Comparison of analgesia nociception index, surgical pleth index and hemodynamic parameters between patients receiving fentanyl versus dexmedetomidine analgesia for supratentorial craniotomy - an open label active-controlled randomized trial.

Dexmedetomidine decreases heart rate (HR) and increases high frequency (HF) component of HR variability (HRV). Analgesia Nociception Index (ANI) measures nociception by analyzing the influence of respiration on HF component of HRV while surgical pleth index (SPI) derives this information from photoplethymographic signals of finger arterioles. Therefore, during administration of dexmedetomidine, reliability of ANI may vary. This study compared the changes in ANI, SPI and hemodynamics (HR and mean arterial pressure [MAP]) during various noxious stimuli with fentanyl and dexmedetomidine intraoperative analgesia. In this trial, patients undergoing elective supratentorial surgery under general anesthesia were randomized to receive either fentanyl or dexmedetomidine infusion for intraoperative analgesia. ANI (instantaneous and mean), SPI, HR and MAP were compared before and after noxious stimuli (intubation, skull pin insertion, skin incision and craniotomy) with respect to magnitude of maximum change in the variable and the time taken for the maximal change (defined as response time) between the groups. A total of 58 patients, 29 in each group were recruited into the study. At intubation, SPI changed significantly more in the fentanyl group compared to dexmedetomidine group (37 versus 20 units, p = 0.007). At skull pinning, ANI values (both instantaneous and mean) changed more in dexmedetomidine group (p = 0.024 and 0.009) with significantly longer response time (p = 0.039). There was no difference between the groups with respect to any of the variables at skin incision and craniotomy. ANI during use of dexmedetomidine and SPI while using fentanyl, might be the better choices as intraoperative nociception monitors.

Paving the way to environment-friendly greener anesthesia.

Health-care settings have an important responsibility toward environmental health and safety. The operating room is a major source of environmental pollution within a hospital. Inhalational agents and nitrous oxide are the commonly used gases during general anesthesia for surgeries, especially in the developing world. These greenhouse gases contribute adversely to the environmental health both inside the operating room and in the outside atmosphere. Impact of these anesthetic agents depends on the total consumption, characteristics of individual agents, and gas flows, with higher levels increasing the environmental adverse effects. The inimical impact of nitrous oxide is higher due to its longer atmospheric half-life and potential for destruction of the ozone layer. Anesthesiologist of today has a choice in the selection of anesthetic agents. Prudent decisions will help in mitigating environmental pollution and contributing positively to a greener planet. Therefore, a shift from inhalational to intravenous-based technique will reduce the carbon footprint of anesthetic agents and their impact on global climate. Propofol forms the mainstay of intravenous anesthesia technique and is a proven drug for anesthetic induction and maintenance. Anesthesiologists should appreciate growing concerns about the role of inhalational anesthetics on the environment and join the cause of environmental responsibility. In this narrative review, we revisit the pharmacological and pharmacokinetic considerations, clinical uses, and discuss the merits of propofol-based intravenous anesthesia over inhalational anesthesia in terms of environmental effects. Increased awareness about the environmental impact and adoption of newer, versatile, and user-friendly modalities of intravenous anesthesia administration will pave the way for greener anesthesia practice.

Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Opioids are the primary analgesics used in patients undergoing spine surgery. Postoperative pain is common despite their liberal use and so are opioid-associated side effects. Non-opioid analgesics are gaining popularity as alternative to opioids in spine surgery. METHODS: This systematic review evaluated current evidence regarding opioid and non-opioid intraoperative analgesia and their influence on immediate postoperative pain and adverse events in spine surgery. RESULTS: A total of 10,459 records were obtained by searching Medline, EMBASE and Web of Science databases and six randomized controlled trials were included. Differences in postoperative pain scores between opioid and non-opioid groups were not significant at 1 h: 4 studies, mean difference (MD) = 0.65 units, 95% confidence intervals (CI) [-0.12 to 1.41], p = 0.10, but favored non-opioid at 24 h after surgery: 3 studies, MD = 0.75 units, 95%CI [0.03 to 1.46], p = 0.04. The time for first postoperative analgesic requirement was shorter (MD = -45.06 min, 95%CI [-72.50 to -17.62], p = 0.001), and morphine consumption during first 24 h after surgery was higher in opioid compared to non-opioid group (MD = 4.54 mg, 95%CI [3.26 to 5.82], p < 0.00001). Adverse effects of postoperative nausea and vomiting (Relative risk (RR) = 2.15, 95%CI [1.37 to 3.38], p = 0.0009) and shivering (RR = 2.52, 95%CI [1.08 to 5.89], p = 0.03) were higher and bradycardia was lower (RR = 0.35, 95%CI [0.17 to 0.71], p = 0.004) with opioid analgesia. CONCLUSION: The certainty of evidence on GRADE assessment is low for studied outcomes. Available evidence supports intraoperative non-opioid analgesia for overall postoperative pain outcomes in spine surgery. More research is needed to find the best drug combination and dosing regimen. Prospero Registration: CRD42020209042.

Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) in neuroanesthesia practice: A review.

Respiratory management is an important aspect of care in neuroanesthesia practice for neurosurgical patients. A wide variety of procedures are performed under sedation in the neurosurgical population, and maintaining oxygenation is of paramount importance during these procedures. The high-flow oxygen devices improve arterial oxygenation by providing higher inspiratory oxygen concentration and maintaining higher dynamic positive airway pressure. These devices have gained importance during the recent years with regard to enhancing patient safety. This narrative review focuses on the role of trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) and high-flow nasal oxygenation (HFNO) techniques in the neuroanesthesia practice and electroconvulsive therapy.

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.

Perioperative Analgesia in Neurosurgery (PAIN): A national survey of pain assessment and management among neuroanesthesiologists of India.

BACKGROUND: Perioperative pain assessment and management in neurosurgical patients varies widely across the globe. There is lack of data from developing world regarding practices of pain assessment and management in neurosurgical population. This survey aimed to capture practices and perceptions regarding perioperative pain assessment and management in neurosurgical patients among anesthesiologists who are members of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) and evaluated if hospital and pain characteristics predicted the use of structured pain assessment protocol and use of opioids for postoperative pain management. METHODS: A 26-item English language questionnaire was administered to members of ISNACC using Kwiksurveys platform after ethics committee approval. Our outcome measures were adoption of structured protocol for pain assessment and opioid usage for postoperative pain management. RESULTS: The response rate for our survey was 55.15% (289/524). One hundred eighteen (41%) responders informed that their hospital setup had a structured pain protocol while 43 (15%) responders reported using opioids for postoperative pain management. Predictors of the use of structured pain protocol were private setup (odds ratio [OR] 2.64; 95% confidence interval [CI] 1.52-4.59; P = .001), higher pain intensity (OR 0.37; 95% CI 0.21-0.64; P < .001) and use of pain scale (OR 7.94; 95% CI 3.99-15.81; P < .001) while availability of structured pain protocol (OR 2.04; 95% CI 1.02-4.05; P = .043) was the only significant variable for postoperative opioid use. CONCLUSIONS: Less than half of the Indian neuroanesthesiologists who are members of ISNACC use structured protocol for pain assessment and very few use opioids for postoperative pain management in neurosurgical patients.

Comparison of intraoperative fentanyl with dexmedetomidine for perioperative analgesia and opioid consumption during craniotomies: A randomised controlled pilot study with non-inferiority design.

BACKGROUND: Moderate to severe pain is common despite the use of potent opioids during craniotomies. Non-opioid agents such as dexmedetomidine reduce undesirable opioid effects and are successfully used as primary analgesic during bariatric surgeries. This study assessed the feasibility of conducting a large randomised controlled trial comparing fentanyl with dexmedetomidine for perioperative analgesia during craniotomy. METHODS: This was a prospective single-centre randomised controlled feasibility trial. Twenty-four consenting adult patients undergoing supratentorial craniotomy at NIMHANS, Bangalore, India, were recruited after ethical approval in March and April 2018. They received either fentanyl 1 µg kg-1  h-1 (n = 12) or dexmedetomidine 0.5  µg kg-1  h-1 (n = 12) as primary intraoperative analgesic drug. Patient, anaesthesiologist, outcome assessor and data analyst were blinded to the study intervention. Our feasibility outcomes (primary) were recruitment and adherence rates. We also explored the potential efficacy of intervention and adverse events. RESULTS: We recruited 24 out of 30 eligible patients and had 100% protocol adherence, thereby demonstrating the feasibility of a larger randomised controlled trial. All 24 patients completed the study. The demographic and clinical parameters were similar between the groups. Compared between fentanyl and dexmedetomidine, there was no difference in the intraoperative fentanyl (top-up) consumption (µg), expressed as median and interquartile range: 25 (0-50) and 0 (0-50); P = 0.844; and no difference in postoperative pain at 15 and 60 minutes. Adverse events were few and similar with fentanyl and dexmedetomidine. CONCLUSIONS: A large-scale randomised controlled trial of perioperative dexmedetomidine versus fentanyl is feasible. Dexmedetomidine has the potential to be non-inferior to fentanyl for perioperative analgesia during craniotomies.

The framing of research questions using the PICOT format in randomized controlled trials of venous ulcer disease is suboptimal: A systematic survey.

Despite several publications on venous ulcers, there is still a lack of evidence from randomized controlled trials (RCTs) to support certain treatments for patients with this disorder. Well-designed research questions using the PICOT (Population; Intervention; Comparator; Outcome; Time-frame) format in RCTs can improve the quality of research. The objectives of this study were to assess how the PICOT format is used to frame research questions in RCTs published on venous ulcer disease and to determine the factors associated with better adherence to the PICOT format. We conducted a systematic survey of RCTs on venous ulcers published in the PubMed database between January 2009 and May 2016. All RCTs published in English addressing therapeutic interventions for venous ulcer disease in human subjects were included. We examined whether the five elements of the PICOT format were used in formulating the research question and scored them between 0 and 5. The primary outcome of this systematic survey was the percentage of studies that adequately reported all five PICOT elements. Eighty-five (85) RCTs were included with median PICOT score of 3 (IQR = 1.5). Four elements of PICOT were present in 28 reports (32.9%) and only 2 RCTS (2.3%) reported all the PICOT elements. Population and intervention were often appropriately described, in (70/85) 82.4% and (83/85) 97.6% of the studies, respectively; however, comparison intervention and outcome were presented in only (53/85) 62.3% and (48/85) 56.5% of studies, respectively. Very few RCTs (7.1%; 6/85) reported the study time frame. No journal or RCT characteristics were found to be significantly associated with better reporting. Use of the PICOT format to frame research questions in RCTs published on venous ulcers is suboptimal, and our study reinforces the importance of framing a good research question to improve the design of trials and quality of evidence in venous ulcer disease.

Effect of Atropine Premedication on Cardiac Autonomic Function During Electroconvulsive Therapy: A Randomized Crossover Study.

OBJECTIVES: Electroconvulsive therapy (ECT) results in significant cardiovascular changes. The acute cardiac autonomic changes during ECT remain unexplored. The primary objective of this study was to compare autonomic dysfunction with and without atropine premedication during ECT and secondarily to evaluate dysautonomia across psychiatric diagnoses before and after ECT. METHODS: In this crossover study, 41 psychiatric patients were monitored during 82 ECT sessions. Patients were randomized either to receive atropine or not to receive atropine during their second ECT session and were crossed over during their third session. Heart rate, blood pressure, and oxygen saturation were continuously monitored from stimulus application until 300 seconds after ECT. Demographic characteristics and ANSiscope indices derived pre- and post-ECT were collected. RESULTS: Autonomic dysfunction (%) before ECT was similar between atropine and no-atropine sessions (32.4 ± 15.7 vs 32.8 ± 16.7; 95% confidence interval, -7.6 to 6.7; P = 0.90) but increased significantly after ECT to 60.9 ± 16.3 and to 47.0 ± 17.3, respectively, and this difference was significant (95% confidence interval, 6.5-21.3; P < 0.001). There was no difference in the autonomic function across psychiatric diagnoses both before (P = 0.07) and after ECT (P = 0.12). CONCLUSIONS: Cardiac autonomic dysfunction worsens after ECT in patients with psychiatric illnesses and to a significantly greater extent with atropine premedication. The degree of dysautonomia is similar across various psychiatric diagnoses both before and after ECT. Atropine premedication during ECT should be restricted to select patients susceptible to bradyarrhythmia and could be avoided in others.

Effect of propofol anesthesia on resting state brain functional connectivity in Indian population with chronic back pain.

OBJECTIVE: Functional magnetic resonance imaging (fMRI) studies in healthy volunteers have shown alterations in brain connectivity following anesthesia as compared to the awake state. It is not known if the anesthesia-induced changes in brain connectivity are different in a pathological state. This study aims to evaluate changes in the resting state functional connectivity in the brain, after propofol anesthesia, in patients with chronic back pain (CBP). MATERIALS AND METHODS: Fourteen adults with CBP were included in this prospective study over 6 months. After excluding structural brain pathology, a resting state fMRI was performed in the awake state, and the sequences were repeated after propofol anesthesia. The primary outcome measure was change in resting state connectivity after propofol. Student's t-test was performed between the pre and post-propofol sedation data of all patients with total brain volume as covariates of interest. A repeated measures analysis of variance was used to compare pre- and post-propofol changes in cardiorespiratory parameters. RESULTS: There were 8 male and 6 female patients in the study, and the mean age of the study population was 46.9 ± 11.3 years. Propofol sedation resulted in an increased strength of functional connectivity between the posterior cingulate cortex (PCC) and thalamus in patients with CBP, whereas there was a generalized decrease in functional integration within the large scale brain networks. The changes in cardiorespiratory parameters before and after propofol administration were not statistically significant. CONCLUSION: Strengthening of functional connectivity was seen between PCC and thalamus with decrease in large scale brain networks following propofol anesthesia in patients with CBP. These changes are similar to those previously described in normal volunteers.

Acute kidney injury in survivors of surgery for severe traumatic brain injury: Incidence, risk factors, and outcome from a tertiary neuroscience center in India.

BACKGROUND: Non-neurological complications like acute kidney injury (AKI) can affect outcome of traumatic brain injury (TBI). This study aims to analyze the incidence, predictive factors, and impact of AKI in operated patients with severe TBI. METHODS: We retrospectively reviewed the data of 395 patients who underwent surgery for severe TBI and survived to be discharged from the hospital over a 1-year period. Of these, 95 patients were finally included in the analysis. Their demographic data, laboratory parameters, and clinical courses were reviewed. Diagnosis and staging of AKI was made using Acute Kidney Injury Network (AKIN) criteria. RESULTS: The incidence of AKI was 11.6% (11 patients). Out of the 11 patients who had AKI, 7 were in stage I (63.6%), 3 were in stage II (27.3%), and 1 in stage III (9.1%). Nine Patients (81.8%) developed AKI within 5 days of admission. Aminoglycoside therapy had an association with occurrence of AKI. There was no mortality and none of the patients required renal replacement therapy (RRT). Renal function of all these patients returned to baseline before hospital discharge. Hospital stay and intensive care unit (ICU) stay were longer and Glasgow coma scale (GCS) was lower in patients with AKI when compared with patients without AKI group at discharge. CONCLUSION: Reversible AKI without need for RRT occurred in nearly 12% of patients with severe TBI requiring surgical intervention. Aminoglycoside therapy was the only predictive factor for the occurrence of AKI. Patients with AKI have a longer period of mechanical ventilation, longer ICU and hospital stay, and poorer GCS at discharge.

A comparative study of dexmedetomidine and propofol as sole sedative agents for patients with aneurysmal subarachnoid hemorrhage undergoing diagnostic cerebral angiography.

PURPOSE: Subarachnoid hemorrhage is an acute neurological emergency requiring urgent confirmation of the diagnosis for planning definitive management. Due to altered consciousness, most patients require sedation for conducting this procedure smoothly. Currently, it is unclear if any one particular sedative drug has a favorable profile in patients undergoing cerebral angiography. The aim of this study was to compare the traditionally used sedative drug propofol with a newer alternative, dexmedetomidine, in patients with subarachnoid hemorrhage undergoing cerebral angiography. METHODS: Sixty adult patients with good grade subarachnoid hemorrhage undergoing diagnostic cerebral angiography were prospectively randomized to receive either propofol (n = 30) or dexmedetomidine (n = 30) following ethics committee approval and informed consent. RESULTS: Compared to dexmadetomidine, propofol was associated with an earlier time for onset of sedation (2.3 ± 1.9 min vs. 15.4 ± 5.7 min; P < 0.001), but with an increased number of adverse respiratory events (11/30 vs 1/30; P = 0.003) and movement during the procedure (5/30 vs. 0/30; P = 0.05), necessitating additional supplementation of sedation (13/30 vs. 7/30; P = 0.17) and repetition of the imaging sequences. The total procedure time and time for recovery were similar for the propofol and dexmedetomidine groups, while the heart rate was lower in patients in the dexmedetomidine group. CONCLUSION: Dexmedetomidine appears to be superior to propofol as a sole sedative agent for sedation during cerebral angiography in patients with subarachnoid hemorrhage.

Anesthetic factors and outcome in children undergoing indirect revascularization procedure for moyamoya disease: An Indian perspective.

BACKGROUND: Moya Moya disease (MMD) is one of the most common cerebro-vascular diseases in children resulting in stroke. Surgical revascularization aims at improving the perfusion to the 'at-risk' ischemic brain. Several factors including peri-operative anesthetic related ones, affect the outcome in these children. This study was performed with the aim to explore the role of anesthetic techniques, pharmacological agents and perioperative management strategies on the neurological outcome following an indirect revascularization procedure for the treatment of MMD. MATERIALS AND METHODS: This was a retrospective chart review of pediatric indirect revascularization procedures for MMD during a three year period at a tertiary neurosciences hospital in southern India. Demographic details, disease characteristics and variables related to anesthetic management were obtained from the patient's charts and analyzed. The main outcome measure was occurrence of postoperative new neurological complications; and, the secondary outcome was length of hospital stay after surgery. RESULTS: Twenty-two children underwent thirty indirect revascularization procedures, of which four patients had new postoperative neurological complications. One child died due to bilateral cerebral infarcts following bilateral surgery as a single stage under the same anesthesia. Female gender and a higher opioid dose were associated with occurrence of postoperative neurological deficits. Younger age, prolonged anesthetic duration and occurrence of postoperative neurological deficits were associated with prolonged postoperative hospital stay. However, none of these factors were predictive of either an adverse neurological outcome or a prolonged hospital stay. CONCLUSION: In this study, anesthetic techniques or medications did not influence the occurrence of postoperative neurological deficits or prolonged hospital stay after an indirect revascularization procedure in children with MMD.

Low-Flow Anesthesia, Low Fresh Gas Flow, and Oxygen Flush: An Interesting Interplay.

Identification and analysis of critical respiratory alarms during use of an advanced anesthesia workstation is essential in the intraoperative period. We present and discuss a scenario in which there was activation of a fresh gas flow alarm during low-flow anesthesia intraoperatively and use of oxygen flush to counteract it led to a diluted concentration of the inspired anesthetic agent.

Incidence and risk factors for oxygen desaturation during recovery from modified electroconvulsive therapy: A prospective observational study.

BACKGROUND AND AIMS: Electroconvulsive therapy (ECT) is an established modality of treatment for severe psychiatric illnesses. Among the various complications associated with ECT, oxygen desaturation is often under reported. None of the previous studies has evaluated the predictive factors for oxygen desaturation during ECT. The objective of this study was to evaluate the incidence of oxygen desaturation during recovery from anesthesia for modified ECT and evaluate its risk factors in a large sample. MATERIALS AND METHODS: All patients aged above 15 years who were prescribed a modified ECT for their psychiatric illness over 1 year were prospectively included in this observational study. The association between age, body mass index (BMI), doses of thiopentone and suxamethonium, stimulus current, ECT session number, pre- and post-ECT heart rate and mean arterial pressure, seizure duration, and pre- and post ECT oxygen saturation, was systematically studied. RESULTS: The incidence of oxygen desaturation was 29% (93/316 patients). Seizure duration and BMI were found to be significantly correlated with post ECT desaturation. CONCLUSION: In this prospective observational study, the incidence of oxygen desaturation during recovery from anesthesia for ECT was high. The study identified obesity and duration of seizure as the independent predictors of this complication. This knowledge is likely to help in identifying and optimizing such patients before subsequent ECT sessions.

Anesthetic management of patients with Joubert syndrome: a retrospective analysis of a single-institutional case series.

OBJECTIVE: To analyze the anesthetic techniques used for sedation during magnetic resonance imaging (MRI) study of patients with Joubert syndrome (JS) and assess the safety and efficacy of these anesthetic regimens in these children. BACKGROUND: Joubert syndrome is a rare neurological disorder with significant anesthetic implications. This study describes the anesthetic management of children with JS undergoing MRI study with different anesthetic agents and implications of various anesthetic techniques in these patients. MATERIALS AND METHODS: The records of ten patients with JS undergoing MRI study with different anesthetic techniques were retrospectively reviewed over the last 5 years. RESULTS: The patients were aged between 6 months and 21 years. The most commonly used sedation technique involved use of alpha-2 agonists, and this technique had least complications such as apnea and patient movement during imaging. None of the patients had postanesthetic respiratory problems, although one patient receiving propofol had apnea and desaturation on induction requiring airway intervention. CONCLUSION: Alpha-2 agonist based anesthetic technique appears to be most suitable for sedation during MRI study in patients with JS with respect to adverse events and outcome.

An abrupt reduction in end-tidal carbon-dioxide during neurosurgery is not always due to venous air embolism: a capnograph artefact.

Venous air embolism (VAE) is a well recognized complication during neurosurgery. Pre-cordial doppler and trans-esophageal echocardiography are sensitive monitors for the detection of VAE. A sudden, abrupt reduction in the end-tidal carbondioxide (ETCO2) pressure with associated hypotension during neurosurgery might suggest VAE, when more sensitive monitors are not available. We describe an unusual cause for sudden reduction in ETCO2 during neurosurgery and discuss the mechanism for such presentation.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study.

Objectives: Anemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes. Methods: This was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon's experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia. Results: The incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon's experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012). Conclusions: Atleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

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.

Seasonal variation in the clinical recovery of patients with Guillain Barré syndrome requiring mechanical ventilation.

BACKGROUND: Guillain Barré Syndrome (GBS) has a variable clinical course. The influence of season on the rate of recovery has not been evaluated previously, despite documentation of seasonal variation in the occurrence of GBS. This study evaluated the influence of season on the rate of recovery from GBS. MATERIALS AND METHODS: Records of 184 patients with GBS over a 10-year period were reviewed. Patients were divided into four groups depending on the date of admission: Q1 (March-May), Q2 (June-August), Q3 (September-November), and Q4 (December-February). Demographic characteristics and recovery characteristics (duration of mechanical ventilation, ICU and hospital stay, and time for recovery from the time of initiation of definitive therapy) were compared across the four quarters. RESULTS: There was no significant difference in age, antecedent illnesses, treatment received, electrophysiological findings, and muscle power at admission across the four groups. Significant differences among various seasons were found with respect to duration of mechanical ventilation (23 ± 20, 36 ± 34, 27 ± 22, and 38 ± 28 days for Q1-Q4, respectively; P = 0.05), ICU stay (27 ± 22, 40 ± 37, 31 ± 23, and 43 ± 30 days for Q1-Q4, respectively; P = 0.05), hospital stay (42 ± 28, 55 ± 44, 47 ± 34, and 72 ± 54 days for Q1-Q4, respectively; P = 0.02), and time for recovery from treatment (15 ± 14, 29 ± 34, 18 ± 14, and 29 ± 20 days for Q1-Q4, respectively; P = 0.02). CONCLUSIONS: This study demonstrates a seasonal variation in the recovery of patients with GBS requiring mechanical ventilation. Patients admitted in Q1 have the fastest recovery and those in Q4 have the slowest recovery.