The Effect of Prophylactic Steroids on Shivering in Adults Undergoing Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Shivering is common following anesthesia and surgery. Corticosteroids (steroids) have been tried to reduce the risk of shivering, but the evidence in favor of their use is uncertain. The primary objective of this review was to evaluate the effect of steroids on the risk of perioperative (intra- and postoperative) shivering versus controls (placebo and active controls). Additional objectives were to assess the risk of severity of shivering, patient satisfaction with shivering prophylaxis, quality of recovery (QoR), and the risk of steroid-related adverse effects. METHODS: PubMed, Embase, Cochrane Central Registry of Trials, Google Scholar, and preprint servers were searched from inception until November 30, 2022. Randomized controlled trials (RCTs) published in the English language were retrieved, provided they reported on shivering either as a primary or secondary outcome following steroid prophylaxis in adult patients undergoing surgery under spinal or general anesthesia. RESULTS: A total of 3148 patients from 25 RCTs were included in the final analysis. The steroids used in the studies were either dexamethasone or hydrocortisone. Dexamethasone was administered intravenously or intrathecally, while hydrocortisone was administered intravenously. Prophylactic administration of steroids reduced the risk of overall shivering (risk ratio [RR], 0.65 [95% confidence interval {CI}, 0.52-0.82]; P = .0002; I2 = 77%) as well as the risk of moderate to severe shivering (RR, 0.49 [95% CI, 0.34-0.71]; P = .0002; I2 = 61%) in comparison to controls. Administration of intravenous dexamethasone (RR, 0.67 [95% CI, 0.52-0.87]; P = .002; I2 = 78%) and hydrocortisone (RR, 0.51 [95% CI, 0.32-0.80]; P = .003; I2 = 58%) were effective in shivering prophylaxis. For intrathecal dexamethasone (RR, 0.84 [95% CI, 0.34-2.08]; P = .7; I2 = 56%), the null hypothesis of no subgroup difference was not rejected ( P = .47), preventing definitive conclusions about the efficacy of this route of administration. The prediction intervals for both overall shivering risk (0.24-1.70) and risk of severity of shivering (0.23-1.0) precluded generalization of results in future studies. Meta-regression analysis was used to further explore heterogeneity. Factors like the dose and timing of administration of steroids or the type of anesthesia were not found to be significant. Patient satisfaction and QoR were higher in the dexamethasone groups versus placebo. No increased risk of adverse events of steroids was noted versus placebo or controls. CONCLUSIONS: Prophylactic steroid administration may be beneficial in reducing the risk of perioperative shivering. However, the quality of evidence in favor of steroids is very low. Further well-designed studies are needed for establishing generalization.

Comparison of oral triclofos and intranasal midazolam and dexmedetomidine for sedation in children undergoing magnetic resonance imaging (MRI): an open-label, three-arm, randomized trial.

The purpose of this study was to compare the efficacy of oral triclofos (TRI), intranasal midazolam (INM), and intranasal dexmedetomidine (IND) in achieving successful sedation in children undergoing MRI. This open-label, three-arm, randomized trial was conducted in a tertiary care teaching hospital over 18-month period. Children scheduled for MRI were enrolled. Rate of successful/adequate sedation was assessed using the Paediatric Sedation State Scale (PSSS). The primary outcome was the efficacy (successful sedation or sedation rate) of the three drugs. One-hundred and ninety-five children were included for the MRI procedure. IND was found to be superior in terms of achieving successful sedation. INM had a shorter onset and duration of sedation compared to IND and TRI, but with an increased failure rate (88.3%). Keeping INM as the reference group, it was found that the odds of sedation increased 4.1 times on changing from INM to IND (p < 0.01), and 2.26 times on changing from INM to TRI (p < 0.01). Adverse events included nasal discomfort (18.3%) in INM group; and self-limited tachycardia (4.6%) and hypotension (10.8%) in the IND group. CONCLUSION: IND was more efficacious than INM or TRI for procedural sedation in children undergoing MRI without any significant adverse events. CLINICAL TRIAL REGISTRATION: CTRI/2019/01/017257; date registered: 25/01/2019. WHAT IS KNOWN: • Oral triclofos (TRI) and intranasal midazolam (INM) have been used for procedural sedation in children undergoing MRI with variable success; but the experience with intranasal dexmedetomidine (IND) is limited. WHAT IS NEW: • IND provides more effective sedation compared to INM or TRI for procedural sedation in children undergoing MRI, without any significant adverse events.

Comparison of four different techniques of i-gel insertion by anaesthesia trainees in children undergoing daycare surgery: A single-blind, randomised, comparative study.

Background and Aims: Different techniques of i-gel insertion have been described with variable success rates. This study aimed to assess the incidence of malposition of i-gel in children with 90° rotation, 180° rotation, jaw thrust-assisted and standard insertion techniques. Methods: The study included 132 children undergoing elective surgery under general anaesthesia without neuromuscular blockade after approval from the Institutional Ethics Committee. The i-gel was inserted using one of the four randomised techniques (90° rotation, 180° rotation, jaw thrust-assisted insertion or standard insertion technique) by anaesthesia trainees. The primary objective of this study was to assess device malposition using three alternative techniques compared to the standard insertion technique by flexible video bronchoscopy. Results: The incidence of malposition was the least in the 180° rotation technique group (27%) versus 39% in the standard and 90° rotation technique groups and 70% in the jaw thrust technique group (P = 0.004). Oropharyngeal leak pressure (OLP) was highest in the 180° rotation technique group, that is, 27.1 (5.3) cm H2O in the 180° rotation technique group versus 23 (4.3), 25.8 (4.1) and 24.7 (5.6) cm H2O in the standard, 90° rotation and assisted jaw thrust groups, respectively (P = 0.006). The time to i-gel insertion was the least with the standard insertion technique, that is, 16.9 (3.3) s, compared to 18.4 (3.1) s in the 90° rotation group, 19.5 (3.2) s in the180° rotation group and 20.1 (3.4) s in the assisted jaw thrust technique group (P < 0.001). Conclusion: The 180° rotation technique for i-gel placement in children by anaesthesia trainees has the lowest incidence of malposition and the best OLP versus other techniques but lacks any clear advantage in clinical performance and ventilation.

Prophylactic Drain Versus No Drain in Curative Gastric Cancer Surgery-A Randomized Controlled Trial.

BACKGROUND: The adoption of enhanced recovery after surgery protocols has questioned the placement of prophylactic drain after curative gastrectomy. A 2015 Cochrane meta-analysis did not find convincing evidence of routine drain placement in gastrectomy, but the quality of evidence was questioned. The present study compared short-term outcomes of prophylactic drain placement versus no drain in gastrectomy. METHODOLOGY: The study is a prospective, non-inferiority, and randomized controlled trial. Histologically proven adenocarcinoma of the stomach undergoing curative gastrectomy with D2 lymphadenectomy was included in the study. Randomization was done intra-operatively. The primary outcome was a postoperative hospital stay. Secondary outcomes included the return of bowel function, achieving adequate enteral feeding, re-surgery, morbidity, and mortality. RESULTS: One hundred fifty-seven patients were registered, of which 108 patients underwent curative surgery, and were randomized to 54 patients in each group. The median age was 55 years (range: 23-78) and 58.5 years (range: 35-80) in the drain and no drain group. No significant difference was noticed in primary or secondary outcomes in both groups. CONCLUSION: Avoid placing a prophylactic drain is not inferior to drain placement following gastrectomy with D2 lymphadenectomy for stomach adenocarcinoma. So, routine prophylactic drain placement can be avoided.

The effect of continuing versus withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers on mortality and major adverse cardiovascular events in hypertensive patients undergoing elective non-cardiac surgery: study protocol for a multi-centric open-label randomised controlled trial.

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) are commonly prescribed to patients with hypertension. These drugs are cardioprotective in addition to their blood pressure-lowering effects. However, it is debatable whether hypertensive patients who present for non-cardiac surgery should continue or discontinue these drugs preoperatively. Continuing the drugs entails the risk of perioperative refractory hypotension and/or angioneurotic oedema, while discontinuing the drugs entails the risk of rebound hypertension and myocardial ischaemia. The aim of this study is to evaluate the effect of continuation vs withholding of ACEIs/ARBs on mortality and other major outcomes in hypertensive patients undergoing elective non-cardiac surgery. METHODS: The continuing vs withholding of ACEIs/ARBs in patients undergoing non-cardiac surgery is a prospective, multi-centric, open-label randomised controlled trial. Two thousand one hundred hypertensive patients receiving ACEIs/ARBs and planned for elective non-cardiac surgery will be enrolled. They will be randomised to either continue the ACEIs/ARBs including on the day of surgery (group A) or to withhold it 24-36 h before surgery (group B). The primary endpoint will be the difference in the composite outcome of all-cause in-hospital/30-day mortality and major adverse cardiovascular and non-cardiovascular events. Secondary endpoints will be to evaluate the differences in perioperative hypotension, angioneurotic oedema, myocardial injury, ICU and hospital stay. The impact of the continuation vs withholding of the ACEIs/ARBs on the incidence of case cancellation will also be studied. DISCUSSION: The results of this trial should provide sufficient evidence on whether to continue or withhold ACEIs/ARBs before major non-cardiac surgery. TRIAL REGISTRATION: Clinical Trials Registry of India CTRI/2021/01/030199. Registered on 4 January 2021.

Influence of 3% Hypertonic Saline Versus 0.9% Saline on Intraoperative Maintenance Fluid Requirements in Adult Patients Undergoing Major Open Abdominal Surgeries: Randomized Controlled Study.

BACKGROUND: Three percent hypertonic saline (3% HTS) acts like an osmotic buffer and draws fluid from the extracellular space into the intravascular compartment. Primary objective was to evaluate whether use of 3% HTS resulted in a difference in intraoperative maintenance fluid requirement versus 0.9% saline (NS). Secondary objectives were to evaluate differences in 24 h fluid requirements and safety of 3% HTS. METHODS: Adult patients of either sex, 18-65 years, undergoing elective major open abdominal surgeries were randomized to receive infusions of 3% HTS or NS at 1 ml/kg/hr through large bore peripheral i.v cannulas, or central venous catheters after anesthesia induction. Intraoperative maintenance fluids were administered to maintain mean arterial pressure (≥70 mmHg), urine output (≥0.5 ml/kg/hr) and central venous pressure of 8-10 cm H2O. RESULTS: Ninety-three patients completed the study (46 in 3% HTS and 47 in NS group). No difference was seen in the volume of intraoperative maintenance fluids (3% HTS vs NS; 2243.9 ± 896.7 ml vs 2093.6 ± 868.7 ml; P = 0.34). Similarly, the 24 h postoperative fluid requirement was not different (3% HTS vs NS; 2006.6 ± 398.6 ml vs 2018.3 ± 389.3 ml; P = 0.94). Patients in 3% HTS group had statistically but not clinically significant higher serum sodium values at postoperative 12th and 24 h. No complication like thrombophlebitis or tissue ischemia was reported due to administration of 3% HTS through peripheral lines. CONCLUSION: Administration of 3% HTS did not reduce intraoperative maintenance fluid requirements in patients undergoing major open abdominal surgeries. TRIAL REGISTRATION: CTRI/2019/09/021032.

Ultrasound-guided transverse abdominis plane block, ilioinguinal/iliohypogastric nerve block, and quadratus lumborum block for elective open inguinal hernia repair in children: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks and transverse abdominis plane (TAP) blocks are widely used for postoperative analgesia in children undergoing inguinal hernia repair (IHR). Quadratus lumborum block (QLB) provides analgesia for both upper and lower abdominal surgery. Very few randomized controlled trials in children have assessed the efficacy of QLB in IHR. Thus, this study was designed to find the comparative effectiveness of QLB versus TAP and II/IH blocks in children undergoing open IHR. MATERIALS AND METHODS: Sixty children scheduled for open IHR were randomly allocated in groups of 20 to receive either ultrasound-guided TAP block with 0.4 mL/kg of 0.25% ropivacaine, II/IH nerve block with 0.2 mL/kg of 0.25% ropivacaine, or QLB with 0.4 mL/kg of 0.25% ropivacaine. Anesthesia was standardized for all patients, and an experienced anesthesiologist performed the blocks after anesthesia induction. PRIMARY OUTCOME: Time to first analgesia. SECONDARY OUTCOMES: Postoperative pain scores, intraoperative and postoperative opioid consumption, cumulative paracetamol usage, block performance time, and block-related complications. RESULTS: The median time to first analgesia was 360 (120), 480 (240), and 720 (240) min in the TAP block, II/IH block, and QLB groups, respectively; and was significantly longer in the QLB versus TAP (p<0.001) and II/IH (p<0.001) groups. The time to first analgesia was not significantly different between the TAP and II/IH groups (p=0.596). The mean postoperative tramadol consumption was 11 (12.7), 4 (7.16), and 3 (8) mg in the TAP, II/IH, and QLB groups, respectively (p=0.023); and it was lowest in the QLB group. No significant differences were found between the groups for other secondary outcomes. CONCLUSIONS: QLB provides a prolonged period of analgesia and leads to decreased opioid consumption compared with TAP blocks and II/IH nerve blocks in children undergoing open IHR. TRIAL REGISTRATION NUMBER: CTRI/2019/09/021377.

A Systematic Review and Meta-Analysis of Efficacy of Ultrasound-Guided Single-Shot Quadratus Lumborum Block for Postoperative Analgesia in Adults Following Total Hip Arthroplasty.

STUDY OBJECTIVE: To evaluate the efficacy of ultrasound-guided single-shot quadratus lumborum block (QLB) for postoperative analgesia in adults following total hip arthroplasty (THA). DESIGN: Systematic review and meta-analysis. SETTING: Perioperative period. PATIENTS: Adult patients undergoing THA. METHODS: Studies were identified by performing searches in the following electronic databases, PubMed (Medline), Cochrane Central Registry of Trials (CENTRAL), and Google Scholar. We sought studies in adult patients undergoing THA, comparing QLB with a control group (no block, sham block or any other ultrasound guided regional nerve blocks). A total of 774 patients from 10 studies (7 randomized controlled, one controlled clinical and two retrospective study) were included in this meta-analysis. MAIN RESULTS: The 24 hour opioid consumption was similar in both the groups (WMD -4.09; 95% CI [-9.00, 0.83]; P = 0.10; I2 = 95%). The pain scores at rest at 24 hours was significantly less in QLB group (WMD -0.62; 95% CI [-1.15, -0.10]; P = 0.02; I2 = 75%). The difference in pain scores was however not clinically significant. The pain scores on movement at 24 hours, time to first analgesic request, and time to discharge from hospital were similar in both the groups. CONCLUSIONS: QLB as part of multimodal analgesia did not result in any significant analgesic benefits in patients undergoing hip arthroplasty in terms of either postoperative opioid consumption or pain scores at rest and on movement. Overall, the level of certainty is low. Further, well-designed trials are required to verify the results.

Use of flexible video bronchoscope for verification of nasogastric tube position in the intubated patient.

We propose a novel method for verifying the nasogastric tube (NGT) position and tip localization using flexible video bronchoscopy in anesthetized and intubated adult patients. The length of the scope used is 65 cm and can thus, track the NGT up to the pyloric canal. We have used this technique in patients with success. For the prevention of fogging of the scope tip, 2 L/min of oxygen is insufflated through the working channel, which also helps in the opening of the esophagus during endoscopy. Gastric distension due to oxygen insufflation is prevented by repeated suctioning. The course of the NGT can be seen in its entirety in the esophagus and stomach. The esophagus is identified by the pale mucosa and symmetrical delicate folds (Fig. 1a). The stomach is identified by the red mucosa and random tortuous folds (Fig. 1b). The pyloric canal can be identified by the convergence of gastric mucosal folds leading to the pyloric opening (Fig. 1c). In each case, the subdiaphragmatic position of NGT was verified with radiography, which is a routine practice in our institute.

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery.

BACKGROUND: Postoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery. METHODS: Medical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay. RESULTS: Twelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I2 = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD - 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I2 = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I2 = 93%) were significantly less in the EEN group. CONCLUSION: EEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings. LEVEL OF EVIDENCE: V.

Subanesthetic intravenous ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgeries: a non-inferiority randomized, single-blind controlled trial.

BACKGROUND: Subanesthetic intravenous (IV) ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain; however, its effectiveness in children is understudied. The primary aim of this study was to evaluate the non-inferiority of subanesthetic IV ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infraumbilical surgery. METHODS: Children aged < 6 years were enrolled in this single-blind study and randomized to receive either subanesthetic IV ketamine (0.3 mg/kg) or caudal 0.125% bupivacaine (1 ml/kg) along with general anesthesia. Postoperative pain was assessed using the FLACC scale at 30 minutes and 1, 2, 3, and 6 h post-operation. Intra- and postoperative opioid consumption, time to extubation, postoperative vomiting, agitation, sedation, and inflammatory markers were also assessed. RESULTS: Altogether, 141 children completed the study (ketamine group: n = 71, caudal group: n = 70) The cumulative proportion of children without significant postoperative pain (FLACC score < 4) in the first 6 h post-surgery was 45.1% in the ketamine group vs. 72.9% in the caudal group (P < 0.001). More children in the ketamine group required an additional dose of intraoperative fentanyl (33.8% vs. 5.7%, P < 0.001) and postoperative tramadol (54.9% vs. 27.1%, P < 0.001). However, postoperative agitation, sedation, and other secondary outcomes were similar between the groups. CONCLUSIONS: Subanesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children aged < 6 years undergoing infra-umbilical surgeries; however, other postoperative outcomes are similar.

Effect of intra-operative high inspired fraction of oxygen on postoperative nausea and vomiting in children undergoing surgery: A prospective randomised double-blind study.

BACKGROUND: Administration of high inspired fraction of oxygen (FiO2) during anaesthesia has been proposed to decrease postoperative nausea and vomiting (PONV) in adults but has not been extensively studied in children. OBJECTIVES: The primary objective of this study was to evaluate the effect of 80% FiO2 on the incidence of PONV in children undergoing surgery. DESIGN: Prospective, randomised, study. SETTING: Single-centre, teaching hospital. PATIENTS: Children of either gender in the age group of 5 to 15 years scheduled for elective surgeries were assessed for eligibility. Emergency surgeries; patients receiving supplemental oxygen pre-operatively or on mechanical ventilation; sepsis; bowel obstruction or ischaemia; poor nutritional status; anaemia (Hb <8 g%) or surgeries lasting less than 1 h or greater than 4 h were excluded from the study. INTERVENTIONS: After induction of anaesthesia, children were randomised to receive either 30 or 80% oxygen in air, till the end of surgery. MAIN OUTCOME MEASURES: Incidence of PONV within 24 h; surgical site infections (SSI)s; serum serotonin and TNF-α levels and the incidence of postoperative pulmonary complications (PPC)s were studied. RESULTS: The overall 24 h incidence of PONV was not different between the low and high FiO2 groups [24 vs. 23%; P = 0.84; odds ratio (OR) 0.92; 95% confidence interval (CI), 0.44 to 2.06]. The incidence of SSIs (15 vs. 12%; P = 0.61; OR 0.77; 95% CI, 0.28 to 2.10) and PPCs (12 vs. 8%; P = 0.38; OR 0.59; 95% CI, 0.18 to 1.92) were not significant between the low and high FiO2 groups, respectively. Intragroup and intergroup comparisons of serum serotonin and TNF-α showed no significant difference either at baseline or at the end of surgery. CONCLUSION: High intra-operative FiO2 of 80% does not provide additional protection against PONV in children. TRIAL REGISTRATION: The study was registered with Clinical Trials Registry of India (CTRI) with trial registration no: CTRI/2018/07/014974.

COVID-19 pandemic and its impact on peer review speed of anesthesiology journals: An observational study.

BACKGROUND AND AIMS: Publication of a scientific article in a reputed journal is an uphill task that demands a significant amount of time and effort from the author and editorial team. It is a matter of great enthusiasm for all prospective researchers to know whether this daily evolving publication load of articles during this pandemic had changed the journal's inherent peer review or publication process. We aimed to compare the peer review speed of anesthesiology journal articles published during pandemic (2020) to the previous year and to analyze various factors affecting peer review speed. MATERIAL AND METHODS: Overall, 16 anesthesiology journals indexed in MEDLINE database were retrospectively analyzed. A set of 24 articles published in 2019 of the included journals were selected from each journal for control and a set of 12 articles published between January to September 2020 was selected for comparison. Time taken for acceptance and publication from the time of submission was noted. Peer review timing was calculated and its relationship with h-index, continent of journal origin and article processing charges were evaluated. RESULTS: The median peer review time in 2019 and 2020 were 116 (108-125) days and 79 (65-105.5) days, respectively. There was a 31.8% decrease (P = 0.0021) in peer review time of all articles in 2020 compared to 2019. The median peer review timings of COVID-19 articles were 35 (22-42.5) days. A 55.6% decrease was noted in peer review time of COVID-19 articles compared to non-COVID-19 articles in 2020. There was a significant correlation between peer review time and h-index (r = 0.558, P = 0.024). There was no significant difference in peer review timing of journals with or without article processing charge (P = 0.75) and between journals from different continents (P = 0.56). CONCLUSION: Anesthesiology journals managed to curtail their turnaround time for peer review during the pandemic compared to previous year. Journal with higher h-index had longer peer review time. The option for articles processing charge and continent of publishing journal had no impact on peer review speed.

Analysis of publication speed of anesthesiology journals: a cross-sectional study.

BACKGROUND: Publication speed is one of the critical factors affecting authors' preference to a journal for manuscript submission. The publication time of submitted manuscripts varies across journals and specialty. OBJECTIVES: Several bibliometric studies in various fields of medicine, except in anesthesiology, have addressed the issue of publication speed and factors that influence the publication speed. We aimed to identify factors affecting the publication speed of indexed anesthesiology journals. METHOD: Overall, 25 anesthesiology journals indexed in MEDLINE database were retrospectively analyzed for the time required during different stages of publication process. A total of 12 original articles published in the year 2018 were randomly selected from each journal based on the number of issues. Time periods from submission to acceptance and from submission to publication were noted, and their association with impact factor (IF), advanced online publication (AOP), and article processing charges (APCs) were evaluated. RESULTS: The median time from submission to acceptance and from submission to publication for the selected journals were 120 (IQR [83-167]) days and 186 (IQR [126-246]) days, respectively. Publication speed was not found to have any correlation with IF and APC. However, journals with AOP required significantly lesser time for publication than those without AOP 138.5 and 240 days, respectively, (p =  0.011). Moreover, the IF of journals with AOP was significantly higher than that of journals without AOP (p =  0.002). CONCLUSION: The study provides an overview of total time required for peer review, acceptance, and publication in indexed anesthesiology journals. Researchers should focus on journals with AOP for expediting the publication process and avoiding publication delays.

Peripheral Cardiopulmonary Bypass in Two Patients With Symptomatic Tracheal Masses: Perioperative Challenges.

Tracheal tumors or masses causing critical airway obstruction require resection for symptom relief. However, the location and extent of these tumors or masses often preclude conventional general anesthesia and tracheal intubation. Peripheral cardiopulmonary bypass often is required before anesthetizing these patients. Herein, two cases of patients with tracheal masses, in whom awake peripheral cardiopulmonary bypass was instituted, are reported. The first case was that of an obese male child weighing 102 kg, with tracheal rhinoscleroma, who developed Harlequin, or north-south, syndrome after institution of femorofemoral venoarterial partial cardiopulmonary bypass. The second case was that of a female patient with adenoid cystic carcinoma of the trachea causing near-total central airway occlusion. She had severe pulmonary artery hypertension, which prevented the use of venovenous bypass. Instead, femoral vein-axillary artery venoarterial bypass was established to avoid Harlequin syndrome. Some of the challenges encountered were the development of Harlequin syndrome with risk of myocardial and cerebral ischemia, type and conduct of extracorporeal bypass, choice of monitoring sites, and provision of regional anesthesia for peripheral extracorporeal cannulations. Management of such patients needs frequent troubleshooting and multidisciplinary coordination for a successful surgical outcome.

Effect of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation: a randomized control trial.

BACKGROUND: Dexmedetomidine, an alpha-2 agonist, has been used for attenuation of hemodynamic response to laryngoscopy but not through the nebulized route. We evaluated the effects of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation and examined the intraoperative anesthetic-analgesic requirements and recovery outcomes. METHODS: Overall, 120 American Society of Anesthesiologists I & II adult patients (of either gender) undergoing elective surgeries and requiring tracheal intubation, were randomized to receive nebulized dexmedetomidine (1 µg/kg in 3-4 ml of 0.9% saline) or 0.9% saline (3-4 ml), 30 min before anesthesia induction. Heart rate (HR) and non-invasive systolic blood pressure (SBP) were monitored for 10 min following laryngoscopy. RESULTS: After laryngoscopy, linear mixed effect modelling showed significantly lower trend of increase in HR in the dexmedetomidine group versus saline (P = 0.012); however, there was no difference in the SBP changes between the two groups (P = 0.904). Induction dose of propofol (P < 0.001), intraoperative fentanyl consumption (P = 0.007), and isoflurane requirements (P = 0.013) were significantly lower in the dexmedetomidine group. There was no difference in the 2 h incidence of postoperative nausea and vomiting (PONV) (P = 0.612) or sore-throat (P = 0.741). CONCLUSIONS: Nebulized dexmedetomidine at 1 µg/kg attenuated the increase in HR but not SBP following laryngoscopy and reduced the intraoperative anesthetic and analgesic consumption. There was no effect on early PONV, sore-throat, or increase in incidence of adverse effects. Nebulized dexmedetomidine may represent a favorable alternative to the intravenous route in short duration surgeries.