Opioid-free anesthesia using a combination of ketamine and dexmedetomidine in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: Opioids administered as bolus doses or continuous infusions are widely used for major and daycare surgeries. Opioid-free anesthesia is multimodal anesthesia and analgesia that does not use opioids, benefiting patients from opioid-related adverse effects. We compared the postoperative analgesic requirements of patients scheduled for elective laparoscopic cholecystectomy under opioid-free and opioid-based anesthesia. METHODS: Study included 88 patients aged 18-60 years with American Society of Anesthesiologists physical status 1 and 2 who underwent elective laparoscopic cholecystectomy. Participants were randomly divided into two groups with 44 in each. The opioid-free group was administered an intravenous bolus of ketamine and dexmedetomidine, whereas fentanyl was used in opioid group. Primary outcome was to compare the total amount of fentanyl consumed by both groups during 6 h postoperative period. Episodes of postoperative nausea and vomiting (PONV) and vital signs were noted throughout the postoperative period to analyze the secondary outcomes. RESULTS: Both groups had similar demographic characteristics. The opioid-free group required lesser analgesia within the first 2 h (61.4 ± 17.4 vs. 79.0 ± 19.4 of fentanyl, P < 0.001), which was statistically significant. However, fentanyl consumption was comparable between the groups at 6 h (152 ± 28.2 vs. 164 ± 33.4, P = 0.061). Compared with 4.5% of the participants in the opioid-free group, 34% of those in the opioid-based group developed moderate PONV. CONCLUSIONS: Opioid-free anesthesia in patients undergoing laparoscopic cholecystectomy reduced the requirement of analgesia in first two-hour postoperative period and was associated with decreased PONV.

Comparison of recovery profiles in target-controlled infusions (TCI) versus manually controlled infusions for total intravenous anesthesia (TIVA) in laparoscopic surgeries. A randomized controlled trial.

Background and Aims: Considerable importance has been attached to early recovery and discharge readiness after surgeries. Many centers use total intravenous anesthesia (TIVA) as their anesthesia technique of choice. Target-controlled infusions (TCI) have been proposed as a method to precisely deliver continuous infusions of propofol and opioids as compared to the traditionally used manual-controlled infusion (MCI) methods. However, TCI has also been shown to result in the administration of larger doses of propofol which could cause delayed emergence and recovery from anesthesia. Studies involving TCI have focused mainly on its effects on anesthesia induction but not much literature is available on recovery profiles of patients on TCI. This study was designed to compare the effect of conventionally used MCI methods versus the target-controlled infusion (TCI) method of administering TIVA on recovery characteristics in patients undergoing laparoscopic surgery. Material and Methods: This was a prospective randomized interventional study on 54 patients. Our primary objective was to compare the rates of recovery from anesthesia as judged by four parameters. Time to return of spontaneous ventilation, time to respond to verbal commands, time to extubation, and time to shift patient out of the operating room after stoppage of propofol infusion. As secondary objectives, intraoperative average bispectral index (BIS) values and total anesthetic drugs (propofol and fentanyl) consumption were also compared. Results: We noted that for laparoscopic surgeries lasting less than 4 hours, both MCI and TCI techniques of TIVA have comparable rates of recovery after the stoppage of propofol infusion. Total consumption of propofol and fentanyl was also similar; however, with the use of the TCI method of TIVA, better depth of anesthesia as evidenced by lower average BIS levels was noted. Conclusion: Recovery rates after TIVA using a target-controlled infusion (TCI) system are similar to BIS-guided MCIs in patients undergoing laparoscopic surgery lasting less than 4 hours. TCI resulted in better depths of anesthesia though per kg/min consumption of propofol was found to be more.

Recent advances in system management, decision support systems, artificial intelligence and computing in anaesthesia.

Advances in artificial intelligence, telemedicine, block-chain technology and electronic medical records are paving the way for a new era in anaesthetic care through automation, non-invasive monitoring, system management and decision support systems. Their utility has been demonstrated in a variety of contexts in the peri-operative setting, including but not limited to, monitoring anaesthesia depth, maintaining drug infusion, predicting hypotension, critical incident evaluation, risk management strategies, antibiotic administration, haemodynamic monitoring, precise ultrasound-guided nerve blocks and a future where possibilities are entirely dependent on how we decide to embrace this progression. The main objective of this article is to provide up-to-date and valuable knowledge about the recent advances in anaesthesia technology during the past few years.

Risk of self-contamination because of improper doffing of personal protective equipment: A randomised cross-over study.

Background and Aims: Many health care staff have been pressed into coronavirus disease-19 patient care with little experience of working in bio-hazard zones because of the overwhelming requirements of manpower. They wear personal protective equipment (PPE) and follow all rules for their safety. However, despite precautions, during doffing, they carry a risk of self-contamination. This randomised cross-over study assessed the risk of self- contamination because of improper doffing of PPEs. Methods: A colourless lotion that glows with a bright-green fluorescent hue under ultraviolet light was applied to simulate germ contamination in various health care workers (HCWs) who volunteered for the study. The primary objective of this study was to know the percentage of HCWs getting self-contaminated. The secondary objectives were to assess which portions of the body get maximally contaminated and infestation of germs on which portions of the PPE carry more risk of self-contaminating after doffing. Results: A total of 152 doffings by 76 participants were analysed, and the volunteers self-contaminated in 43 doffings (28.28%). In 18 of these 43 doffings, self-contamination was noted at more than one location. The most commonly contaminated areas were the arms (33%), clothes on the abdomen (24%), and areas in the lower limb (23%). Germ infestation on the upper parts of a PPE is 2.39 times more likely to cause self-contamination after improper doffing. Conclusion: Faulty doffing resulted in self-contamination in 28.28% of all doffings. Risk is 2.39 times more when germs are nested in the upper body portions of the PPE suit.

Dissertation writing in post graduate medical education.

A dissertation is a practical exercise that educates students about basics of research methodology, promotes scientific writing and encourages critical thinking. The National Medical Commission (India) regulations make assessment of a dissertation by a minimum of three examiners mandatory. The candidate can appear for the final examination only after acceptance of the dissertation. An important role in a dissertation is that of the guide who has to guide his protégés through the process. This manuscript aims to assist students and guides on the basics of conduct of a dissertation and writing the dissertation. For students who will ultimately become researchers, a dissertation serves as an early exercise. Even for people who may never do research after their degree, a dissertation will help them discern the merits of new treatment options available in literature for the benefit of their patients.

Six-month Morbidity and Mortality in Patients after Recovery from COVID-19.

Background: This telephonic survey was aimed to identify the proportion of coronavirus disease-2019 (COVID-19) patients who died from any cause, within 6 months of discharge from a tertiary COVID-19 care hospital. We also analyzed whether any clinical and/or laboratory variables were associated with post-discharge mortality. Materials and methods: All adult patients (age ≥18 years) who had been discharged during the period between July 2020 and August 2020 from a tertiary COVID-19-care hospital after initial hospitalization for COVID-19 were included. A telephonic interview was conducted 6 months after discharge to assess morbidity and mortality in these patients. Results: Out of the 457 patients who responded, 79 patients (17.21%) were symptomatic, and breathlessness was found as most common symptom (6.12%). Fatigue was noted in (5.93%) of study patients, followed by cough (4.59%), sleep disturbances (4.37%), and headache (2.62%). Of the 457 patients who responded, 42 patients (9.19%) required expert medical consultation for their persistent symptoms. Thirty-six patients (7.88%) required re-hospitalization for post-COVID-19 complications within 6 months of discharge. A total of 10 patients (2.18%) succumbed within 6 months of their discharge from the hospital. 6 patients were males and 4 females. Most of these patients (7/10) succumbed in the second month after discharge. Seven patients had moderate-to-severe COVID-19 disease and most of these (7/10) had not been treated in the intensive care unit (ICU). Conclusion: Post-COVID-19 mortality figures were not very high in our survey despite the high perceived risk of thromboembolic events after recovery from COVID-19. A significant proportion of patients reported persistent post-COVID-19 symptoms. Breathing difficulty was the most common symptom noted by us, closely followed by fatigue. How to cite this article: Rai DK, Sahay N. Six-month Morbidity and Mortality in Patients after Recovery from COVID-19. Indian J Crit Care Med 2022;26(11):1179-1183.

Efficacy of Baska mask as an alternative airway device to endotracheal tube in patients undergoing laparoscopic surgeries under controlled ventilation.

BACKGROUND AND AIMS: Newer supraglottic devices with an additional gastric channel offer greater protection from aspiration and avoidance of laryngoscopy for their insertion would result in attenuated hemodynamic responses.The primary objective was to assess hemodynamic responses to insertion of Baska mask as compared to tracheal intubation. The time and attempts taken to secure airway and evidence of regurgitation and pulmonary aspiration of gastric contents were also assessed. MATERIAL AND METHODS: This prospective, randomized study was conducted in 80 patients undergoing laparoscopic cholecystectomy. All patients received standardized anaesthesia protocol. Baska mask was used to secure airway in Group B, while tracheal intubation was done in group T. Methylene blue was injected through Ryle's tube into stomach in both groups. At end of surgery, fibreoptic bronchoscopy was performed to detect bluish staining of trachea and/or main bronchi as evidence of aspiration of gastric contents and bluish staining in oropharynx as evidence of regurgitation. Chi-square test and Independent sample t-test were applied. RESULTS: The time taken to secure airway was significantly longer in Group B as compared to Group T (45.3 ± 12.6 vs. 24.3 ± 9.1 sec) Percentage of patients who had oropharyngeal blue stain was comparable in both groups. No patient in both groups had tracheal blue stain. Group T had significantly higher HR and MAP after intubation till 10 min later. CONCLUSION: Baska mask insertion was associated with attenuated hemodynamic responses, though more time and attempts were required for securing the airway. It could be considered as an alternative to tracheal intubation during laparoscopic surgeries.

Post-COVID-19 pulmonary fibrosis: A case series and review of literature.

The most common lung problem faced by a post-COVID patient is lung fibrosis. Clinical recovery is generally complete in mild-to-moderately severe COVID-19 cases but a small proportion of patients with severe disease may go on to develop lung fibrosis. Patient groups at the highest risk to develop lung fibrosis are the elderly, especially those requiring ICU stay and mechanical ventilation. No definitive therapy for managing this pulmonary fibrosis exists as of date, even though various options are being explored. This case series highlights three cases of post-COVID lung fibrosis and reviews the existing literature.

Defecation and Micturition may Cause Syncope in COVID-19 Patients on High Oxygen Requirement.

How to cite this article: Naaz S, Kumar A, Sahay N, Kumar R, Ozair E, Valiaparambath A. Defecation and Micturition may Cause Syncope in COVID-19 Patients on High Oxygen Requirement. Indian J Crit Care Med 2021;25(5):599-600.