Ultrasonography Imaging versus Waveform Capnography in Detecting Endotracheal Tube Placement during Intubation at a Tertiary Hospital.

Background: There is continued research to find new faster, highly accurate, easily accessible, and portable methods of confirming endotracheal tube position during intubation. A newer modality for visualizing endotracheal tube location is transtracheal or transcricothyroid ultrasonography. The aim of this study was to see if ultrasound machine can also be routinely used for the confirmation of endotracheal tube position in operating theaters along with capnograph. Methods: The study was observational and prospective, conducted from January 2017 to July 2017. Study locations were at the Tribhuvan University Teaching Hospital and Manmohan Cardiothoracic Vascular and Transplant Center operating rooms. Sample size taken was 95. Results: In the study, 11 patients had esophageal intubation out of the 95. The accuracy of both ultrasonography and capnography was found to be 96.84%. For ultrasonography, the sensitivity, specificity, along with positive predictive value and negative predictive value were 97.62%, 90.91%, 98.80%, and 83.33%, respectively, while that for capnography were found to be 96.43%, 100%, 100%, and 78.57%, respectively. The kappa value was calculated to be 0.749, which suggested the degree of agreement of result between the methods to be good. Compared to capnography, ultrasonography was found to be significantly faster for the confirmation of endotracheal tube location by 16.36 s (15.70-17.02) (P = 0.011). Conclusion: Both waveform capnography and ultrasonography were found to be accurate and reliable in confirming endotracheal tube location. The use of ultrasound during intubation can help confirm endotracheal tube location faster and also aid in precision when used along with capnography. Manual bag ventilations are not necessary when confirming endotracheal tube position by ultrasonography and thus may help in preventing aspiration of gastric contents into the lungs of the patient.

Prevalence of non-convulsive seizures and electroencephalographic abnormalities in critically ill patients-A retrospective observational study.

OBJECTIVE: Electroencephalographic (EEG) abnormalities especially non-convulsive status epilepticus (NCSE) have been found to be associated with worse outcomes in critically ill patients. We aimed to assess the prevalence of non-convulsive seizures and electroencephalographic abnormalities in critically ill patients. Furthermore, we aimed to investigate any association between the type of EEG abnormality and outcomes including ICU mortality and successful ICU discharge. METHODS: This was a cross-sectional observational study carried out among critically ill patients in a mixed medical-surgical ICU from January 1, 2018 to May 15, 2020. A total of 178 records of 30 min bedside EEG records were found. EEG findings were grouped as normal, non-convulsive seizures (NCS), non-convulsive status epilepticus (NCSE), and other abnormalities. Descriptive analytical tools were used to characterize the case details in terms of the type of EEG abnormalities. Chi square test was used to describe the EEG abnormalities in terms of mortality. The status epilepticus severity scores (STESS) were further calculated for records with NCSE. These data were then analyzed for any association between STESS and mortality for cases with NCSE. RESULTS: The prevalence of EEG abnormality in our cohort of all critically ill patients was found to be 7.3% (170/2234). Among the patients with altered sensorium in whom EEG was done, 42.9% had non-conclusive seizure activity with 25.2% in NCSE. Though the study was not adequately powered, there was a definite trend towards a lower proportion of successful ICU discharge rates seen among patients with higher STESS (>2) with only 33.3% being discharged for patients with a STESS of 6 versus 92.9% for those with STESS 3. SIGNIFICANCE: When combined with a strong clinical suspicion, even a 30-min bedside EEG can result in detection of EEG abnormalities including NCS and NCSE. Hence, EEG should be regularly included in the evaluation of critically ill patients with altered sensorium. PLAIN LANGUAGE SUMMARY: Electroencephalographic (EEG) abnormalities and seizures can have high prevalence in critically ill patients. These abnormalities notably, non-convulsive status epilepticus (NCSE) has been found to be associated with poor patient outcomes. This was a retrospective observational study analyzing 178 EEG records, from a mixed medical-surgical ICU. The indication for obtaining an EEG was based solely on the clinical suspicion of the treating physician. The study found a high prevalence of EEG abnormalities in 96.5% in whom it was obtained with 42.9% having any seizure activity and 28.8% having NCSE. The study was not powered for detection of association of the EEG abnormalities with clinical outcomes. However, a definite trend towards decreased chances of successful discharge from the ICU was seen. This study used strong clinical suspicion in patients with altered sensorium to obtain an EEG. High detection rates of EEG abnormalities were recorded in this study. Hence, combination of clinical judgement and EEG can improve detection of EEG abnormalities and NCSE.

Nepalese version of Douleur Neuropathique 4 (DN4) questionnaire for detection of neuropathic pain signs and symptoms: Translation and psychometric properties.

OBJECTIVE: This study aimed to translate the DN4 questionnaire into Nepalese version and assess its psychometric properties: diagnostic accuracy, internal consistency, and test-retest reliability. METHODS: An observational study was conducted in a tertiary level teaching hospital of Kathmandu, Nepal. We included 166 patients with chronic pain visiting a pain clinic over a period of one year. The Nepalese version of the DN4 questionnaire was used for detecting signs and symptoms of neuropathic pain. The English version of the questionnaire was translated into Nepali in accordance with the standard guideline with the help of linguistic experts. The patients who met the inclusion criteria were examined and interviewed twice in an interval of two weeks. The association between the index test and the reference test was analyzed using Chi-square test. Diagnostic accuracy was assessed using sensitivity, specificity, Youden's index, and positive and negative predictive values. We calculated internal consistency using Cronbach's alpha (∝), and test-retest reliability using Cohen's kappa and Intra-class correlation coefficient (ICC). RESULTS: The study showed a significant association between the result of DN4 questionnaire and the gold standard (physician's diagnosis) (p<0.001). The sensitivity and specificity values for the DN4 questionnaire were 75% and 95.3% respectively. Similarly, positive and negative predictive values were 93.8% and 80.4% respectively. Our study showed adequate internal consistency (∝ = 0.710) and a good test-retest reliability (kappa = 0.872, ICC = 0.877). CONCLUSIONS: The Nepalese version of DN4 questionnaire is a valid and reliable tool for the identification of signs and symptoms of neuropathic pain. This can be used for screening neuropathic pain signs and symptoms in clinical as well as research settings.

Peripheral Nerve and Plexus Blocks for Hip Surgery in a Nonagenarian with Severe Cardiac Disease.

The hemodynamic alterations and stress response associated with anesthesia and surgery are often poorly tolerated by elderly patients. Regional anesthesia techniques are useful in the elderly as they provide excellent perioperative analgesia with minimal hemodynamic perturbations. We report the case of a 90-year-old man with valvular heart disease and severe left ventricular systolic dysfunction, who underwent dynamic hip screw fixation of fractured femur neck under combined pericapsular nerve group block, lumbar plexus block, and para-sacral sciatic nerve block. We are not aware of any previous report of the combination of these blocks used for surgical anesthesia in hip fracture surgery. Keywords: Geriatric; hip fracture; pericapsular nerve group block; regional anesthesia.

Management of nitrobenzene poisoning with oral methylene blue and vitamin C in a resource limited setting: A case report.

Nitrobenzene can cause life threatening methaemoglobinemia. Its management includes the use of intravenous methylene blue to reduce the iron moiety from its ferric to ferrous state. Due to unavailability of intravenous preparation, enteral methylene blue was used in our case. This case report is to highlight that even oral preparations can be successfully used in a resource limited setting where often intravenous preparations are unavailable.

Topical nitroglycerin for management of peripheral extravasation of vasopressors: a case report.

Peripheral route for administration of vasopressors is often opted due to resource limitations or as a rescue until central venous access is established. This, however, is not devoid of complications, the most common being extravasation and tissue injury. Phentolamine is the only drug approved for management of vasopressor extravasation; however, successful use of other agents has been reported. Here we report a case of peripheral extravasation of vasopressors, successfully managed with topical nitroglycerin in intensive care unit in Kathmandu. To our knowledge, this is the first report of such kind from Nepal.

Acupuncture induced pneumothorax: A case report.

Various forms of alternative medicinal practices are gaining popularity. With this, there will be rise in the complications arising from these practices. Acupuncture is also such practice which though safe can rarely cause life-threatening complications.

Delayed Neurological Recovery After Ultrasound-Guided Brachial Plexus Block: A Case Report.

INTRODUCTION: Brachial plexus blocks are frequently practiced and safe mode of anaesthsia. Although minor complications may occur, major complications are a rarity. However, we report a rare case of prolonged supraclavicular brachial plexus block which required almost 4 months to recover without a perceivable cause. CASE PRESENTATION: A 22-year-old gentleman posted for open reduction and internal fixation of both forearm bones was administered an ultrasound-guided supraclavicular brachial plexus block. The intra-operative period was uneventful. However, the block persisted for a very prolonged period of time. All perceivable causes were ruled out. A total of 19 weeks was required for the entire block to regress with no residual neurological deficits thereafter. CONCLUSION: Although peripheral neuropathies are known complications of peripheral nerve blocks, such a prolonged brachial plexus block is a rare event. The only plausible cause for the patient's condition could have been the prolonged drug effect; however, it has been rarely documented.

Continuous Fascia Iliaca Compartment Block for Post Operative Analgesia in Fracture Femur.

The postoperative pain management in the elderly is challenging due to comorbidities and change in physiology due to age itself. This limit the use of medication which include pain medication also. The fascia iliaca compartment block has been described in the literature for fracture of femur. It has even been safely used by non anaesthesiologist also. To our knowledge, we did not find any case report of continuous fascia iliaca compartment block published in Nepal. This is our first experience of successful continous fasicia iliaca compartment block in case of 89 year old lady with multiple co morbidities in whom traditional pain medication might be difficult to use. We encourage to practice this block which is both safe and easy to perform with good results.

Comparison of outcome predictions by the Glasgow coma scale and the Full Outline of UnResponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit.

Assessment of level of consciousness is very important in predicting patient's outcome from neurological illness. Glasgow coma scale (GCS) is the most commonly used scale, and Full Outline of UnResponsiveness (FOUR) score is also recently validated as an alternative to GCS in the evaluation of the level of consciousness. We carried out a prospective study in 97 patients aged above 16 years. We measured GCS and FOUR score within 24 h of Intensive Care Unit admission. The mean GCS and the FOUR scores were lower among nonsurvivors than among the survivors and were statistically significant (P < 0.001). Discrimination for GCS and FOUR score was fair with the area under the receiver operating characteristic curve of 0.79 and 0.82, respectively. The cutoff point with best Youden index for GCS and FOUR score was 6.5 each. Below the cutoff point, mortality was higher in both models (P < 0.001). The Hosmer-Lemeshow Chi-square coefficient test showed better calibration with FOUR score than GCS. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.91 (P < 0.001).