Post-COVID-19 mucormycosis: A prospective, observational study in patients undergoing surgical treatment.

Background and Aims: Post the second wave of COVID-19 in India, our institute became a dedicated center for managing COVID-19-associated mucormycosis (CAM), but there was a paucity of data regarding perioperative considerations in these patients. The objectives of present study was to describe the preoperative clinical profile, the perioperative complications and outcome of CAM patients undergoing urgent surgical debridement. Material and Methods: This prospective observational study was conducted on CAM patients presenting for surgical debridement from July to September 2021. During preoperative visits, evaluation of extent of disease, any side effects of ongoing medical management and post-COVID-19 systemic sequalae were done. The details of anaesthetic management of these patients including airway management, intraoperative haemodynamic complications and need for perioperative blood transfusion were noted. Results: One hundred twenty patients underwent surgical debridement; functional endoscopic sinus surgery (FESS) was carried out in 63% of patients, FESS with orbital exenteration in 17.5%, and maxillectomy in 12.5%. Diabetes mellitus was found in 70.8% and post-COVID new onset hyperglycemia in 29.1% of patients. Moderate-to-severe decline in post-COVID functional status (PCFS) scale was observed in 73.2% of patients, but with optimization, only 5.8% required ICU management. The concern during airway management was primarily difficulty in mask ventilation (17.5%). Intraoperatively, hemodynamic adverse events responded to conventional treatment for hypotension, judicious use of fluids and blood transfusion. Perioperatively, 10.8% of patients required blood transfusion and 4.2% of patients did not survive. Non-surviving patients were older, with a more aggressive involvement of CAM, and had comorbidities and a greater decline in functional capacity. Conclusion: A majority of patients reported a moderate-to-severe decline in PCFS that required a preoperative multisystem optimization and a tailored anesthetic approach for a successful perioperative outcome.

Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units.

BACKGROUND: Percutaneous dilatational tracheostomy (PCDT) using fiber-optic bronchoscope (FOB) is a widely practiced technique, but its availability and cost remain a concern in nations with limited resources. Mini-surgical technique of PCDT incorporating minimal blunt dissection has shown improved results even without the use of FOB. The study is primarily intended to compare these two techniques and establish a safer cost-effective alternative to FOB-guided PCDTs. PATIENTS AND METHODS: This randomized comparative study [registered (CTRI/2018/04/013191)] was conducted on 120 mechanically ventilated patients. In 60 patients, mini-surgical PCDT (group-M) was performed with 2 cm longitudinal skin incision and blunt dissection till pretracheal fascia without FOB guidance using Portex-Ultraperc™ sets. In remaining 60 patients, PCDT was performed under FOB vision with similar skin incision (without blunt dissection) using Portex-Ultraperc™ sets (group-F). Two techniques were compared with regard to procedural time and percentage of complications occurred during or after the procedure. RESULTS: Procedure time [group-M: 6.30 ± 1.28 minutes; group-F: 14.43 ± 1.84 minutes (p <0.001)] and mean blood loss [group-M: 5.33 ± 1.69 mL; group-F: 6.87 ± 3.11 mL (p = 0.001)] was significantly less in group-M. Higher incidence of desaturation [group-M: 16.7%; group-F: 35% (p = 0.022)] was noted in group-F, whereas arrhythmias [group-M: 21.7%; group-F: 6.7% (p = 0.018)] were higher in group-M. There was no statistical difference in incidence of pneumothorax and subcutaneous emphysema. There was no incidence of posterior tracheal wall perforation in any of the patients. CONCLUSION: Mini-surgical technique is a faster alternative of FOB-guided PCDT with comparable incidence of complications. It can safely be used in intensive care units (ICUs) where FOB is not available. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2018/05/014307. NAME OF REGISTRY: Clinical Trials Registry of India (CTRI), URL-http://ctri.nic.in. HOW TO CITE THIS ARTICLE: Kumar A, Kohli A, Kachru N, Bhadoria P, Wadhawan S, Kumar D. Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units. Indian J Crit Care Med 2021;25(11):1269-1274.

Comparative evaluation of dexmedetomidine and fentanyl in total intravenous anesthesia for laparoscopic cholecystectomy: A randomised controlled study.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy is one of the commonly performed ambulatory surgeries. The selection of anesthetic agents for ambulatory surgeries should be done bearing in mind the need for early discharge. Opioids form an integral component of total intravenous anesthesia (TIVA) but their associated side effects may result in an increased hospital stay. Hence, we planned a study to compare the opioid (fentanyl) and non-opioid (dexmedetomidine) based technique of TIVA for laparoscopic surgery. MATERIAL AND METHODS: Ninety ASA I and II patients between 18-60 years of either sex posted for laparoscopic cholecystectomy were randomly allocated into two groups namely group D (Dexmedetomidine) and group F (Fentanyl). Patients received propofol infusion along with group specific drug infusion, after which an appropriate size proseal laryngeal mask airway was placed. The patients were assessed for discharge time from post-anesthesia care unit (PACU), on table recovery time, time to first rescue analgesia, hemodynamic parameters, incidence of postoperative nausea and vomiting (PONV) and any other complication. RESULTS: Demographic profile of both the groups was comparable. Group D had longer on table recovery time (13.00 ± 2.34 min vs 6.29 ± 2.46 min; P < 0.001) and time to discharge from PACU (6.80 ± 3.96 min vs 2.36 ± 1.67 min; P < 0.001) compared to group F. Group F had better hemodynamic stability compared to group D. In group D, 77% patients required rescue analgesia in first one hour post surgery, unlike 22% in group F. No patient in group D had PONV. CONCLUSION: Opioid based technique (Fentanyl) of TIVA is superior over non-opioid based (dexmedetomidine) technique with faster recovery, early discharge, decreased postoperative pain scores and better hemodynamic stability. PONV is observed with opioids which can be treated successfully with antiemetics.

Comparative evaluation of I-gel vs. endotracheal intubation for adequacy of ventilation in pediatric patients undergoing laparoscopic surgeries.

BACKGROUND AND AIMS: The use of newer supraglottic devices has been extended to laparoscopic procedures. We conducted this study to compare and evaluate the efficacy of these two devices in pediatric laparoscopic surgeries. MATERIAL AND METHODS: Eighty children, 2-8 years of age, scheduled for elective short laparoscopic procedures were randomly allocated to the I-gel or endotracheal tube (ETT) group. Standard anesthesia protocol was followed for inhalational induction. I-gel or ETT was inserted according to the manufacturer's recommendations. Ventilation was set with tidal volume 10 ml/kg and a respiratory rate of 16/min. Carboperitoneum was achieved up to an intra-abdominal pressure of 12 mmHg. STATISTICAL ANALYSIS: The primary outcome variable was adequacy of ventilation (peak airway pressure, end-tidal CO2, minute ventilation, and SPO2). These variables were recorded after securing airway, after carboperitoneum and desufflation of the peritoneal cavity. The oropharyngeal leak pressures were also noted. Statistical analysis was done using SPSS software version 17.0. P <0.05 was considered statistically significant. RESULTS: No significant difference was observed in the heart rate or mean arterial pressure. There was a significant increase in the PECO2 and peak airway pressure after creation of carboperitoneum. There was significant increase in minute ventilation in both groups after creation of carboperitoneum. CONCLUSION: To conclude, I-gel is comparable to endotracheal intubation in terms of adequacy of ventilation. The increase in peak airway pressures is less with I-gel. In addition, postoperative complications are fewer with I-gel.

Single-point versus double-point injection technique of ultrasound-guided supraclavicular block: A randomized controlled study.

BACKGROUND AND AIMS: This study aims to compare the single-point injection and double-point injection technique of ultrasound-guided supraclavicular block with regard to the success rate, time taken to perform the procedure, onset and duration of sensory and motor block, and complications. MATERIAL AND METHODS: A total of 60 American Society of Anesthesiologists physical status I and II patients between 20 and 50 years of age, with body mass index ≤30 kg/m2 posted for forearm surgeries, with anticipated surgical duration more than 1 h were randomly divided into two groups: group S (single-point injection) and group D (double-point injection technique). After locating the brachial plexus with ultrasound, needle was inserted from lateral to medial direction to reach the plexus. In group D, 20 ml of inj. bupivacaine 0.5% was deposited as 10 ml each in superior (in the cluster) and inferior pocket (corner pocket) between the plexus and subclavian artery with the help of hydrodissection while in group S the total 20 ml was deposited in the superior (in the cluster) pocket. The onset of sensory and motor block was assessed using pin prick method and modified Bromage scale. Adequacy of block was ensured by assessing the ulnar, radial, and median nerve distribution. Procedural time was defined from the point of scanning the plexus till the drug was injected completely. Total sensory, motor duration, and complications if any were noted. RESULTS: Group D had higher success rate compared to group S (96.7 vs. 83.3%; P < 0.0001). The total procedural time was significantly more in group D compared to group S (14.6 ± 2.7 vs. 10.1 ± 1.7 min; P < 0.0001). The onset of sensory and motor block was faster and the duration of sensory and motor block was significantly longer in group D. CONCLUSION: The adequacy of block, sensory, and motor duration was significantly high in newer double-point injection technique. However, it requires longer procedural time compared to single-point injection technique.

Anesthesia for intellectually disabled.

Anesthetizing an intellectually disabled patient is a challenge due to lack of cognition and communication which makes perioperative evaluation difficult. The presence of associated medical problems and lack of cooperation further complicates the anesthetic technique. An online literature search was performed using keywords anesthesia, intellectually disabled, and mentally retarded and relevant articles were included for review. There is scarcity of literature dealing with intellectually disabled patients. The present review highlights the anesthetic challenges, their relevant evidence-based management, and the role of caretakers in the perioperative period. Proper understanding of the associated problems along with a considerate and unhurried approach are the essentials of anesthetic management of these patients.

Intraoperative endobronchial rupture of pulmonary hydatid cyst: An airway catastrophe.

Hydatid cyst disease of lungs may not be symptomatic. It may present as spontaneous rupture in pleura or a bronchus. During spontaneous breathing, cyst content of endobronchially ruptured pulmonary hydatid cyst is mostly evacuated by coughing. However, during positive pressure ventilation such extruded fragments may lodge into smaller airway leading to an airway catastrophe. We present such accidental endobronchial rupture of pulmonary hydatid cyst during surgery, its prompt detection, and management by rigid bronchoscopy.

Anesthetic management of an infant for aortopexy.

Tracheomalacia is a rare condition characterized by weakness of tracheobronchial cartilaginous bridges. Severe weakness results in tracheal collapse during inspiration, obstructing normal airflow. Tracheomalacia may also be associated with esophageal atresia, tracheoesophageal fistula, and gastroesophageal reflux. Aortopexy is an established surgical procedure for treatment of severe tracheomalacia. A 2-month-old boy was scheduled for aortopexy. He had already undergone repair of tracheoesophageal fistula and had failed multiple attempts at extubation. Intraoperative flexible fiberoptic bronchoscopy was performed to guide the amount and direction of aortopexy for assuring the most effective tracheal decompression. Since tracheomalacia is best assessed in a spontaneously breathing patient, it was an anesthetic challenge to maintain an adequate depth of anesthesia while allowing the patient to breathe spontaneously. Throughout the intraoperative period, SpO2 remained ≥96%. Following the procedure, the trachea was extubated and patient was able to breathe normally.

Anesthetic management of a patient with Montgomery t-tube in-situ for direct laryngoscopy.

The Montgomery silicone t-tube used for post-procedural tracheal stenosis has advantage of acting as both stent and tracheostomy tube. The anesthetic management of patient with t-tube in situ poses a challenge. Safe management of such patients requires careful planning. We describe anesthetic management for direct laryngoscopy of a patient with t-tube in situ.

Ketodex for MRI sedation in syndromic children with congenital cardiac anomalies - A case series.

Safe paediatric sedation in a magnetic resonance imaging (MRI) suite can be challenging. The challenges intensify in uncooperative syndromic children compounded by an accentuated risk of periprocedural cardio-respiratory complications with anaesthetic sedation in this peculiarly predisposed subset. Amidst ardent debates on the ideal sedative agent for paediatric MRI, we report an encouraging application of ketamine-dexmedetomidine combination (ketodex) sedation for MRI in our case-series including syndromic children with coexistent congenital cardiac anomalies.

Correlation of Patient Profiles and Biomarkers with Outcomes in Covid-19 Icu Patients: A Retrospective Analysis.

Background: COVID-19 is a novel disease with a highly variable and unpredictable clinical course. Various clinicodemographic factors and numerous biomarkers have been identified in studies from the West and marked as possible predictors of severe illness and mortality which may be used to triage patients for early aggressive care. This triaging becomes even more significant in resource-limited critical care settings of the Indian subcontinent. Methods: This retrospective observational study recruited 99 cases of COVID-19 admitted to intensive care from 1 May to 1 August 2020. Demographic, clinical and baseline laboratory data were collected and analysed for association with clinical outcomes, including survival and need for mechanical ventilatory support. Results: Male gender (p=0.044) and diabetes mellitus (p=0.042) were associated with increased mortality. Binomial logistic regression analysis revealed Interleukin-6 (IL6) (p=0.024), D-dimer (p=0.025) and CRP (p<0.001) as significant predictors of need of ventilatory support and IL6 (p=0.036), CRP (p=0.041), D-dimer (p=0.006) and PaO2FiO2 ratio (p=0.019) as significant predictors of mortality. CRP >40 mg/L predicted mortality with sensitivity of 93.3% and specificity of 88.9% (AUC 0.933) and IL6> 32.5 pg/ml with a sensitivity of 82.2% and specificity of 70.4% (AUC 0.821). Conclusion: Our results suggest that a baseline CRP >40 mg/L, IL6 >32.5 pg/ml or D-dimer >810 ng/ml are early accurate predictors of severe illness and adverse outcomes and may be used to triage patients for early intensive care.

I-Gel as an intubation conduit: Comparison of three different types of endotracheal tubes.

BACKGROUND AND AIMS: I-Gel®, a novel SAD has been introduced as a ventilating device but has widely gained popularity as conduit for intubation. Unlike intubating laryngeal mask airway (ILMA), I-Gel® does not have an endotracheal tube specially designed for it. Hence the aim of this study was to compare the rate of successful intubation via I-Gel® using three different types of endotracheal tubes. METHODS: We randomised 75 American Society of Anesthesiologists (ASA) physical status I and II patients, between the age group 18-60 years of either sex undergoing elective surgery under general anaesthesia into three groups on the basis of endotracheal tube (ETT), used for intubation via I-Gel®: Group P (Polyvinyl chloride ETT), Group I (Intubating laryngeal mask airway ETT), Group F (flexometallic ETT). After following the standard induction protocol, appropriate size I Gel® was inserted in all patients. Thereafter group specific ETT was inserted via I-Gel®. We recorded and compared the time taken for successful intubation, the success rate, number of attempts taken, manoeuvres used, and complications among three different types of ETT. Quantitative variables were compared using Kruskal Wallis test and the qualitative variables were compared using Chi-square test. RESULTS: The time taken for successful intubation was least in group P (10.51 ± 3.82 seconds). Group P also had the highest first attempt (68%) and overall rate of successful intubation (88%). CONCLUSION: PVC ETT had highest first attempt success rate and required minimum time for endotracheal intubation via I-Gel® when compared to ILMA ETT and Flexible ETT.

Entropy vs standard clinical monitoring using total intravenous anesthesia during transvaginal oocyte retrieval in patients for in vitro fertilization.

STUDY OBJECTIVE: Day care surgery is an important arena for monitors of anesthetic depth where minimizing drug use is essential for rapid turnover. Underdosage, on the other hand, carries the risks of intraoperative awareness and pain. Transvaginal oocyte retrieval (TVOR), often performed under total intravenous anesthesia using propofol and fentanyl in Indian patients, is a procedure of special interest because, in addition to the above concerns, toxic effects of propofol on oocytes have been described. We have studied the role of entropy monitor, a depth of anesthesia monitor, in optomising drug titration and facilitating distinction between analgesic and hypnotic components of anesthesia. DESIGN: Prospective randomized controlled study. SETTING: Operating theater and postoperative recovery area. PATIENTS: One hundred twenty American Society of Anesthesiologists class I and II female patients coming to the IVF centre for TVOR under total intravenous anesthesia using propofol and fentanyl. They were randomly allocated into 2 groups: Group EM (drugs titrated as per entropy values: state entropy and response entropy) and group CM (drugs titrated as per standard clinical monitoring). INTERVENTION: None. MEASUREMENTS: Total propofol consumption (TP), total fentanyl consumption (TF), on-table recovery time (T1), time to discharge (T2), intraoperative awareness (A). MAIN RESULTS: Patients in group EM demonstrated 6.7% lesser consumption of propofol (P= .01), 10.9% more consumption of fentanyl (P= .007) and 1 minute faster recovery on-table (P= .009) as compared to group CM. In the PACU, only 10% patients of group EM required supplemental analgesia as opposed to 28.3% in CM group (P= .01). Time to discharge was similar in both groups and no intraoperative awareness was noted. CONCLUSION: Entropy monitor is a useful tool allowing distinction between analgesic and hypnotic components of general anesthesia in patients undergoing TVOR and facilitating drug titration accordingly. Its impact on intraoperative awareness needs to be further evaluated.

Management of swine-flu patients in the intensive care unit: Our experience.

BACKGROUND: H1N1 pandemic in 2009-2010 created a state of panic not only in India, but in the whole world. The clinical picture seen with H1N1 is different from the seasonal influenza involving healthy young adults. Critical care management of such patients imposes a challenge for anesthesiologist. MATERIALS AND METHODS: A retrospective analysis of hospitalized positive H1N1 patients was performed from July 2009-June 2010. Those requiring the ventilatory support were included in the study. RESULT: 54 patients were admitted in the swine-flu ward during the study period out of which 19 required ventilatory support. The average day of presentation to the health care facility was 6(th) day causing delay in initiation of antiviral therapy and increased severity of the disease. 65% of the ventilated patients were having associated comorbidities. Mortality was 74% among ventilated patients. CONCLUSION: Positive H1N1 with severe disease profile have a poor outcome. Early identification of high-risk factors and thus early intervention in the form of antiretroviral therapy and respiratory care will help in reducing the overall mortality.

Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass.

Anesthetic management of superior vena cava syndrome carries a possible risk of life-threatening complications such as cardiovascular collapse and complete airway obstruction during anesthesia. Superior vena cava syndrome results from the enlargement of a mediastinal mass and consequent compression of mediastinal structures resulting in impaired blood flow from superior vena cava to the right atrium and venous congestion of face and upper extremity. We report the successful anesthetic management of a 42-year-old man with superior vena cava syndrome posted for cervical lymph node biopsy.

Use of intubating laryngeal mask airway in a morbidly obese patient with chest trauma in an emergency setting.

A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.

Donepezil: A cause of inadequate muscle relaxation and delayed neuromuscular recovery.

A 74-year-old female with diabetes mellitus type II and Alzheimer's disease, taking donepezil for 4 months was operated for right modified radical mastectomy under general anesthesia. During the procedure a higher dose of non-depolarizing muscle relaxant was required than those recommended for her age yet the muscle relaxation was inadequate intra-operatively. Residual neuromuscular blockade persisted postoperatively, due to the cumulative effect of large doses of non-depolarizing muscle relaxant, needing post-operative ventilatory assistance. After ruling out other causes of resistance to non-depolarizing muscle relaxants, we concluded that acetylcholinesterase inhibitor donepezil was primarily responsible for inadequate muscle relaxation and delayed post-operative neuromuscular recovery.