Dexamethasone in anesthesia practice: A narrative review.

Dexamethasone is routinely used in anesthesia practice and has been regarded as one of the ideal perioperative agents. It is a synthetic glucocorticoid with potent antiinflammatory action. It reduces postoperative nausea and vomiting, pain, postoperative opioid requirements after general anaesthesia as well as spinal anaesthesia. It has been used via intravenous, epidural and perineural routes. It has been used successfully in fascial blocks. It significantly decreases fatigue, shivering and postoperative sore throat and improves quality of recovery.

Exploring the unknown territories in the new normal world of COVID.

It is now well known that the severe acute respiratory syndrome (SARS-CoV-2) originated in the Wuhan province of Hubei, China in 2019. Having spread across different countries of the world, this highly contagious disease has posed many challenges for the healthcare workers to work without endangering themselves and their patients' wellbeing. Several things are yet not clear about the virus and the presence or absence of the virus in the cerebrospinal fluid (CSF) is currently a debated topic. This article reports the perioperative management of two coronavirus disease-19 positive cases, one of whom was a pregnant patient. Their CSF samples, which were collected during the administration of spinal anesthesia, tested to be negative for viral reverse transcription polymerase chain reaction (RT-PCR) test. We wish to highlight from these cases, that during spinal anesthesia, CSF in mildly symptomatic COVID-19 cases probably does not pose a risk of transmission to the anesthesiologist. However, we suggest that due to the varied presentations of the virus, health care personnel, especially anesthesiologists have to be careful during the perioperative management of such cases.

Anaesthesia for laparoscopic surgery: General vs regional anaesthesia.

The use of laparoscopy has revolutionised the surgical field with its advantages of reduced morbidity with early recovery. Laparoscopic procedures have been traditionally performed under general anaesthesia (GA) due to the respiratory changes caused by pneumoperitoneum, which is an integral part of laparoscopy. The precise control of ventilation under controlled conditions in GA has proven it to be ideal for such procedures. However, recently the use of regional anaesthesia (RA) has emerged as an alternative choice for laparoscopy. Various reports in the literature suggest the safety of the use of spinal, epidural and combined spinal-epidural anaesthesia in laparoscopic procedures. The advantages of RA can include: Prevention of airway manipulation, an awake and spontaneously breathing patient intraoperatively, minimal nausea and vomiting, effective post-operative analgesia, and early ambulation and recovery. However, RA may be associated with a few side effects such as the requirement of a higher sensory level, more severe hypotension, shoulder discomfort due to diaphragmatic irritation, and respiratory embarrassment caused by pneumoperitoneum. Further studies may be required to establish the advantage of RA over GA for its eventual global use in different patient populations.

Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation.

BACKGROUND AND AIM: Induced hypotension limits intra-operative blood loss to provide better visibility of the surgical field and diminishes the incidence of major complications during functional endoscopic sinus surgery (FESS). We aimed at comparing nitroglycerine, esmolol and dexmedetomidine for inducing controlled hypotension in patients undergoing FESS. MATERIAL AND METHODS: One hundred and fifty American Society of Anesthesiologists physical status I or II adult patients undergoing FESS under general anesthesia were randomly allocated to three groups of 50 patients each. Group E received esmolol in a loading and maintenance dose of 1 mg/kg over 1 min and 0.5-1.0 mg/kg/h, respectively. Group D received a loading dose of dexmedetomidine 1 µg/kg over 10 min followed by an infusion 0.5-1.0 µg/kg/h, and group N received nitroglycerine infusion at a dose of 0.5-2 µg/kg/min so as to maintain mean arterial pressure (MAP) between 60 and 70 mmHg in all the groups. The visibility of the surgical field was assessed by surgeon using Fromme and Boezaart scoring system. Hemodynamic variables, total intra-operative fentanyl consumption, emergence time and time to first analgesic request were recorded. Any side-effects were noted. The postoperative sedation was assessed using Ramsay Sedation Score. RESULT: The desired MAP (60-70 mmHg) could be achieved in all the three study groups albeit with titration of study drugs during intra-operative period. No significant intergroup difference was observed in Fromme's score during the intra-operative period. The mean total dose of fentanyl (µg/kg) used was found to be significantly lower in group D compared to groups E and N (1.2 ± 0.75 vs. 3.6 ± 1.3 and 2.9 ± 1.1 respectively). The mean heart rate was significantly lower in group D compared to groups E and N at all times of measurement (P < 0.05). The MAP was found to be significantly lower in group D compared to groups E and N after infusion of study drugs, after induction, just after intubation and 5 min after intubation (P < 0.05). The Ramsay Sedation Scores were significantly higher in group D (score 3 in 46%) when compared to group E (score 2 in 50%) and group N (score 2 in 54%) (P < 0.001). The emergence time was significantly lower in group E and group N compared to group D. Time to first analgesic request was significantly longer in group D. CONCLUSION: Dexmedetomidine and esmolol provided better hemodynamic stability and operative field visibility compared to nitroglycerin during FESS. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.

Nasocardiac reflex during aspiration and injection through a nasogastric tube: An infrequent occurrence.

Nasocardiac reflex is a relatively less discussed variant of trigeminovagal reflex where the afferent arc of the reflex is represented by any of the branches of the trigeminal nerves, and the efferent arc is via the vagus nerve. Elicitation of this reflex is commonly seen during surgical manipulation and is manifested as bradycardia or even asystole. We report a case where nasocardiac reflex was unusually observed in a patient when aspiration and injection were done through a nasogastric tube.

Basics, common errors and essentials of statistical tools and techniques in anesthesiology research.

The statistical portion is a vital component of any research study. The research methodology and the application of statistical tools and techniques have evolved over the years and have significantly helped the research activities throughout the globe. The results and inferences are not accurately possible without proper validation with various statistical tools and tests. The evidencebased anesthesia research and practice has to incorporate statistical tools in the methodology right from the planning stage of the study itself. Though the medical fraternity is well acquainted with the significance of statistics in research, there is a lack of in-depth knowledge about the various statistical concepts and principles among majority of the researchers. The clinical impact and consequences can be serious as the incorrect analysis, conclusions, and false results may construct an artificial platform on which future research activities are replicated. The present tutorial is an attempt to make anesthesiologists aware of the various aspects of statistical methods used in evidence-based research and also to highlight the common areas where maximum number of statistical errors are committed so as to adopt better statistical practices.

Interdisciplinary position statement on management of hyperglycemia in peri-operative and intensive care.

Hospitalized patients with diabetes pose numerous clinical challenges, including hyperglycemia, which may often be difficult to control. The therapeutic challenges are further accentuated by the difficulty in practical application of existing guidelines among Indian and South Asian patients. The present review highlights the various clinical challenges encountered during management of different diabetic hospitalized populations, and attempts to collate a set of practical, patient and physician friendly recommendations to manage hyperglycemia in such patients.

Intravenous insulin use: technical aspects and caveats.

Insulin has been in use for nearly a century, but its real clinical worth has been utilized only in the last one and half decade after the landmark study on tight glycaemic control by van Den Berghe. Intravenous (i.v.) insulin is the mainstay of treatment for hyperglycaemia in many acute settings as well as in managing diabetic complications. However, i.v. insulin usage may be associated with numerous potential errors which may have unintended consequences. A thorough knowledge of various aspects associated with insulin injection techniques such as preparations of i.v. insulin, calculation of correct dosage, precautions while using insulin with various i.v. fluids, formulating strategies to minimize insulin adsorption to tubing surface, choosing appropriate insulin injection accessories and devices, can help in optimal control of hyperglycaemia with minimal errors. Improvisation of insulin injection techniques is often necessary in resource challenged settings to minimize the morbidity and mortality associated with uncontrolled hyperglycaemia.

Clinical profile of levobupivacaine in regional anesthesia: A systematic review.

The quest for searching newer and safer anesthetic agents has always been one of the primary needs in anesthesiology practice. Levobupivacaine, the pure S (-)-enantiomer of bupivacaine, has strongly emerged as a safer alternative for regional anesthesia than its racemic sibling, bupivacaine. Levobupivacaine has been found to be equally efficacious as bupivacaine, but with a superior pharmacokinetic profile. Clinically, levobupivacaine has been observed to be well-tolerated in regional anesthesia techniques both after bolus administration and continuous post-operative infusion. The incidence of adverse drug reactions (ADRs) is rare when it is administered correctly. Most ADRs are related to faulty administration technique (resulting in systemic exposure) or pharmacological effects of anesthesia; however, allergic reactions can also occur rarely. The available literary evidence in anesthesia practice indicates that levobupivacaine and bupivacaine produce comparable surgical sensory block, similar adverse side effects and provision of similar labor analgesia with good comparable maternal and fetal outcome. The present review aims to discuss the pharmacokinetic and pharmacological essentials of the safer profile of levobupivacaine as well as to discuss the scope and indications of levobupivacaine based on current clinical evidence.

Recent advancements in total intravenous anaesthesia and anaesthetic pharmacology.

Target-controlled infusion pumps and depth of anaesthesia monitors have made total intravenous anaesthesia (TIVA) easy, safe, and precise. The merits of TIVA were highlighted during the coronavirus disease 2019 (COVID-19) pandemic, confirming its potential further in the post-COVID clinical practice as well. Ciprofol and remimazolam are newer drugs that are being tried with a hope to upgrade the practice of TIVA. While research on safe and effective drugs continues, TIVA is being practised with a combination of drugs and adjuncts to overcome the disadvantages of each and to provide complete and balanced anaesthesia with additional benefits in recovery and pain relief postoperatively. Modulation of TIVA for the special population groups is still under process. Advancement in digital technology with mobile apps has increased the scope of TIVA in day-to-day use. The formulation and update of guidelines can establish a safe and efficient practice of TIVA.

Recent advances in research, training and teaching in anaesthesia and critical care.

Teaching and learning in anaesthesia and critical care has traditionally included seminars, journal clubs and clinical teaching in the operation theatre. The aim has always been to ignite the spark of thinking and self-directed learning in the students. The process of 'dissertation preparation' introduces basic knowledge and interest in research in the postgraduate student. All this is followed by an examination at the end of the course including the theory and practical assessment in the form of long and short case discussions and table viva-voce. The National Medical Commission in 2019 introduced the competency-based medical education curriculum for anaesthesia postgraduates. This curriculum focuses on structured teaching and learning. It has specific learning objectives in theoretical knowledge, skills and attitude development. The building up of communication skills has been given due importance. Though research in anaesthesia and critical care is steadily progressing, much work needs to be done on its improvement.

A novel approach in understanding the basic modes of ventilation in a recent generation mechanical ventilator- A review of the underlying principles.

Understanding the basic concepts and the dynamics of the equation of motion will help the anaesthesiologist and the intensive care physician in gaining an insight into the basics of modern mechanical ventilation. An equation of the type Vt = V0 × (1-e-kt) is often encountered while studying the concepts of mechanical ventilation. This leaves one wondering about the meaning of 'e'. It is explained as the base of a natural logarithm, and the base e as an irrational constant approximately equal to 2. 7182. In medical literature, various physiological mechanisms are explained by using the exponential function e. However, the explanations do not sufficiently help the learner to demystify the enigmatic term e. In this article, an effort is made to explain this function with the help of simple analogies and relevant mathematical concepts. The process of volume build-up in the lungs during mechanical ventilation is used as a model for the explanations.

Use of Articaine in loco-regional anesthesia for day care surgical procedures.

The popularity of day case surgical procedures has increased immensely over the last few years. Though various techniques are available for carrying out day-case anesthesia, preference for a technique depends upon the type of procedure, patient profile, associated co-morbidities, available infrastructure and back-up facilities, monitoring devices and comfort of the attending anesthesiologist with the technique. Day-case spinal anesthesia for ambulatory surgery has gained a wider acceptance and numerous drugs are available for use in loco-regional anesthesia. Articaine is one such amide local anesthetic drug which is increasingly being used in day care surgeries. Properties of articaine such as faster onset, shorter elimination time and rapid recovery from sensory and motor blockade make it a very useful agent in local and regional anesthesia for day care surgical procedures. This article aims to review these properties of articaine so as to evaluate how useful articaine can be for ambulatory surgical procedures.

Breaking barriers to remain healthy and fit during a residency in anaesthesiology.

Anaesthesiology is a high-demand speciality of medicine in terms of long and unpredictable work hours, stressful work requirements, pressure for a cent per cent productivity in academics, clinical work and research. Higher stress levels can cause non-communicable diseases like hypertension, obesity and depressed immunity, among many others. In the journey as a trainee anaesthetist, vigorous and diligent efforts are needed to gain perfection in knowledge and skills ultimately. While this path is being transversed, it is essential to address physical and mental fitness by exercising it to the recommended benefits, to ward away stress and burnout. In this special article, the authors will discuss the barriers young anaesthesia trainees face to staying healthy and fit during their training and practical and appropriate measures to mitigate the same through intervention at various levels of hierarchy.

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.

Emergency medicine - A great career field for the anaesthesiologist!

Emergency Medicine (EM) is a fast upcoming medical speciality wherein patients presenting with emergent life-saving medical and surgical problems are managed. Emergency physicians are first-line providers of emergency care. They diagnose important clinical conditions even before completing patient assessment, order investigations, interventions, resuscitation and treatment for life-threatening acute conditions. There are several interesting sub-specialisations of EM like trauma care, disaster medicine, toxicology, ultrasonography, critical care medicine, hyperbaric medicine, etc. In some countries, the speciality of EM is a popular choice among medical students; whereas in some other countries, the speciality is now evolving. In India, the speciality is growing fast; Nonetheless, the National Medical Commission has made the existence of the department of EM compulsory in all medical colleges in India from the session of 2022-23. Anaesthesiologists suit the speciality of EM because they have quick decision making skills and swift reflexes as well as diverse knowledge and skills in the fields of critical care, resuscitation and pain management. This article written by anaesthesiologists working in the field of EM, attempts to guide the postgraduate students wanting to take up a career in EM.

Private practice in anaesthesia: A comprehensive analysis.

The idea of a 'private practising anaesthesiologist'is generally that of a busy practitioner running from case to case, from one nursing home to the other, at all times of the day and night with no time for academics, teaching and family life.But is that really so? Is taking up a career in private practice going to be so full of hardships?There are several advantages of choosing private practice in anaesthesia. To survive in private practice, you need to be very confident in your work, skilful, punctual and good in communication. You can be your own master as a private practitioner. Private practice in anaesthesia is both challenging and interesting. This article, written by private practitioners in anaesthesia who have gone through the exciting and mundane phases of private practice examines the pro and cons of private practice; this can possibly help postgraduate students contemplating to take up private practice as a career.

Point-of-Care Ultrasound (POCUS) for the assessment of volume status and fluid management in patients with severe pre-eclampsia: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Appropriate volume assessment and fluid management can prevent maternal deaths in the severely pre-eclamptic (SPE) parturients. We planned a systematic review and meta-analysis (MA) to evaluate the role and ability of point-of-care ultrasound (POCUS) in the assessment of volume status and early detection of lung oedema in an SPE parturient. METHODS: An e-literature search was done from several databases. Data were extracted under five domains including POCUS-derived parameters like echo comet score (ECS), lung ultrasound (LUS) scores, B-patterns, optic nerve sheath diameter (ONSD), E/e' ratio, presence of pleural effusion, pulmonary interstitial syndrome and pulmonary congestion. The risk of bias was assessed. Extracted data were analysed using MetaXL and Revman 5.3. Heterogeneity in the studies was evaluated using the Cochrane Q test and I2 statistics. Funnel plots were used for the assessment of publication bias. RESULTS: Seven prospective studies including 574 parturients (including 396 pre-eclamptics) were selected. POCUS included lung, optic nerve, cardiac and thoracic US. In two studies, the ECS and LUS scores pre-delivery were higher in pre-eclamptics. Two studies found a mean ONSD of 5-5.84 mm before delivery. MA revealed a significantly lower mean ECS score at post-delivery than pre-delivery, and the summary prevalence of B-pattern and pleural effusion among SPE parturients was found to be 0.28 (0.03-0.84) and 0.1 (0-0.2), respectively. A good correlation was observed between B-line patterns and diastolic dysfunction (increased E/e' ratio), LUS score and thoracic fluid content, ONSD and ECS in individual studies. CONCLUSION: POCUS parameters can be useful as early markers of fluid status and serve as useful tools in the precise clinical management of pre-eclampsia.

Telemedicine for chronic pain management during COVID-19 pandemic.

Treatment of chronic pain is an essential service. Due to lockdown, travel restrictions, social and physical distancing requirements or fear that health care facilities may be infected; patients may avoid visiting health care facilities in person. It is also imperative to decrease the risk of exposure of the health care workers (HCWs) to severe acute respiratory syndrome corona virus 2 (SARS CoV2) and to ease the overtly burdened health care system. But any disruption in pain practice will have alarming consequences for individuals, society, and whole of health care system and providers. In the current scenario of COVID-19 pandemic, telemedicine is emerging as a key technology for efficient communication and sustainable solution to provide essential health care services and should be considered for chronic pain patients (CPPs). Recently, Board of Governors in supersession of Medical Council of India along with National Institution for Transforming India (NITI Aayog) released "Telemedicine Practice Guidelines" enabling registered medical practitioners to provide healthcare using telemedicine. This article describes the challenges in CPPs during COVID-19 pandemic and the use of telemedicine as the rescue management vehicle for CPPs in current scenario.