Prevalence and predictors of preoperative cardiac autonomic dysfunction among elective neurosurgical patients: A prospective observational study.

Background and Aims: The autonomic nervous system (ANS) is cardinal for systemic homeostasis. Autonomic dysfunction is prevalent in as high as 65% of patients presenting for cardiac surgery in the Indian scenario. Pre-existing cardiac autonomic dysfunction (CAD) in surgical patients can accentuate perioperative haemodynamic fluctuations during stressful intraoperative events, predispose to adverse cardiac events, and contribute to morbidity and mortality. The prevalence and predictors of CAD in the elective neurosurgical population are unknown in the Indian scenario. The current study was conducted to bridge this knowledge gap. Methods: In this single-centre prospective observational study conducted at a tertiary care neurosciences centre, among 400 consenting adult patients of either gender, between 18 and 80 years of age, undergoing elective neurosurgery, the preoperative ANS function at the bedside was assessed as the primary outcome measure. The ANS status was evaluated using ANSiscope™-derived indices of heart rate variability. The diagnosis of CAD was made when the ANS index exceeded a threshold of 13.5. Data regarding predictors of CAD were collected from patient records as the secondary outcome measure. Statistical analysis was done using the R software. A P-value of <0.05 was considered statistically significant. Results: The prevalence of preoperative CAD in our study population was 79.7% (319/400 patients). None of the demographic and baseline clinical characteristics we studied predicted CAD in our study. Conclusion: We observed a significant prevalence of preoperative CAD among elective neurosurgical patients. None of the parameters we evaluated predicted CAD in our study.

Role of substance P in cerebral edema and association with an estimated specific gravity of the brain and an outcome prediction in post-traumatic cerebral edema.

Purpose: The study aims to evaluate the role of substance P in cerebral edema and outcomes associated with acute TBI. Method: Patients with acute TBI who presented within 6 h and a CT scan showed predominantly cerebral edema were included in the study. Substance P level was assessed from a serum sample collected within 6 h of trauma. We also evaluated the brain-specific gravity using the Brain View software. Result: A total of 160 (128 male) patients were recruited. The median serum substance P concentration was 167.89 (IQR: 101.09-238.2). Substance P concentration was high in the early hours after trauma (p = 0.001). The median specific gravity of the entire brain was 1.04. Patients with a low Glasgow coma scale (GCS) at admission had a high concentration of the substance P. In the univariate analysis, low GCS, elevated serum concentrations of substance P level, high Rotterdam grade, high cerebral edema grade, a high international normalized ratio value, and high blood sugar levels were associated with poor outcomes at six months. In logistic regression analysis, low GCS at admission, high cerebral edema grade, and elevated blood sugar level were strongly associated with poor outcomes at six months. The area under the receiver operating characteristic curve was 0.884 (0.826-0.941). Conclusion: Serum substance P is strongly associated with the severity of cerebral edema after TBI. However, brain-specific gravity does not directly correlate with posttraumatic cerebral edema severity. Serum substance P does not influence the clinical outcome of traumatic brain injury.

Transcranial ultrasonographic evaluation of effect of ventriculoperitoneal shunt on intracranial dynamics: A prospective observational study.

BACKGROUND: Transcranial sonographic (TCS) evaluation of optic nerve sheath diameter (ONSD), third ventricular diameter (TVD) and mean flow velocities (Vm) and pulsatility index (PI) of middle cerebral artery (MCA) can provide important insights to the change in intracranial dynamics following ventriculo-peritoneal (VP) shunt surgery. The primary objective of this study was to observe changes in ONSD values following VP shunt at 12 h, compared to pre-VP shunt values. METHODS: After obtaining ethical approval, patients admitted with a diagnosis of hydrocephalus posted for a VP shunt surgery were prospectively enrolled. TCS evaluation was done before induction of anesthesia and 12-hour post-VP shunt surgery. We recorded the values of ONSD, TVD and Vm and PI MCA at both time points. RESULTS: Thirty-four patients (19 male) were evaluated for ONSD and for the improvement of symptoms. Transtemporal window could not be obtained in six patients. At 12 h following VP shunt, bilateral median ONSD values reduced significantly from their pre-VP shunt values [right ONSD- 0.62 (0.59-0.64) to 0.53 (0.5-0.54) mm (p < 0.001); left ONSD- 0.62 (0.59-0.63) to 0.53 (0.5-0.54) mm (p < 0.001)]. Similarly, the median TVD at 12 h post-VP shunt reduced significantly from its pre-VP shunt measurements [0.97 (0.85-1.09) to 0.74 (0.7-0.84) cm]. PI MCA values reduced significantly, while Vm MCA values increased significantly from the pre-VP shunt values. CONCLUSION: VP shunt reduced the ONSD, TVD, PI MCA and increased the Vm MCA after shunt surgery as early as 12hrs.

Comparison of hands-free Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) with conventional facemask ventilation technique for oxygenation in patients undergoing electroconvulsive therapy - A cross over study.

OBJECTIVES: Modified ECT is routinely conducted using face mask (FM) and bag ventilation technique. Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) is a novel hands-free insufflation technique that provides oxygenation and prolongs apnoea time. There is limited literature comparing the two techniques. Primary objective of this study was to compare oxygen desaturation between THRIVE and FM techniques during ECT while secondary objective was to compare hemodynamics and complications. METHODS: Patients aged 18-50 years undergoing 3rd-5th ECT treatments were enrolled. First ECT was with FM technique followed by THRIVE (with LUBO collar) in the next ECT. Except for the oxygenation technique, the protocol for ECT administration was similar with both techniques. SpO2 values were recorded every minute for 10 min while hemodynamic parameters were measured at 2 min and 5 min following administration of electrical stimulus. Any drop in SpO2 below 92 % was considered as a desaturation event. RESULTS: A total of 201 patients underwent ECTs, one each with FM and THRIVE technique. Median age of patients was 28 years. There was no difference in SpO2 between the techniques (main effect P = 0.324, interaction P = 0.14). Only one patient had desaturation with THRIVE requiring intervention with FM. None of the patients had any airway complications in terms of nasal injury, hoarseness, or pneumothorax with THRIVE. CONCLUSION: THRIVE is a safe alternative option for hands-free oxygenation while administering ECT. However, considering patient safety, an anaesthesiologist competent in airway management must be readily available.

The requirement of propofol for induction of anesthesia in patients with traumatic brain injury determined using bilateral bispectral index and target controlled infusion - An observational cohort study.

Background and Aims: Patients with traumatic brain injury (TBI) frequently require emergency surgery. There is a paucity of literature with regard to anesthetic requirements in these patients. The aim of the study was to compare the dose of propofol required for induction of anesthesia in patients with different grades of TBI. Material and Methods: This prospective, observational study included patients with mild, moderate, and severe grades of TBI undergoing emergency surgery within 48 h of injury. Bispectral Index (BIS) values were recorded using a bilateral BIS sensor. Anesthesia was induced with a target controlled infusion (TCI) pump. Once BIS reached 40, plasma (Cp) and effect-site (Ce) concentration and total dose of propofol required were noted from the TCI pump. Results: Of the 96 patients recruited, 27, 36, and 33 patients belonged to mild, moderate, and severe TBI (sTBI) groups, respectively. The Ce of propofol in mild, moderate, and sTBI groups was 6 ± 0.9, 5.82 ± 0.98, and 4.48 ± 1.5 µg/mL (P < 0.001), and the dose of propofol required was 1.9 ± 0.2, 1.8 ± 0.4, 1.41 ± 0.5 mg/kg, respectively (P < 0.001). Baseline BIS on the injured side was 80 ± 7.8, 71 ± 9.4, 55 ± 11.6, and on the uninjured side was 89 ± 5.5, 81 ± 8.4, and 65 ± 12 in mild, moderate, and sTBI groups, respectively. Conclusions: The requirement of propofol was reduced in patients with sTBI. The dose of propofol required for induction of anesthesia as determined using Ce was significantly lower only between sTBI and mild TBI and not between patients with sTBI and moderate TBI or between mild and moderate head injury. BIS values were significantly different between the groups (highest in mild TBI and lowest in sTBI) and between normal and injured sides within each group.

The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage.

Background: Vasopressors are used in patients with subarachnoid hemorrhage (SAH) to increase blood pressure with the idea of reversing the ischemic process. The current study is designed to evaluate the changes in systemic and cerebral hemodynamics, including cerebral blood flow autoregulation, at different pharmacologically augmented blood pressure levels using norepinephrine in patients with spontaneous aneurysmal SAH following surgery. Materials and methods: This prospective observational study was carried out in patients with ruptured anterior circulation aneurysms who underwent surgical clipping and required norepinephrine infusion. Postoperatively, when the treating physician decided to start a vasopressor, norepinephrine infusion was started at 0.05 µg/kg/min. The infusion rate was increased by 0.05 µg/kg/min every 5 minutes to achieve a 20% and then 40% increase in the systolic blood pressure (SBP). When the blood pressure stabilized at each level for 5 minutes, hemodynamic and transcranial doppler (TCD) parameters in the middle cerebral artery (MCA) were recorded. Results: Peak systolic, end-diastolic, and mean flow velocities in the MCA increased with targeted blood pressure increase in the hemispheres with impaired autoregulation and not in the hemispheres with intact autoregulation. The interaction of changes in TCD flow velocities between hemispheres with and without intact autoregulation was significant (p < 0.001). Cardiac output changes following norepinephrine infusion were not significant (p = 0.113). Conclusion: Hypertensive therapy with norepinephrine increases cerebral blood flow velocity only when autoregulation is impaired, an effect that is desirable in patients with focal cerebral ischemia following SAH. How to cite this article: Lakshmegowda M, Muthuchellapan R, Sharma M, Ganne SUR, Chakrabarti D, Muthukalai S. The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage. Indian J Crit Care Med 2023;27(4):254-259.

Utility of 3D T1-weighted turbo spin echo black blood sequence for the diagnosis of cerebral venous thrombosis.

PURPOSE: Accurate assessment of dural sinus, deep and cortical venous thrombosis on MR imaging is challenging. The aim of this study is to evaluate the accuracy of 3D-T1 turbo spin echo (T1S), sequences in detecting venous thrombosis and comparing it with susceptibility-weighted imaging (SWI), magnetic resonance venography (MRV) and post contrast T1 magnetization-prepared rapid acquisition gradient echo (T1C). METHODS: A blinded retrospective observational analysis of 71 consecutive patients evaluated for cerebral venous thrombosis (CVT) and 30 control patients was performed. Multimodality reference standard adopted included T1C, SWI with MRV. Sub-analyses in superficial, deep and cortical venous segments were performed in addition to correlation of signal intensity of thrombus with the clinical stage. RESULTS: A total of 2222 segments in 101 complete MRI examinations were evaluated. Sensitivity/specificity/positive predictive value/negative predictive value/accuracy and precision of T1S for detection of cortical vein thrombosis was 0.994/1/1/0.967/0.995/1, 1/0.874/0.949/1/0.963/0.950 for detection of superficial venous sinus thrombosis and 1/1/1/1/1/1 for deep venous thrombosis. The AUC yield for T1S was 0.997 for cortical, 1 for deep and 0.988 for superficial venous segments. CONCLUSION: T1S paralleled the accuracy of conventional sequences in the overall detection of CVT but showed superior accuracy in the detection of cortical venous thrombosis. It makes a fitting addition to the CVT MRI protocol in scenarios demanding negation of gadolinium administration.

Postoperative delirium after intracranial neurosurgery: A prospective cohort study from a developing nation.

INTRODUCTION: Post-operative delirium (POD) is a major complication after anesthesia and surgery with an incidence varying from 5 to 50%. The incidence of POD after intracranial surgery is likely to be higher due to the pre-existing brain pathology and direct handling of the brain during neurosurgery. The primary objective of this study was to assess the incidence of POD after intracranial neurosurgery and our secondary objective was to identify the potential risk factors for its occurrence. MATERIALS AND METHODS: This prospective observational study was conducted after the institutional ethics committee approval between october 2020 and march 2021. We included patients of either gender aged ≥ 18 years and undergoing elective intracranial neurosurgery. Exclusion criteria included patients aged below 18 years, undergoing emergency neurosurgery, patients with impaired consciousness and patients with psychiatric comorbidities or those taking psychotropic medications. We planned to exclude patients from analysis who were transferred to intensive care unit (ICU) or if they were not extubated after surgery. Our study outcome was development of POD as assessed by confusion assessment method (CAM). RESULTS: The overall incidence of POD during the three postoperative days was 19.2% (n=60/313). The incidence of POD on days 1, 2, and 3 were 19.2% (n=60/313), 17.2% (n=50/291), and 16.3% (n=39/239). Preoperative delirium and hyperactive Emergence Delirium were found to be the significant predictors of POD. CONCLUSION: Every one in five patients undergoing intracranial neurosurgery is vulnerable for the development of POD within first three days after surgery. The incidence of occurrence of POD is time-sensitive and is decremental.

Clinical Scoring and Ultrasound-Based Diaphragm Assessment in Predicting Extubation Failure in Neurointensive Care Unit: A Single-Center Observational Study.

BACKGROUND: Patients in the neurointensive care unit (NICU) fail extubation despite successful weaning from mechanical ventilation. Parameters currently used in the general intensive care unit do not accurately predict extubation success in the NICU. In this study, peak cough expiratory flow rate, ultrasound-based diaphragm function assessment, and comprehensive clinical scoring systems were measured to determine whether these new variables, in isolation or combination, could predict extubation failure successfully in the NICU. METHODS: All adult patients extubated after 48 h of mechanical ventilation in the NICU of a single tertiary care center were recruited into the prospective cohort. The patient's cough peak expiratory flow rate (C-PEFR), diaphragm function, and clinical scores were measured before extubation. C-PEFR was measured using a hand-held spirometer, diaphragm function (excursion, thickness fraction, and diaphragm contraction velocity on coughing) was assessed using ultrasound, and the clinical scores included the visual pursuit, swallowing, age, Glasgow Coma Scale for extubation (VISAGE) and respiratory insufficiency scale-intubated (RIS-i) scores. The patients requiring reintubation within 48 h were considered as extubation failure. Univariate and multivariate logistic regression analyses were done to identify predictors of extubation failure. RESULTS: Of the 193 patients screened, 43 were recruited, and 15 had extubation failure (20.9%). Patients with extubation failure had higher RIS-i scores (p < 0.001) and lower VISAGE scores (p = 0.043). The C-PEFR and diaphragm function (excursions and contraction velocity on coughing) were lower in patients with extubation failure but not statistically significant. The variables with p < 0.2 in univariate analysis (RIS-i, VISAGE, and diaphragm cough velocity) were subjected to multivariate regression analysis. RIS-I score remained an independent predictor (odds ratio 3.691, 95% confidence interval 1.5-8.67, p = 0.004). In a receiver operating characteristic analysis, the area under the curve for RIS-i was 0.963. An RIS-i score of 2 or more had 94% specificity and 89% sensitivity for predicting extubation failure. CONCLUSIONS: The RIS-i score predicts extubation failure in NICU patients. The addition of ultrasound-based diaphragm measurements to the RIS-i score to improve prediction accuracy needs further study. Clinical trial registration Clinical Trials Registry of India identifier CTRI/2021/03/031923.

Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-antinociception balance in paediatric craniotomies: a prospective observational study.

INTRODUCTION: Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-anti-nociception balance has not been studied in paediatric neurosurgery. The objectives were to study the correlation between ANI (Mdoloris Education system) and revised FLACC (r-FLACC) score for the prediction of acute postoperative pain in paediatric population undergoing elective craniotomies and to compare the changes in ANI values with heart rate (HR), mean arterial pressure (MAP) and surgical plethysmographic index (SPI) during various time points of intraoperative noxious stimulation and before and after opioid administration. METHODS: This prospective observational pilot study included 14 patients between 2 and 12 years of age undergoing elective craniotomies. HR, MAP, SPI, ANI instantaneous (ANIi) and ANI mean (ANIm) values were recorded intraoperatively and before and after opioid administration. Postoperatively HR, MAP, ANIi and ANIm, and pain scores (r-FLACC scale) were recorded. RESULTS: There was a statistically significant negative correlation between ANIi and ANIm with r-FLACC during the time course of PACU stay (r = - 0.89, p < 0.001 and r = - 0.88 and p < 0.001 respectively). Intraoperatively, in patients with ANIi values < 50, with additional fentanyl administration, there was an increasing trend in values beyond 50, which was statistically significant (p < 0.05) at 3, 4, 5 and 10 min. The trend in changes of SPI after opioid administration was not found to be significant for patients irrespective of the baseline SPI values. CONCLUSION: The ANI is a reliable tool for objective assessment of acute postoperative pain as assessed by r-FLACC in children undergoing craniotomies for intracranial lesions. It may be used as a guide to nociception-antinociception balance during the peri-operative period in this population.

Postoperative delayed neurocognitive recovery: Evaluation of its incidence and correlation with intraoperative cerebral desaturation - A prospective observational study.

BACKGROUND: Delayed neurocognitive recovery (DNR) is commonly seen in patients in the postoperative period. Literature has shown that monitoring cerebral desaturation intraoperatively can predict the development of DNR in elderly patients undergoing surgery in prone position. This prospective observational study was conducted in patients of all ages, with the primary objective to determine the incidence of DNR and its correlation with cerebral oximetry. The secondary objectives were to determine if intraoperative cerebral desaturation influenced the neuropsychometric variables from preoperative to postoperative period. METHODS: This study included 61 patients, aged > 18 years undergoing spinal surgery in prone position. An evening before surgery and at 48 h postoperatively, patients were subjected to neuropsychological examination; Hindi Mental State Examination, Colour Trail Test 1 (CTT 1), CTT 2, Auditory Verbal Learning (AVLT) tests conducted by principal investigator (PI). DNR was defined as a 20% change in any of the test scores from the baseline. rSO2 was recorded bilaterally every 10 min throughout surgery by an independent person. Cerebral desaturation was defined as a 20% drop in rSO2 from the control value. RESULTS: The incidence of DNR was 24.6%. The duration of anesthesia and cerebral desaturation were found to be independently predictive of DNR, with each hour of anesthesia causing a two-fold increase in the chances of development DNR (P = 0.019) and presence of cerebral desaturation causing a 6-fold increase (P = 0.039). CTT 1 and CTT 2 tests had significantly larger increase in test scores in the postoperative period, in patients with cerebral desaturation. CONCLUSION: Duration of anesthesia and cerebral desaturation were factors predictive of the development of DNR in patients undergoing spine surgery in prone position.

Reliability of Pre-Induction Inferior Vena Cava Assessment with Ultrasound for the Prediction of Post-Induction Hypotension in Neurosurgical Patients Undergoing Intracranial Surgery.

Background: Hypotension is one of the most common complications following induction of general anesthesia. Preemptive diagnosis and correcting the hypovolemic status can reduce the incidence of post-induction hypotension. However, an association between preoperative volume status and severity of post-induction hypotension has not been established in neurosurgical patients. We hypothesized that preoperative ultrasonographic assessment of intravascular volume status can be used to predict post-induction hypotension in neurosurgical patients. Our study objective was to establish the relationship between pre-induction maximum inferior vena cava (IVC) diameter, collapsibility index (CI), and post-induction reduction in mean arterial blood pressure in neurosurgical patients. Materials and Methods: A prospective observational study was conducted including 100 patients undergoing elective intracranial surgeries. IVC assessment was done before induction of general anesthesia. Receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of maximum and minimum IVC diameter (IVCDmax and IVCDmin, respectively) and CI for prediction of hypotension. Results: Post-induction hypotension was observed in 41% patients. Patients with small IVCDmax and higher CI% developed hypotension. The areas under the ROC curve (AUCs) were 0.64 (0.53-0.75) for IVCDmax and 0.69 (0.59-0.80) for IVCDmin. The optimal cutoff values were1.38 cm for IVCDmax and 0.94 cm for IVCDmin. The AUC for CI was 0.65 (0.54-0.77) and the optimal cutoff value was 37.5%. Conclusion: Pre-induction IVC assessment with ultrasound is a reliable method to predict post-induction hypotension resulting from hypovolemia in neurosurgical patients.

Full-text publications of presentations at neuroanesthesia meetings of India: A 5-year audit and analysis.

Backgroud and Aims: Conference presentations provide an opportunity to rapidly share findings of new research despite limitations of details and reach. Earlier studies have examined publication rates of conference presentations in anesthesia. However, conversion rate of neuroanesthesia meeting presentations to publications is unknown. We assessed the publication rate of neuroanesthesia conference presentations from India over a 5-year period and identified factors contributing to subsequent publications. Material and Methods: Conference abstracts of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) from 2014 to 2018 were studied with regard to conversion to full-length publications. Details of presentations were obtained from abstracts published in the journal of ISNACC and details of publications were collected by searching Google and PubMed using title and author details. Results: Only 17.5% (40/229) of the abstracts presented at ISNACC conferences over a 5-year period resulted in subsequent full-text publications in peer-reviewed journals. Prospective cohort studies (OR [95% CI] 2.84 [1.05-8.56], P = 0.048), randomized trials (OR [95% CI] 2.69 [1.04 to 7.9], P = 0.053), and abstracts from public institutions (OR [95% CI] 3.44 [1.4 to 10.42], P = 0.014) were significantly associated with publications after conference presentations. Conclusion: The conversion rate of conference presentations of neuroanesthesia society of India into journal publications is significantly low. There is need for neuroanesthesia community of India to work together to improve the translation of presentations into publications.

Reliability of analgesia nociception index (ANI) and surgical pleth index (SPI) during episodes of bleeding - A pilot study.

Background and Aims: Analgesia Nociception Index (ANI) and Surgical Pleth Index (SPI) are measures of nociception-antinociception balance during general anaesthesia. The validity of these two monitors during autonomic changes brought about by intraoperative blood loss and noradrenaline infusion has not been studied earlier. The primary objective of the study was to determine the effect of bleeding on ANI and SPI. The secondary objective was to observe the effect of noradrenaline infusion on ANI and SPI and the correlation between ANI and SPI. Methods: In this prospective observational study, 43 patients undergoing surgery for excision of a meningioma or for traumatic brain injury were included. Heart rate, mean arterial pressure, ANI, SPI, response and state entropy were recorded every 5 min from anaesthetic induction till skin closure. ANI and SPI values before bleeding were compared with the values following bleeding. The effect of bleeding and noradrenaline on ANI and SPI were studied using linear mixed effect model. Results: Bleeding increased the values of ANI and the increase was higher in the presence of noradrenaline and it was statistically significant (P = 0.028 and 0.023). SPI was not affected by bleeding or with noradrenaline infusion. ANI and SPI had a poor negative correlation (r = - 0.01). Conclusion: Values of ANI increased significantly during episodes of intraoperative acute blood loss and with co-administration of noradrenaline. SPI seems to be more dependable when compared to ANI under such conditions.

Emergence delirium after intracranial neurosurgery- a prospective cohort study.

OBJECTIVES: The primary objective of this study was to estimate the incidence of emergence delirium (ED) including hypo- and hyperactive ED, after intracranial neurosurgery. Secondary objective was to identify perioperative risk factors of ED in these patients. METHODS: This prospective observational study was conducted at an academic neurosciences hospital. All consecutive adult patients (age ≥ 18 years) with a preoperative Glasgow Coma Scale score of 15 undergoing elective intracranial surgery under general anesthesia during the six-month period from October 2020 to March 2021 were included in this study. Perioperative patient data were collected till one hour after surgery. ED was defined as per Riker's sedation agitation score (SAS) as hyperactive ED when SAS was >4 and hypo active ED when SAS was <4 on a 1 to 7 scale. RESULTS: Data of 320 patients were analyzed in this study. The overall incidence of ED was 22 % (71/320), with incidence of hyperactive ED of 4.3 % (n = 14) and hypoactive ED of 18 % (n = 57). The risk factors for ED were preoperative delirium (odds ratio [OR], 95 % confidence interval [CI] and p value of 4.41, 1.3-15.19, and 0.002), education level (OR = 2.21, [0.98-4.94], p = 0.05), minimum alveolar concentration of inhalational anesthetic (OR = 1.47, [1.17-1.88], p = 0.002), postoperative nausea and vomiting (OR = 4.56, [2.04-10.32], p = 0.001), and body weight (OR = 1.69, [1.1-2.68], p = 0.02). Hyperactive ED was predicted by preoperative delirium (OR = 5.28, [1.12-21.21], p = 0.024) and low education level (OR = 4.35, [1.2-17.04], p = 0.027). CONCLUSIONS: Atleast one in five patients undergoing brain surgery under anesthesia develop ED. Addressing modifiable risk factors might reduce ED.

Effect of Preanesthetic Fluid Loading on Postinduction Hypotension and Advanced Cardiac Parameters in Patients with Chronic Compressive Cervical Myelopathy: A Randomized Controlled Trial.

Purpose Hypotension during the early intraoperative phase is common and can lead to adverse perioperative outcomes. Fluid preloading is one of the methods to limit its occurrence. Patients with chronic compressive cervical myelopathy may have autonomic dysfunction, which can aggravate hemodynamic alterations during anesthesia. This study compared the occurrence of postinduction hypotension and changes in cardiac dynamic indices in patients with and without crystalloid preloading undergoing decompressive cervical spine surgery. Methods This randomized controlled trial was conducted over 15 months after obtaining patient consent, approval of the institute ethics committee, and trial registration. We compared preanesthetic fluid loading with Ringer's lactate (20 mL/kg over 30 minutes) with no preloading (2 mL/kg/h maintenance) in 60 consecutive patients undergoing cervical spine surgery. The ANSiscope was used to determine baseline cardiac autonomic function. Noninvasive cardiac output monitor was used to assess changes in heart rate, mean arterial pressure, cardiac index (CI), stroke volume variation (SVV), and total peripheral resistance index during study intervention, anesthetic induction, tracheal intubation, and change in position from supine to prone. Results The incidences of postinduction hypotension were 26.7% (8/30) and 86.7% (26/30) and the median doses of mephentermine used were 0 and 6 mg, respectively, in patients with and without fluid preloading (both p < 0.001). Preloading resulted in improvement in CI, reduction in SVV, and lesser vasopressor use. Conclusion Preloading reduced the occurrence of postinduction hypotension and vasopressor use, improved CI, and reduced SVV during the early intraoperative period. Registration number of Clinical Trial The trial was registered with Clinical Trial Registry of India (CTRI/2018/07/014970 on 19/07/2018).

Role of Nimodipine and Milrinone in Delayed Cerebral Ischemia.

OBJECTIVE: The role of nimodipine and milrinone in the management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) was studied using clinical and TCD (transcranial Doppler) parameters. METHODS: In this prospective observational study, patients with DCI after aneurysmal SAH presenting between November 2020 and June 2021 who were treated by either intra-arterial nimodipine (IAN) or intravenous milrinone (IVM) were included after excluding patients in whom both IAN and IVM had been given or mechanical angioplasty was performed. Twelve-hourly TCD was performed during the course of the therapy. Clinical improvement and the development of new brain infarcts were also assessed. A P value <0.05 was considered statistically significant. RESULTS: Thirty-four patients fulfilled the inclusion criteria (IVM, 13/34 [38%]; IAN, 21/34 [62%]); patients in the IVM group (vs. IAN group) had poorer median Glasgow Coma Scale score (12 vs. 13), poorer motor response (