleft lip and palate, the laryngoscope blade often tends to lodge inside midline clefts, causing reduced manoeuvrability and tissue trauma. The paraglossal technique avoids the midline and offers better Cormack Lehane (CL) grades. We aimed to assess the first-pass intubation rate in performing the left paraglossal laryngoscopy with a curved-blade videolaryngoscope (VLS) versus direct laryngoscope (DLS) in children with cleft palate and evaluate the time taken for successful endotracheal intubation (TTI) and Intubation Difficulty Score (IDS) with both devices. METHODS: This randomised controlled trial included 60 patients with cleft palate, between 3 months and 6 years. Patients were randomised into group V (VLS) (n = 30) and group D (DLS) (n = 30). Left paraglossal laryngoscopy was done with VLS or DLS, and the first-pass intubation, TTI, CL grade and IDS were recorded. RESULTS: First-pass intubation (primary outcome) was successful in all cases in group V and in 29 (96%) cases in group D (P = 0.923). Amongst the secondary outcomes, the IDS of the majority in both groups was 1-4 (slight difficulty) (P = 0.98) and the mean TTI In group D was 34.6 s (SD = 19.0) (95% CI: 27.5-41.7) versus 39.8 s (SD = 5.2) (95% CI: 37.8-41.7) in group V (P = 0.151). CONCLUSIONS: There was no significant difference in the use of a VLS over a DLS in performing the left paraglossal laryngoscopy in terms of first-pass intubation rate, CL Grade, IDS and TTI. Further studies with different VLS may be done to improve the ease of this technique.

Vitamin D levels of anesthesiologists working in tertiary care hospital of South Asian country: An observational study.

BACKGROUND AND AIMS: Vitamin D deficiency is now emerging as a major global health problem. Doctors spend most of their time indoors and hence, have very low sun exposure. With limited studies on vitamin D levels of anesthesiologists and no published study from South Asian countries, we planned to determine vitamin D levels in anesthesiologists. MATERIAL AND METHODS: One hundred twenty anesthesiologists, working in two tertiary care hospitals, were enrolled in this study. The participants were asked to complete the questionnaire and blood samples were drawn at the same sitting for measuring serum 25(OH) D and serum calcium levels. A subgroup analysis of anesthesiologists was done based on vitamin D status levels defined as per Endocrine society clinical practice guidelines 2011 on vitamin D deficiency. Vitamin D deficiency: 25(OH) D <20 ng/ml (<50 nmol/l), Vitamin D insufficiency: 25(OH) D of 21-29 ng/ml (52.5-72.5 nmol/l), Vitamin D sufficiency: 25(OH) D of ≥30 ng/ml (≥75 nmol/l). RESULTS: The mean working hours in a day [mean ± standard deviation (SD)] were 10.70 ± 1.56 hours with a range of 8-15 hours. The mean ± SD level of vitamin D in anesthesiologists was 14.56 ± 9.39 ng/ml with a range of 5.30-58.00 ng/ml. Out of 120 anesthesiologists, 101 (84.2%) anesthesiologists had deficient levels of vitamin D, 10 (8.3%) had insufficient levels, and 9 (7.5%) anesthesiologists had sufficient levels of vitamin D. Majority of the anesthesiologists had normal serum calcium levels. A total of 91.5% of doctors had vitamin D deficiency who were not taking vitamin D supplement groups as compared to 28.6% in doctors who had taken vitamin D supplements in the past. CONCLUSION: Prevalence of vitamin D deficiency/insufficiency was high among anesthesiologists. However, levels were optimal in professionals taking vitamin D supplements.

Efficacy of dexmedetomidine as an adjunct to ropivacaine in transversus abdominis plane block for paediatric laparoscopic surgeries: A double-blinded randomised trial.

BACKGROUND AND AIMS: α2 agonists have been utilised in regional blocks, but very little data is available for their use in transversus abdominis plane (TAP) block in paediatric laparoscopic (LAP) surgeries. This study investigated the analgesic effect of ropivacaine alone versus its combination with dexmedetomidine for TAP block in children undergoing LAP surgery. METHODS: A randomised, double-blind trial was conducted in 50 American Society of Anesthesiologists (ASA) 1 and 2 children of 2-8 years undergoing LAP abdominal surgery. Children were randomised to receive a total volume of 0.5 ml/kg of 0.2% ropivacaine (LA group) or 0.2% ropivacaine with 1 µg/kg dexmedetomidine (LAD group) for performing ultrasound-guided bilateral TAP block postoperatively (PO). Patients were monitored PO for vital signs, pain, sedation, time to first rescue analgesic and total analgesic consumption for 24 h. Time to first rescue analgesic was expressed as mean ± standard deviation (SD) and analysed using Kaplan-Meier survival analysis. Pain and sedation scores were expressed as median [interquartile range (IQR)] and analysed using Mann-Whitney U test. RESULTS: First rescue analgesic demand was significantly longer (P = 0.001) in LAD (474.8 min) versus LA group (240.9 min) but total analgesics consumption in first 24 h was comparable. Pain scores were significantly lower (P < 0.05) in LAD compared to LA group at all times PO. Each group had comparable but significantly lower sedation scores up to 24 h PO. CONCLUSION: Addition of dexmedetomidine to ropivacaine in TAP block prolongs the time to first analgesic requirement without a difference in the total analgesic consumption.

Specialised training in paediatric anaesthesia: Need of the hour.

Paediatric anaesthesia is an upcoming speciality which is gaining wide interest and can be a career choice for the new trainees. The need to develop paediatric anaesthesia as a speciality was realised with the progress in the field of paediatric surgery. The profile of the 'patient' encountered by a paediatric anaesthesiologist spans from an extremely premature neonate on the fringes of survival, to a full-grown adolescent equivalent to an adult. Perioperative morbidity and mortality are 2-3 times higher in infants and neonates compared to adults particularly in middle and low-income countries. The anatomical, physiological, pharmacological variations and presence of congenital cardiac, pulmonary and metabolic diseases in young children make perioperative management challenging. Special expertise and training are required for anaesthetic management of these preverbal children. In India, 3-years DM and 1-year Fellowship courses in paediatric anaesthesia are now available for specialisation. An ideal paediatric anaesthesia training centre should have substantial paediatric and neonatal patient load with exclusive intensive care facility. Paediatric anaesthesiologists, having knowledge of several facets of paediatrics and anaesthesia are capable of coordinating with health care professionals performing procedures outside the operating room. Paediatric anaesthesia, as a career thus offers a great opportunity to enhance quality and safety of anaesthesia in this high-risk surgical population. Persistent coordinated team efforts improve patient outcomes, reduce stress at work and increase job satisfaction.

Evaluation of various anthropometric airway parameters as predictors of difficult airway in neonates: A prospective observational study.

OBJECTIVE: To determine the relationship between various anthropometric parameters (age, weight, neck circumference, head circumference, thyromental distance, sternomental distance, frontal plane to chin distance, and frontal plane to chin distance by weight ratio) in neonates with difficult laryngoscopy and difficult intubation. DESIGN: A Prospective, double-blind, observational study. SETTING: Conducted in a Tertiary care Hospital in India. The study was conducted over a period of one year. PATIENTS: Participants included 100 neonates undergoing either elective or emergency non-cardiac surgery under general anesthesia. INTERVENTIONS: The various anthropometric parameters were correlated with Difficult laryngoscopy (Cormack Lehane grading III, IV) and Difficult intubation (Intubation Difficulty score>5). MEASUREMENTS: Difficult laryngoscopy (Cormack lehane grade III, IV) and Difficult intubation (Intubation Difficulty score >5). MAIN RESULTS: We found a statistically significant difference between weight (2.5 (2.2-2.8) kg vs 1.9 (1.55-2.35) kg), (p = 0.006), TMD (3.03 (2.74-3.46) cm vs 2.70 (2.45-3.13) cm), (p = 0.029), SMD (5.18 (5.06-5.76) cm vs 5.02 (4.84-5.29) cm), (p = 0.020) and FPCD/Wt ratio (0.31 (0.27-0.36) vs 0.44 (0.37-0.44)) with p = 0.001 in neonates with Easy and Difficult laryngoscopy. Using ROC curve analysis we calculated AUC, optimal cut off value, sensitivity, specificity, PPV and NPV for weight, TMD, SMD and FPCD/Wt ratio and found FPCD/Wt ratio to be best predictor for difficult laryngoscopy with highest AUC (0.844), high sensitivity (77.78%) and NPV (97.44%). CONCLUSIONS: No single parameter can provide a high index of sensitivity and specificity to predict difficult airway in neonates. Therefore, a combination of tests, including Weight, TMD, SMD, and FPCD/Wt ratio, should be used. To the best of our knowledge, this is the first prospective study to assess predictors to the difficult airway in neonates.

Prospective audit of sedation/anesthesia practices for children undergoing computerized tomography in a tertiary care institute.

BACKGROUND AND AIMS: The aim of the study was to enumerate the sedative drugs used, assess the efficacy of sedative drugs, and determine the incidence of adverse events. MATERIAL AND METHODS: A prospective audit of children sedated for computerized tomography (CT) by anesthesiology team was conducted for a period of 4 months. The data included patient demographic variables, fasting period, medications administered, adequacy of sedation, imaging characteristics, adverse events, and requirement for escalated care. RESULTS: A total of 331 children were enrolled for sedation by the anesthesia team. The drugs used for sedation were propofol, ketamine, and midazolam. Twenty-two percent children received one sedative drug, 60% children were administered two drugs, and 5% children required a combination of all three drugs for successful sedation. Sedation was effective for successful conduct of CT scan in 95.8% patients without the requirement of a repeat scan. Twelve (5%) children experienced adverse events during the study period. However, none of the adverse events necessitated prolonged postprocedural hospitalization or resulted in permanent neurologic injury or death. CONCLUSIONS: The current practice of sedation with propofol, ketamine, and midazolam, either single or in combination was efficacious in a high percentage of patients. The incidence of adverse events during the study period was low.