Deep Machine Learning Might Aid in Combating Intensive Care Unit-Acquired Weakness.

Secondary muscle weakness in critically ill patients like intensive care unit (ICU)-associated weakness is frequently noted in patients with prolonged mechanical ventilation and ICU stay. It can be a result of critical illness, myopathy, or neuropathy. Although ICU-acquired weakness (ICU-AW) has been known for a while, there is still no effective treatment for it. Therefore, prevention of ICU-AW becomes the utmost priority, and knowing the risk factors is crucial. Nevertheless, the pathophysiology and the attributing causes are complex for ICU-AW, and proper delineation and formulation of a preventive strategy from such vast, multifaceted data are challenging. Artificial intelligence has recently helped healthcare professionals understand and analyze such intricate data through deep machine learning. Hence, using such a strategy also helps in knowing the risk factors and their weight as contributors, applying them in formulating a preventive path for ICU-AW worth trials.

The Efficacy and Safety of Spinal Anesthesia With Hyperbaric Ropivacaine 0.75% and Bupivacaine 0.5% in Patients Undergoing Infra-Umbilical Surgeries: A Randomized, Double-Blind Study.

BACKGROUND: Spinal anesthesia utilizing hyperbaric 0.75% ropivacaine has been gaining clinical acceptance recently. It is a pure S-enantiomer of bupivacaine, which is expected to have a better clinical profile, but the studies for the same are yet limited. We aimed to compare the efficacy and safety of these two drugs. METHODS: Sixty patients, aged 18 to 60 years of either sex, classified as American Society of Anesthesiologists class I and II, who were undergoing elective infra-umbilical surgery, were randomly assigned to receive either 3 mL of 0.5% bupivacaine heavy or 3 mL of 0.75% ropivacaine heavy intrathecally. Efficacy parameters, including the onset and duration of sensory and motor block, time to rescue analgesia, hemodynamics, and safety in terms of complications, were recorded. We compared the data for statistical significance, considering a p-value of less than 0.05 as significant. RESULTS: Ropivacaine exhibited a slower onset for both sensory (153.90 ± 6.53 versus 92.46 ± 12.16 seconds; p < 0.001) and motor blockades (301 ± 6.62 versus 239.96 ± 6.27 seconds; p < 0.001). Two-segment sensory and motor blockade regression were faster with ropivacaine compared to bupivacaine (p < 0.001). However, the mean duration of sensory blockade for ropivacaine compared to that for bupivacaine (219.29 ± 15.14 versus 227.31 ± 17.20 minutes) and the requirement for rescue analgesia were not statistically different (p > 0.05). Ropivacaine also caused fewer side effects on a percentage scale. CONCLUSION: In patients undergoing infra-umbilical surgery, hyperbaric ropivacaine at an equipotent dose (0.75%) proved to be a comparable and safer alternative to hyperbaric bupivacaine (0.5%). Furthermore, it had better motor-recovery profiles.

Steroid Premedication Might Protect From Postoperative Erythema Nodosum Leprosum in Leprosy: A Case Report.

Leprosy is known for its diverse pathophysiologic involvement and resulting multisystemic manifestation and morbidities. Despite global efforts to eliminate this public health illness, it is still prevalent in some Asian and European countries. Perioperative management of a leprosy patient is challenging owing to the indirect and direct involvement of the airway, respiratory, and cardiac systems; treatment-related side-effects involving the hepato-renal systems affecting the anesthesia techniques and drugs pharmacokinetic and pharmacodynamics. While anaesthesiologists are aware of such happenings and often tailor the anesthesia management for the concerning issues, immunological aspects of the disease and drug-related adverse events are less enquired about, such as type-2 lepra reaction, i.e., erythema nodosum leprosum (ENL), etc. Further, data on perioperative ENL management and prevention are still being determined. We report one case of a 52-year-old female who underwent gynecology surgery and developed ENL on the third postoperative day, which was managed using Steroids. Unfortunately, the patient had a surgical site infection, which required another surgery within the month, while the patient was still under the steroid successfully without any adverse events. Although a single case cannot provide causation or association, the case is presented to highlight the probable preventive action of steroids on the occurrence of postoperative ENL, where surgical stress is considered a risk factor.

Effect of Sevoflurane, Isoflurane, and Desflurane on the Random Blood Glucose Levels in Non-diabetic Patients Undergoing General Anesthesia: A Randomized, Single-Blind Study.

BACKGROUND: Volatile anesthetic agents like sevoflurane, isoflurane, and desflurane are widely used for maintaining general anesthesia (GA). Their effect on the autonomic system is different and can impact the blood sugar homeostasis. This study compares the intraoperative blood glucose levels in non-diabetic patients undergoing non-cardiac surgery under GA with the three volatile agents. METHODS: A randomized, single-blind, parallel-arm study recruited 105 non-diabetic patients into three groups. GA induction and maintenance were standardized except for the volatile agent. Capillary blood sugar levels were measured at different time points and compared between and within the groups. A p-value of <0.05 was considered significant. RESULTS: Entire participants completed the study, and their baseline characteristics were statistically indifferent. Intraoperative blood glucose rise and variation were the highest in the desflurane group and the lowest in the isoflurane group; the differences were statistically significant at 15, 30, and 45 minutes. The highest blood sugar level was noted at 60 minutes in all groups; after that, the level started falling. However, none of the raises were beyond 140 mg% to categorize them as hyperglycemia. CONCLUSION: Intraoperative glycemic variation was evident with isoflurane, sevoflurane, and desflurane. The maximum increase from the pre-induction level was noted at 60 minutes. However, none of the readings reached the hyperglycemia level. The rise was significantly higher in desflurane-based anesthesia than in isoflurane. This study was, however, conducted in non-diabetic patients; hence, results might not be extrapolated to diabetic patients.

Perioperative Management Conundrum for a Case With Multiple Commonly Used Drug Hypersensitivity.

Perioperative hypersensitivity reactions vary from mild to potentially fatal anaphylaxis, resulting in significant morbidity and mortality. Most of the perioperative hypersensitivity and allergic reactions are attributed to antibiotics, antiseptic solutions, latex, and opioids. In the current thrust for opioid-free anesthesia, owing to its multiple advantages, paracetamol and nonsteroidal antiinflammatory agents play a significant role in multi-modal pain and inflammatory response management. Nearly nine out of ten individuals experience postoperative pain, one-third experience postoperative nausea and vomiting, and one-fourth experience fever, irrespective of surgery and type of anesthesia, often as an inflammatory response. While perioperative hypersensitivity reactions are common, a patient allergic to multiple commonly used drugs for the treatment of pain, fever, acid-peptic disorder, and nausea and vomiting is scarce. Such cases pose a great challenge in perioperative management. A 14-year-old male child with a traumatic foot drop planned for tibialis posterior tendon transfer developed an allergic reaction with mild fever following an injection of Ranitidine and Ondansetron in the preoperative area. Surgery was deferred and was investigated for allergy profile testing for commonly used drugs, which showed high IgE levels and moderate to severe hypersensitivity for diclofenac and paracetamol. The patient was operated on after one month under spinal anesthesia, avoiding ranitidine, ondansetron, diclofenac, and paracetamol. The following morning, he developed a high-grade fever (102.3° F), which did not resolve with conservative measures. Hypersensitivity and allergic reactions to NSAIDs are reported in the literature. While there are multiple drugs available as NSAIDs, cross-sensitivity or allergy to other drugs within the same group, and even chemically related groups, is also another possibility that needs to be considered while managing such patients. Mefenamic acid controlled the fever, and the child was discharged home after 48 hours of observation. However, the case posed a great perioperative management dilemma; the present report intends to highlight and discuss it.

Preintubation Machine-Delivered Pressure Support Ventilation With Positive End-Expiratory Pressure Versus Manual Bag-Mask Ventilation for Oxygenation in Overweight and Obese Patients: A Randomized, Pilot Study.

BACKGROUND: Noninvasive positive pressure ventilation (NIPPV) maintains mean airway pressures well, and its usability for preoxygenation is well described. Anesthesia machine-delivered NIPPV-based preoxygenation has recently been evaluated against the traditional manual bag-mask ventilation (BMV). The efficiency of such a technique over the traditional one is yet to be established well. The present study evaluated the feasibility of machine-delivered preoxygenation using pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and compared the effectiveness with BMV. METHODS: Thirty overweight and obese adults belonging to the American Society of Anesthesiologist's physical status I-II were randomized to receive PSV+PEEP or BMV for preintubation preoxygenation targeted to a fraction of expired oxygen (FeO2) of 85% and 90% or for a maximum period of five minutes, whichever came first. Postintubation, the patient was observed for the time taken until 1% desaturation without ventilation. Arterial blood gases, respiratory variables, FeO2 achieved, and different times were collected and compared. RESULTS: The baseline characteristics and arterial blood gases were similar between the two groups. The PSV+PEEP group had consistent and favorable tidal volume and airway pressure delivery. The difference in time to reach a FeO2 of 85% between the two groups was not statistically different. Only two patients achieved a FeO2 of 90% in the PSV+PEEP group versus none in the BMV group. However, partial pressure of oxygen at 1% desaturation (217.42±109.47 versus 138.073±71.319 mmHg, p 0.0259) was higher in the PSV+PEEP group. Similarly, the time until 1% desaturation was significantly prolonged in the PSV+PEEP group (206.6±76.952 versus 140.466±54.245 seconds, p 0.0111). CONCLUSION: The present pilot study findings indicate that preintubation machine-delivered PSV+PEEP-based preoxygenation is feasible and might be more effective than traditional BMV in overweight and obese patients.

Anesthesia Services in Low- and Middle-Income Countries: The Fragile Point for Safe Surgery and Patient Safety.

The Safe Surgery Saves Life campaign of the World Health Organization advocates patient safety best practices during surgical procedures. Anesthesia service is indivisible from the patient safety best practices. Although anesthesia services are safer than ever before, safe delivery of anesthesia service and patient safety depends significantly on the availability of qualified anesthesiologists, the knowledge and competency of anesthesiologists, the work environment, and the availability of essential equipment and monitoring facilities. Despite anesthesiologists being the midstream of perioperative care, their role and service are often underacknowledged, especially in low- and middle-income countries (LMICs). Anesthesia services in LMICs face myriad challenges such as a shortage of skilled personnel, inadequate resources, limited training opportunities, and minimal administrative say, which act as the fragile point in the chain of safe surgery delivery. Specific solutions should focus on strengthening the anesthesia workforce, providing fair remuneration and incentives, advocating for anesthesia autonomy, and facilitating access to educational resources. Nevertheless, managing these problems requires a collaborative effort involving governments, healthcare organizations, and international stakeholders to develop sustainable solutions and prioritize the well-being of both anesthesia providers and patients. This editorial focuses on it briefly, emphasizing the anesthesia of rural healthcare service and patient safety.

The Uneventful Use of Modern-Day Anesthetic Drugs in Post-polio Paralytic Patients: A Report of Three Cases.

The Western world has been polio-free for decades; however, many are affected by the stigmata of polio in several countries, including India. While general anesthesia (GA) and subarachnoid block (SAB) have been used successfully and widely, all those cases were mostly done with relatively older drugs and without additives. Therefore, further literature is needed to note the effect of newer anesthetic agents on post-polio paralytic patients for both GA, viz., propofol, fentanyl, rocuronium, and desflurane, and SAB with intrathecal hyperbaric bupivacaine and adjuvants. We report three male cases from Central India, in their 40s, with post-polio residual paralysis (PPRP), sarcopenia, and deformity of the lower limb and scoliosis; one case was managed under GA using desflurane-based low-flow anesthesia technique, and the other two under SAB, one with intrathecal fentanyl as an adjuvant to bupivacaine and the other without an adjuvant. The case series describes the effect of these modern-day anesthetic drugs and techniques.

Clinico-Demographic Profiles of Herpes Zoster Cases in Patients With and Without COVID-19 Infection During the Pandemic: A Retrospective Analysis of 32 Cases.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has multiple impacts on the human body. The immunological effect is one of the prominent ones, which is thought to be fundamental in many physical manifestations and disease severity. Herpes zoster (HZ) reactivation has been well-linked to immunity; immunocompromised states predispose a person to HZ. Studies have raised concerns about HZ incidences in COVID-19 patients; however, the clinical characteristics of the HZ cases among patients with and without COVID-19 are another area to be explored. METHODS: In this retrospective analysis, we compared the clinical and demographic characteristics of HZ cases presented to our outpatient department immediately before and during the early second wave of the COVID-19 pandemic (September 2020 to April 2021) in India. The cases were divided into two groups based on the history of COVID-19 infections. The clinico-demographic characteristics were then compared using an unpaired t-test, Fisher's exact test, and analysis of variance as applicable using InStat software; a two-sided p-value <0.05 was considered significant. RESULTS: During the period, 32 cases (17 HZ cases with a history of COVID-19; 15 HZ cases without) were detected. The age and gender distribution were indifferent statistically. Our analysis showed that multi-dermatomal and disseminated involvements were significantly higher in HZ cases having a history of COVID-19. CONCLUSION: The present retrospective analysis of 32 cases indicates that persons who suffered from COVID-19 and presented with HZ were likely to have a higher chance of multi-dermatomal and disseminated involvement. While our analysis cannot establish a true association between COVID-19 infection and HZ reactivation, which will require a large-scale study, clinicians might get a clue of the possible progression of the extent of HZ manifestations from our findings.

Ischemic Stroke as the Presenting Feature for Non-acute Promyelocytic Leukemia Variant of Acute Myeloid Leukemia: A Case Report.

Acute myeloid leukemia (AML) patients encounter complications mainly due to their underlying disease or chemotherapy. Although they are at high risk for both hemorrhagic and thrombotic complications, thrombotic vascular complication as an initial manifestation is less common and rarely reported, especially in non-acute promyelocytic leukemia (non-APML). A 58-year-old female with no co-morbidity presented with fever, decreased appetite, headache, and weakness in her left upper and lower limbs. Laboratory findings showed hyperleukocytosis with 90% blast cells and thrombocytopenia (50,000/dl). While investigated and conservatively managed, she developed a seizure and loss of consciousness on the same day and was admitted to the intensive care unit. Computed tomography showed a massive right infarct in the middle cerebral artery territory with a significant midline shift. Flow cytometry indicated the diagnosis of non-APML; chemotherapy, platelet transfusion, unfractionated heparin, mechanical ventilation, and other supportive treatments were started. While managing this case, we faced challenges in decision-making on thrombolysis, craniotomy, and chemotherapy. The case highlights the salient points and dilemmas in managing such an acutely ill patient in critical care.

Atracurium Versus Cis-Atracurium for Laryngeal Relaxation and Hemodynamic Stability in Pediatric Patients: A Randomized, Double-Blind Study.

Background and aim Equipotent dose of atracurium and cis-atracurium has failed to show clinically equi-effective muscle relaxation actions required for laryngoscopy and endotracheal intubation (LETI) in adults. There needs to be more data on children. We aimed to compare the efficacy of equipotent atracurium and cis-atracurium for producing optimal LETI. We also compared the hemodynamic stability and side effects. Methods With approvals and informed consent, 104 children between three and 12 years were enrolled in the present randomized, double-blind, parallel-arm study. Fifty-two participants were recruited in each group and received either 2ED95 atracurium (0.5mg/kg) or 2ED95 cis-atracurium (0.1mg/kg). Three-point scale, i.e., excellent, good, and poor, were assigned based on jaw relaxation, vocal cords, diaphragmatic movement, coughing, and resistance to the laryngoscope blade. Basic hemodynamics and adverse events like flushing, hemodynamic instability, and airway spasms were noted. The groups were compared using Wilcoxon-Mann-Whitney U or Chi-square tests as applicable; a p-value <0.05 was considered significant. Results Entire enrolled participants completed the study. Excellent LETI conditions were significantly higher in the atracurium than in cis-atracurium (53.8% versus 19.2%, p-value <0.001). In the present study, blunted laryngoscopy-related sympathetic surge containing the increase in hemodynamic parameters within 20% from the baseline was noted in both groups, but the blunting and fall back of hemodynamic towards the baseline was rapid in the atracurium (within 7 minutes of LETI) group than cis-atracurium, i.e., 72 minutes; p-value <0.001. Only one flushing was noted in the atracurium group compared to none in the cis-atracurium. Conclusion 2ED95 dose of cis-atracurium (0.1mg/kg), although have minor advantages of maintaining hemodynamic better, has lower adverse events, it provides significantly lower 'Excellent LETI conditions' when compared to 2ED95 dose of atracurium (0.5mg/kg) in children of age three to 12 years.

Perioperative Management of Emergency Craniotomes in Children With Cyanotic Congenital Heart Disease: A Case Series.

While congenital heart disease is not uncommon, cyanotic congenital heart disease (CCHD) accounts for a minor fraction of them. However, when cyanosis is present, it usually indicates a severe or critical illness. Tetralogy of Fallot (TOF) is one of the common CCHDs, representing 7-10% of all congenital cardiac malformations. Double-outlet right ventricle (DORV) is another CCHD similar to the TOF and associated with decreased pulmonary flow, ventricular septal defect (VSD), and aorta receiving blood from both ventricles. Reduced oxygen arterial saturation and increased viscosity by polycythemia induce focal cerebral ischemia, often in the area supplied by the middle cerebral artery leading to brain abscess. Brain abscesses require craniotomy, which is a major surgery. These patients also often show features of sepsis and increased intracranial pressure. The presence of CCHD further complicates the situation, making perioperative management even more challenging. There are studies in the literature on the management of similar cases, and they report successful management in most of them. However, not all such cases need intensive postoperative management. We present four pediatric cases who had either TOF or DORV and had to undergo craniotomy for brain abscess or ventriculoperitoneal shunt placement. We describe case management and highlight the critical features and cases that require prolonged postoperative critical care management.

Transillumination and Point-of-Care Ultrasonography to Delineate Tracheal Deviation for Challenging Tracheostomy: A Case Report.

Tracheostomy is indicated for varied reasons and is a relatively safe procedure that can be done with both open and percutaneous methods. However, the procedure is often challenging in cases of distorted neck anatomy. Neck swellings often push the trachea laterally or shield it. Even some gross intrathoracic pathology may shift the trachea from the typical trajectory making it challenging to delineate the course of the trachea. A bedside point-of-care technique having a visual aid that can guide the performer thus appears beneficiary. Fiber-optic assistance for correct puncture and confirmation is known, and light-based techniques have been used for tracheostomies. As fiberscopes are not infrequent in tertiary and even secondary care hospitals, transillumination from a flexible bronchoscope can identify the altered course of the trachea, much like a navigation system, and systematically aid the performer in steering away from the obstacles. We present two cases in two scenarios with tracheal deviation who underwent either open or percutaneous tracheostomy with point-of-care ultrasound and transillumination to delineate the course of the trachea and facilitate difficult tracheostomies safely.

Effect of Postoperative Anesthesiologists' Single Visit on Patient Satisfaction: A Hospital-Based Non-Randomized Study.

Background Continuity of personal care by the anesthesiologist is crucial for patient satisfaction. Over and above the consultation and service in the preoperative area, intraoperative care, and post-anesthesia care unit, anesthesia services frequently incorporate a pre-anesthesia evaluation clinic and a preoperative visit in the inpatient ward for their services, which helps with rapport building. However, routine post-anesthesia visits in the inpatient ward by the anesthesiologist are infrequent, causing a break in the continuity of care. The effect of such a routine post-operative visit by anesthesiologists has been tested only rarely in the Indian population. The present study aimed to evaluate the impact of a single postoperative visit by the same anesthesiologist (continuity of care) on patient satisfaction and compare it with a postoperative visit by another anesthesiologist and no postoperative visit. Methods After institutional ethical committee approval, 276 American Society of Anesthesiologists physical status (ASA PS) I and II, consenting, elective surgical inpatients older than 16 years were enrolled in a tertiary care teaching hospital from January 2015- September 2016. Consecutive patients were allocated into three groups based on the postoperative visit (i.e., group A: by the same anesthesiologist; group B: another anesthesiologist; and group C: no visit). Data related to patients' satisfaction were collected in a pretested questionnaire. Chi-Square and Analysis of Variance (ANOVA) were applied to analyze the data and compare among the groups; a p < 0.05 was considered statistically significant.  Results The mean age of the entire cohort was 38.1 years, comprising 39.9% men. Demographic, socioeconomic, and educational statuses were similar in all groups (p >0.05). The percentages of patient satisfaction were 61.47%, 51.52%, and 38.5% in groups A, B, and C, respectively (p=0.0001). Satisfaction with the fulfillment of "continuity of personal care" was the highest for group A (69.35%), which was significantly higher than group B (43.69%) and group C (35.65%). Group C had the lowest fulfillment of patient expectations and was significantly less satisfied than even group B (p=0.02). Conclusion Continuity of anesthesia care with the addition of routine postoperative visits had the highest positive impact on patient satisfaction. Even a single postoperative visit by the anesthesiologist significantly increased the patients' satisfaction.

Atypical Presentations of Myocardial Infarction: A Systematic Review of Case Reports.

There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to receive treatment and missed diagnoses. Although health professionals are aware of typical AMI presentation, atypical MI is difficult to diagnose, which on the other hand, is likely to have an impact on morbidity and mortality. Therefore, it is prudent to know such atypical presentations, especially for emergency and primary care physicians. We aimed to systematically evaluate the clinical presentations of atypical MI and analyze them to characterize the common clinical presentations of atypical MI. We researched the PubMed database, did citation tracking, and performed Google Scholar advanced search to find the cases reported on the atypical presentation of MI published from January 2000 to September 2022. Articles of all languages were included; Google Translate was used to translate articles published in languages other than English. A total of 496 (56 PubMed articles, 340 citations from included PubMed articles, and 100 articles from Google Scholar advanced search) were screened; 52 case reports were evaluated, and their data were analyzed. Atypical presentations of myocardial infarction are vast; patients may have chest pain without typical characteristics of angina pain or may not have chest pain. No typical characterization could be done. Most patients were in their fifth decade or above of their life and commonly presented with pain and discomfort in the abdomen, head, and neck regions. Prodromal symptoms were consistent findings, and many patients had two to three comorbidities out of four common comorbidities, i.e., diabetes, hypertension, dyslipidemia, and substance abuse. A patient who is 50 years old or more, having comorbidities such as diabetes, hypertension, dyslipidemia, history of tobacco or marijuana usage, presenting with prodromal symptoms like shortness of breath, dizziness, fatigue, syncope, gastrointestinal discomfort or head/neck pain should be suspected for atypical MI.

A Holistic Approach to Managing Secondary Dysphagia Following Prolonged Intubation and Tracheostomy: A Case Report.

The ability to swallow and maintain the airway is a critical rehabilitation milestone for patients with swallowing disorders following prolonged tracheal intubation. Tracheostomy and dysphagia often coexist in critically ill patients and given the medical complexity analyzing the evidence to optimize swallowing assessment and management is challenging. It takes a holistic approach to dealing with issues in a critical care patient as we also need to deal with issues other than medical. We present a case of a 68-year-old gentleman who was admitted to the critical care unit following a double barrel ileostomy and had multiple complications and organ dysfunction requiring prolonged supportive management, tracheostomy, and mechanical ventilation. After recovering from primary illness and complications, he had a swallowing disorder (secondary dysphagia), which was managed successfully over the next month. The case highlights the need for screening, a multidisciplinary team, empathy, and effort as a part of a holistic management approach.

Practices During Intubation in COVID-19 Intensive Care Units in India: A Cross-Sectional Questionnaire-Based Survey.

Background Healthcare workers are committed to learning from each other's experience to safely optimize patient management of COVID-19. Acute hypoxemic failure is common in COVID-19 patients, and nearly 3.2% may require intubation. Intubation is an aerosol-generating procedure (AGP) that might predispose the performer to COVID-19 infection. This survey was intended to evaluate the practices during tracheal intubation in COVID-19 intensive care units (ICUs) and analyze them against the recommendations of the All India Difficult Airway Association (AIDAA) for safe practice. Methodology It was a web-based, multicentric cross-sectional survey. The choices in the questions were based on guidelines for airway management in COVID-19. Survey questions were divided into two parts - the first part consisted of demographics and general information, and the second part focused on safe intubation practices. Results A total of 230 responses were obtained from physicians all over India, presuming their active involvement in COVID-19 cases, of which 226 responses were taken into account. Two-thirds of responders did not receive any training before ICU posting. The Indian Council of Medical Research (ICMR) guideline was followed by 89% of responders for personal protective equipment use. Intubation in COVID-19 patients was predominantly conducted by a senior anesthesiologist/intensivist in the team and a senior resident (37.2%). Rapid sequence intubation (RSI) and modified RSI were preferable among the responder's hospitals (46.5% vs. 33.6%). In most centers, responders used direct laryngoscope for intubation (62.8%), whereas video laryngoscope was used by 34%. Most responders confirmed the endotracheal tube (ETT) position by visual inspection (66.3%) over end-tidal carbon dioxide (EtCO2) concentration tracing (53.9%). Conclusions Safe intubation practices were followed in most of the centers across India. However, teaching and training, preoxygenation methods, alternative ventilation strategies, and confirmation of intubation pertinent to COVID-19 airway management need more attention.

Difficult Spinal-Arachnoid Puncture (DSP) Score: Development and Performance Analysis.

BACKGROUND: Difficult and traumatic neuraxial blocks and procedures are not uncommon. Although score-based prediction has been attempted, the practical application of those has remained limited for various reasons. The aim of this study was to develop a clinical scoring system from the strong predictors of failed spinal-arachnoid puncture procedures assessed previously using artificial neural network (ANN) analysis and analyze the score's performance on the index cohort. METHODS: The present study is based on the ANN model analyzing 300 spinal-arachnoid punctures (index cohort) performed in an academic institute in India. For the development of the score, i.e., Difficult Spinal-Arachnoid Puncture (DSP) Score, the coefficient estimates of the input variables, which showed a Pr(>|z|) value of <0.01, were considered. The resultant DSP Score was then applied to the index cohort for receiver operating characteristic (ROC) analysis, Youden's J point determination for best sensitivity and specificity, and diagnostic statistical analysis for the cut-off value for predicting the difficulty. RESULTS: A DSP Score incorporating spine grades, performers' experience, and positioning difficulty was developed; the minimum and maximum scores were 0 and 7, respectively. The area under the ROC curve for the DSP Score was 0.858 (95% confidence interval 0.811-0.905), Youden's J point for cut-off was at 2, which showed a specificity and sensitivity of 98.15% and 56.5%, respectively. CONCLUSION: The ANN model-based DSP Score developed for predicting the difficult spinal-arachnoid puncture procedure showed an excellent area under the ROC curve. At the cut-off value 2, the score had a sensitivity plus specificity of approximately 155%, indicating that the tool can be useful as a diagnostic (predictive) tool in clinical practice.

Inventory Control Mechanism of the Pharmacy Store of a Recently Established National Institute in Eastern India: A Cross-Sectional, Investigative Analysis.

Background New establishments frequently face challenges. Pharmacy is integral to healthcare delivery institutes, and inventory management is crucial. The present study investigated the problems faced by the pharmacy of a newly established health institute and proposed relevant solutions to identify drugs needing stringent management control. Methods Responses were collected from seven pharmacists for questionnaires focusing on pharmacy problems and possible solutions. Always better control (ABC), vital essential desirable (VED), and ABC-VED matrix analysis were done on the drugs dispensed during the financial 2022-23. Results The predominant challenges identified were stockouts and shortages, expiry of medications, and supplier-related issues. The causes were mainly related to rural location, communication hurdles, and vendor management. Proposed solutions were integrating patients' electronic health records and bar code technology with the pharmacy's inventory management system, conducting pharmacy knowledge and skills upgradation sessions every six months, adopting ABC and VED analysis, and first-in first-out (FIFO), just-in-time (JIT). Total annual drug expenditure (ADE) for the drugs dispensed was 1,18,81,520 Indian Rupees. ABC analysis revealed 109 (22.8%), 115 (24.06%), and 254 (53.14%) of medicines as A, B, and C categories, respectively, accounting for 69.98, 20.00, and 10.07% of ADE. On ABC-VED matrix analysis, 125 (26.15%), 267 (55.86%), and 86 (17.99%) of drugs were found to be category I, II, and III items, respectively, accounting for 71.52, 23.84, and 4.64% of ADE. Conclusion Our study identified different pharmacy problems for a developing institute and suggested relevant measures. Categorization of drugs based on ABC and VED analysis will help to strengthen inventory control.

A Rare Case of Giant Occipital Encephalocele With Thoracic Myelomeningocele: An Anesthetic Conundrum.

Encephalocele and myelomeningocele are congenital defects in the cranium and spine with herniation of contents into an extracranial and extraspinal sac, respectively. The occurrence of encephalocele and myelomeningocele in the same patient has rarely been described in the literature. The anesthetic management of such cases is associated with multiple challenges, which include difficulty in securing the airway, prone positioning, blood loss, electrolyte imbalance, hypothermia, cardiorespiratory disturbances, and perioperative care. The main aims are, to prevent hemodynamic fluctuations and excessive pressure on the sac to avoid premature rupture and manage a possible difficult airway due to the head and neck mass. We report such a rare case to highlight and share our experiences faced during perioperative management of a giant vascular occipital encephalocele with impending rupture and thoracic myelomeningocele requiring surgical excision and repair. Previous similar case reports were also reviewed, and potential perioperative complications were discussed.