Comparative evaluation of self-pressurized Air-Q® and Proseal™ LMA® in patients undergoing elective surgery under general anaesthesia: A randomized clinical trial.

Background and Aims: Intra-cuff pressure of Air-Q self-pressurized laryngeal airways (Air-Q SP) balances airway pressure and adapts to patient's pharyngeal and periglottic structures, thus improves oropharyngeal leak pressure (OLP).This study was performed to compare efficacy of Air-Q SP with Proseal laryngeal mask airway (PLMA) in patients undergoing elective surgery. Material and Methods: The study design was prospective, randomized and controlled. Ninety patients were randomly assigned to Air-Q SP or PLMA group. All patients were premedicated and shifted to operation theatre. Monitoring was instituted. After securing IV-line, induction with inj. Morphine + Propofol, relaxation with inj. Vecuronium was done. Supraglottic was inserted according to group allocation. Outcome measures were OLP, fibreoptic view of larynx, success rate, device insertion parameters, haemodynamic and respiratory parameters and post-operative laryngopharyngeal complications. Neostigmine + glycopyrrolate were given, device was extubated. Results: All supraglottic airway devices (SADs) were successfully placed in two attempts. The mean initial OLP, OLP at 10 minutes, and device insertion time were significantly lower in Air-Q SP group. Fiber-optic laryngeal view grading was significantly better with Air-Q SP. No significant difference was observed with respect to rate of successful insertion in first attempt, ease of insertion, and manipulations required. The hemodynamic/respiratory parameters and post-operative sore throat in the two both groups were similar. Conclusions: Proseal LMA has a higher OLP than Air-Q SP but average insertion time was better, and fiber-optic grading of laryngeal view was shorter with Air-Q SP. However, Air-Q SP and Proseal LMA were both effective for lung ventilation.

Fournier's gangrene and diabetic ketoacidosis with lower-than-anticipated glucose levels associated with SGLT-2 inhibitor: A double trouble.

Empagliflozin has a demonstrated cardiovascular benefit. It is co-prescribed as a glucose-lowering medication in patients with type II diabetes mellitus. Herein, we discuss dual-emergency side-effects, Fournier's gangrene (FG) and diabetic ketoacidosis with lower-than-anticipated glucose levels in a patient on Empagliflozin, a sodium-glucose transport protein 2 inhibitor (SGLT-2i). The pathophysiologic mechanism of FG in correlation with SGLT-2i is not yet elucidated. SGLT-2i increase predisposition to genital mycotic and urinary infections, a mechanism favouring FG. A patient with type II diabetes mellitus on SGLT-2i presented with acute necrotic infection of the scrotum and simultaneous diabetic ketoacidosis with lower-than-anticipated glucose levels. This dual emergency was managed with debridement and medical treatment on lines of diabetes ketoacidosis, respectively. A re-look at this group of glucose-lowering medications from bedside towards benchtop research may help to prod into any other mechanistic basis of these life-threatening clinical occurrences.

Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid.

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20-30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ≤30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the second line of therapy in diabetes mellitus type 2. They are frequently coprescribed with other noninsulin glucose-lowering medications. Diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels is an important SGLT2i-related adverse effect in postoperative patients. This case highlights the need for increased postoperative surveillance of patients on this group of medications. Ketonuria was managed with short-acting insulin infusion with dextrose-containing intravenous fluid, as a part of the ongoing intensive care treatment to which the patient responded well. Awareness of DKA with lower-than-anticipated glucose levels is an important clinical challenge, an entity that can be confused in the setting of major and complex surgeries. The frequency of this arcane and underreported diagnosis in the perioperative setting is unknown. How to cite this article: Vadi S, Lad V, Kapoor D. Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery. Indian J Crit Care Med 2021;25(8):958-959.

Linezolid-induced rare triad of hypoglycaemia, bone marrow suppression and hyponatraemia in elderly.

WHAT IS KNOWN AND OBJECTIVE: Linezolid, a member of the oxazolidinone class of antibacterial drugs, is approved by the US Food and Drug Administration (FDA) for the treatment of vancomycin-resistant Enterococcus faecium infections, nosocomial and community-acquired pneumonia, as a part of anti tubercular regimen and complicated and uncomplicated skin and soft tissue infections, including diabetic foot infections. Linezolid has potential adverse effects like bone marrow suppression, peripheral neuropathy and hyponatremia. One of the extremely rare reported adverse effects of the drug is hypoglycaemia. We present a case of Linezolid toxicity presenting as resistant hypoglycemia, bone marrow suppression and severe hyponatremia all together in a single patient. CASE DESCRIPTION: We present a case of an 82 years old gentleman with no known chronic co-morbidities. He was started on Linezolid 600 mg twice a day for 10 days by a local doctor possibly for some minor infection post hip surgery. He was in respiratory distress on arrival. Blood sugars showed severe hypoglycemia of 36 mg/dL (2.0 mmol/L). He was admitted in intensive care unit and started on injectable antibiotics and 5% dextrose infusion and sugars were strictly monitored. His blood tests revealed severe hyponatremia with sodium level of 119 mEq/L and haemoglobin (Hb) of 8.8 gm/dL, leucocytes of 6500/µL, platelets of 82 000/µL. The infection markers were normal throughout. The platelet count went progressively down from 82 000/µL on admission to 20 000/µL 2 days later; before it started rising back. Similarly there was drop in Hemoglobin and white cell counts. He required vasopressors to maintain mean arterial pressures. The blood sugar levels stabilized after the same. However patient had suffered acute lung injury secondary to aspiration and became NIV dependent and eventually passed away. WHAT IS NEW AND CONCLUSION: Our case was unique in a way that our patient had adverse effects of linezolid like myelosuppression as well as the rare side effects of hypoglycemia at the same time. This combination of adverse events has never been described in the past to our knowledge. All the adverse effects responded to antibiotic de-challenge in our case. We had ruled out the possibility of other causes of Hypoglycemia such as sepsis, insulinoma, alcohol excess, malnutrition or hypoadrenalism. We searched the PubMed database and found four case reports out of which two were diabetics and other two were non diabetics. Out of 15 cases described by Vishwanathan et al only three cases were non diabetics. Our patient was non diabetic as well. Therefore our case is only the sixth reported case of hypoglycemia in non diabetic receiving Linezolid to our knowledge.

Comparative evaluation of Ambu Aura-i and Fastrach™ intubating laryngeal mask airway for tracheal intubation: A randomized controlled trial.

BACKGROUND AND AIMS: Ambu Aura-i was compared with Fastrach™ (FT)-laryngeal mask airway (LMA) as a conduit for tracheal intubation. MATERIAL AND METHODS: A hundred consenting patients were randomly allocated into two groups of 50 patients each in a prospective randomized study. Standard anesthesia technique was used for all patients and FT-LMA or Ambu Aura-i was selected. After insertion of airway device, the cuff was inflated and ventilation was attempted. Once satisfactory ventilation was achieved, with or without maneuvers, a fiberoptic scoring for glottis view was noted. A polyvinylchloride (PVC) tracheal tube of appropriate size was inserted through the airway device as per procedure. If no resistance was felt while advancing the tracheal tube, it was fully inserted into the device and tracheal tube cuff was inflated. The device was removed and tracheal tube was left in situ. If the first attempt failed during tracheal tube insertion, the recommended maneuvers were used. A maximum of three attempts were allowed for intubation. First attempt for tracheal intubation attempt was a blind, second attempt was made with maneuver. If second attempt of intubation was unsuccessful, fiberoptic-guided intubation was performed as a third attempt. When tracheal intubation was unsuccessful, it was performed by direct laryngoscopy and considered as failed intubation. Rest of the anesthesia management was as per the discretion of attending anesthesiologists. The success rate of device insertion, fiberoptic score of glottis view, tracheal intubation via FT-LMA or Aura-i and time were recorded. RESULTS: Both FT-LMA and Aura-i were successfully placed within two attempts. The success rate of blind intubation was 92% in FT-LMA and 76% in Aura-i (P < 0.01). Time taken for tracheal intubation at first attempt was lesser in group FT-LMA and Aura-i, respectively (P < 0.01). Fiberoptic-guided intubation success rate was higher with Aura-i than with FT-LMA. CONCLUSIONS: FT-LMA had a higher success rate in facilitating blind tracheal intubation compared with Ambu Aura-i.

Continuous Bilateral Transversus Thoracicmuscle Plane Block: An Analgesia Boon for Scoliotic Patients Undergoing Cardiac Surgery.

ABSTRACT: A person with thoracolumbar scoliosis for cardiac surgery presents with problems of restrictive lung disease with the additional risk of reduced lung compliance and respiratory complications compared to the other patients. Post-operative analgesia in the form of continuous bilateral transversus thoracic muscle plane block (TTMPB) may help such patients in early respiratory rehabilitation by decreasing the time to extubation, reducing the opioid requirement, and early initiation of physiotherapy decreasing the risk of complications.

Real-time ultrasound guided percutaneous dilatational tracheostomy in critically ill patients: A step towards safety!

There are few reports and observational data that support the safety and efficacy of real-time ultrasound guided (USG) percutaneous dilatational tracheostomy (PDT) when compared with unguided tracheostomy. We performed real-time USG PDT in our intensive care unit (ICU) patients with the aim of providing safe and cost effective point-of-care management. Real-time ultrasonography has the potential advantage of enabling the clinicians to define the needle path by showing displacement of tissues ahead of needle.