Ultrasound-guided pericapsular nerve group (PENG) block versus femoral nerve block for positioning during spinal anaesthesia in proximal femur fractures: A randomised comparative study.

Background and Aims: Femoral nerve block is a widely used analgesia technique for positioning before spinal anaesthesia for proximal femur fracture surgeries. Pericapsular nerve group (PENG) block is a newer technique with motor-sparing characteristics. We compared the analgesic efficacy of these blocks for patient positioning for spinal anaesthesia. Methods: In this study, 60 patients were randomised to either the PENG group (n = 30) or the femoral group (n = 30). After performing the block, the pain was assessed every 10 min using a visual analogue scale (VAS) score for 30 min. The primary objective was the median [interquartile range (IQR)] reduction in pain (dynamic VAS with 15-degree passive limb elevation) at 30 min. Secondary objectives were ease of spinal position score (EOSP), angle obtained during positioning, duration of postoperative analgesia and quadriceps weakness. Results: The demographics were comparable in both groups. After 30 min, the median (IQR) VAS was 6 (5-7) in the PENG group and 5 (5-6) in the femoral group (P = 0.004). Secondary outcomes such as EOSP score and angle obtained by patients were comparable. In the postoperative period, patients had significantly lower pain in the PENG group compared to the femoral group. The duration of analgesia was prolonged with PENG block. Quadriceps weakness was significantly low with PENG block (P < 0.001). Conclusion: PENG block provides better analgesia than a femoral block before spinal anaesthesia for proximal femur fracture surgery. The postoperative duration of analgesia was also longer.

Preparing future Indian medical graduates for emergencies at the Foundation Course: Do the knowledge and self-confidence increase after basic cardiac life support training?

Background and Aims: Medical professionals must be able to perform life-saving skills like cardiopulmonary resuscitation (CPR) during emergency situations, even outside the hospital. The foundation course for the first-year medical students includes first aid and CPR training. This quasi-experimental study was conducted to assess the effectiveness of basic cardiac life support (BCLS) training based on Indian guidelines, on the self-confidence and knowledge regarding CPR of first-year medical students. Methods: This study was conducted during the foundation course for first-year medical students. The training included a common lecture for all the students followed by a 4 day long practical training in groups of 45-46 students, each day. BCLS training was carried out in three skill stations - airway, chest compressions and full sequence CPR. Students' skills were recorded real time on a skill assessment manikin after completion of the hands-on training. The students were asked to fill a questionnaire regarding knowledge and self-confidence, before and after the training. The outcome measures were the difference in knowledge and self-confidence with regard to CPR before and after the training. Results: Out of the 199 students, 181 were included in the analysis. There was significant improvement in the knowledge score (pre-test - 1.46 versus post-test - 8.27, P < 0.001). The overall confidence regarding first aid skills, BCLS knowledge and self-confidence for performing BCLS improved significantly. Conclusion: There is improvement in knowledge and self-confidence regarding CPR and the students develop an acceptable level of skills after the training.

Long-term outcomes of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia.

PURPOSE: We assessed long-term outcomes of dexamethasone 12 mg versus 6 mg given daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia. METHODS: We assessed 180-day mortality and health-related quality of life (HRQoL) using EuroQoL (EQ)-5D-5L index values and EQ visual analogue scale (VAS) in the international, stratified, blinded COVID STEROID 2 trial, which randomised 1000 adults with confirmed COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 26 hospitals in Europe and India. In the HRQoL analyses, higher values indicated better outcomes, and deceased patients were given a score of zero. RESULTS: We obtained vital status at 180 days for 963 of 982 patients (98.1%) in the intention-to-treat population, EQ-5D-5L index value data for 922 (93.9%) and EQ VAS data for 924 (94.1%). At 180 days, 164 of 486 patients (33.7%) had died in the 12 mg group versus 184 of 477 (38.6%) in the 6 mg group [adjusted risk difference - 4.3%; 99% confidence interval (CI) - 11.7-3.0; relative risk 0.89; 0.72-1.09; P = 0.13]. The adjusted mean differences between the 12 mg and the 6 mg groups in EQ-5D-5L index values were 0.06 (99% CI - 0.01 to 0.12; P = 0.10) and in EQ VAS scores 4 (- 3 to 10; P = 0.22). CONCLUSION: Among patients with COVID-19 and severe hypoxaemia, dexamethasone 12 mg compared with 6 mg did not result in statistically significant improvements in mortality or HRQoL at 180 days, but the results were most compatible with benefit from the higher dose.

Effect of 12 mg vs 6 mg of Dexamethasone on the Number of Days Alive Without Life Support in Adults With COVID-19 and Severe Hypoxemia: The COVID STEROID 2 Randomized Trial.

Importance: A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease. Objective: To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia. Design, Setting, and Participants: A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021. Interventions: Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days. Main Outcomes and Measures: The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and ≥1 serious adverse reactions at 28 days). Results: Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29]). Conclusions and Relevance: Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference. Trial Registration: ClinicalTrials.gov Identifier: NCT04509973 and ctri.nic.in Identifier: CTRI/2020/10/028731.

Critically ill obstetric patients requiring mechanical ventilation in rural western India: A retrospective analysis.

BACKGROUND: There is a dearth of studies on the clinical profile and therapeutic aspects of critically ill obstetric patients from rural areas, especially those requiring tertiary care support and ventilator therapy. METHODS: We retrospectively analysed the aetiological, clinical, interventional and outcome-related factors of obstetric patients requiring mechanical ventilation in western India. We analysed factors that influence seeking of antenatal care, pregnancy and its complications, severity assessment score, indications and initiation of mechanical ventilation, multiorgan failure and their correlation with maternal mortality. RESULTS: Of the 6708 obstetric admissions studied, 1112 were of critically ill (16.5%) patients and 200 (17%) of these required mechanical ventilation. Over three-fourths (77%) of patients were from rural areas, 83.5% were referred and 97% had inadequate antenatal care. Severe pregnancy-induced hypertension/eclampsia, massive haemorrhage and sepsis were the common obstetric complications. Pulmonary oedema (32.5%), acute respiratory distress syndrome (ARDS, 14%) and acute lung injury (22.5%) were the three most common indications for mechanical ventilation. In 26% of patients, mechanical ventilation was initiated early based on a worsening cardiorespiratory profile. A sequential organ failure assessment score of >5 on admission and delay in treatment resulted in multi-organ failure and worsening outcome. The maternal mortality ratio was 32.5%, incidence of multi-organ dysfunction syndrome was 71%, and pregnancy loss was 43.5%. The odds ratio for maternal mortality in patients ventilated early was 0.39 as against 5 in those with ARDS. CONCLUSIONS: Inadequate antenatal care, delayed referral practices, pregnancy-induced hypertension, obstetric haemorrhage and sepsis remain the major causes of complications in obstetric patients from rural areas. The common indications for mechanical ventilation were pulmonary oedema, ARDS and acute lung injury. Early initiation of mechanical ventilation upon detection of imminent.

Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care.

Therapeutic transfusion techniques such as apheresis and phlebotomy are frequently used in intensive care units. Use of the apheresis technique for the treatment of various diseases in critically ill patients is growing day by day. There are increasing evidences for using apheresis as a primary therapy or as an adjunct to other therapies for various diseases such as thrombotic thrombocytopenic purpura, haemolytic uremic syndrome, drug toxicities, autoimmune disease, sepsis and fulminant hepatic failure. Apheresis is an invasive procedure. It has significant physiologic consequences, so the care of these patients requires continuous supervision. Phlebotomy is performed as an intervention for some disease management. Its use is nowadays restricted to conditions such as polycythaemia, haemochromatosis and porphyria cutanea tarda. In this review, we have looked at various indications, procedure and complications of apheresis and phlebotomy in critical care unit.

Evaluation of ultrasound for central venous access in ICU by an in experienced trainee.

BACKGROUND AND AIMS: Central venous catheter placement is an important procedure for ICU (Intensive Care Unit) patients. We studied the usefulness of ultrasonography for placement of central venous catheter by in-experienced anesthetists. MATERIALS AND METHODS: A prospective observational study of 32 patients requiring central venous access (CVA) in surgical ICU (SICU). Data collected were patient's demographics, indication, type of catheter, success rate, attempts, complication rate and access time were recorded and compared with other studies. RESULT: The overall success rate was 89.5% in the IJV (Internal Jugular Vein) and 92.3% for SCV (Subclavian Vein) group. The success rates for insertion at first, second, and third attempt were 52.6%, 31.6%, and 5.2% for IJV and 46.2% and 53.8% for SCV. Average number of attempts made for IJV cannulation was 1.74 +/- 1.04 and 1.54 +/- 0.51 for SCV. The total time taken for IJV access was 858.78 +/- 381.9 sec, whereas in the SCV group, it was 984 +/- 328.98 seconds. In our study, overall rate of complication was 21.05% (4/19 patients) for IJV and 23.07% (3/13 patients) for SCV insertion. Incidence of various complications like arterial puncture, misplacement of CVC, hematoma, pneumothorax, and hemothorax were also noted. CONCLUSION: This study concludes that real time ultrasound guidance during IJV and SCV cannulation can achieve higher success rate, fewer complications, number of attempts, and failure rate among inexperienced anesthetists.

Educational intervention to improve death certification at a teaching hospital.

BACKGROUND: Information recorded in the 'cause of death' section of death certificates is an important source of mortality statistics. It is used for policy decisions, development of healthcare programmes and health research. Errors in death certificates can lead to inappropriate allocation of resources. Errors are universal and have been reported previously. We planned an educational intervention aimed at resident doctors from various specialties at our teaching hospital to improve the accuracy of the 'cause of death' section in death certificates. METHODS: Three workshops, each of 90 minutes, were conducted for residents. A total of 198 death certificates (96 before and 102 after intervention) were audited. We compared the frequency of major and minor errors before and after the educational Intervention. RESULTS: Following the educational intervention, there was a significant decrease in major errors such as unacceptable underlying cause of death (39.6% v. 24.5%, p = 0.034), reporting of mechanism without underlying cause of death (13.5% v. 1%, p = 0.001) and improper sequencing of events (25% v. 6%, p = 0.004). There was no significant decrease in minor errors such as absence of time intervals, use of abbreviations and reporting a mechanism with a legitimate cause. CONCLUSION: Both major and minor errors are common in death certification at teaching hospitals. Educational interventions can improve the accuracy of reporting in death certificates.

Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced by iv fentanyl.

PURPOSE: Fentanyl, a synthetic opioid, is a popular choice amongst anesthesiologists in the operating room. Preinduction iv fentanyl bolus is associated with coughing in 28-45% of patients. Coughing due to fentanyl is not always benign and at times may be explosive requiring immediate intervention. We have studied the role of aerosol inhalation of salbutamol, beclomethasone and sodium chromoglycate in preventing fentanyl induced coughing and have compared their efficacy. METHODS: Two hundred patients aged 18-60 yr, undergoing elective laparoscopic cholecystectomy were randomized into four groups of 50 each. Group I served as control, while Groups II, III and IV received an aerosol inhalation of salbutamol, beclomethasone or sodium chromoglycate 15 min prior to entering the operating room. Following iv fentanyl (2 micro g x kg(-1)) the incidence of cough was recorded and graded as mild (1-2), moderate (3-5) and severe (> 5) depending on the number of coughs observed. Results were analyzed using 'z' and Fischer's Exact test. A P value of < or = 0.05 was considered significant. RESULTS: The incidence of cough was 28% in the control group, 6%, 0% and 4% in the salbutamol, beclomethasone and sodium chromoglycate groups respectively. Occurrence of cough was significantly low (P < or = 0.05) in the treatment groups, however the difference amongst the groups was not significant (P >/= 0.05). CONCLUSION: The use of salbutamol, beclomethasone or sodium chromoglycate aerosol 15 min prior to iv fentanyl administration minimizes fentanyl-induced coughing.

Gabapentin for the treatment of pain in guillain-barré syndrome: a double-blinded, placebo-controlled, crossover study.

UNLABELLED: Pain syndromes of Guillain-Barré are neuropathic as well as nociceptive in origin. We aimed to evaluate the therapeutic efficacy of gabapentin in relieving the bimodal nature of pain in Guillain-Barré syndrome in a randomized, double-blinded, placebo-controlled, crossover study in 18 patients admitted to the intensive care unit for ventilatory support. Patients were assigned to receive either gabapentin (15 mg. kg(-1). d(-1) in 3 divided doses) or matching placebo as initial medication for 7 days. After a 2-day washout period, those who previously received gabapentin received placebo, and those previously receiving placebo received gabapentin as in the initial phase. Fentanyl 2 micro g/kg was used as a rescue analgesic on patient demand or when the pain score was >5 on a numeric rating scale of 0-10. The numeric rating score, sedation score, consumption of fentanyl, and adverse effects were noted, and these observed variables were compared. The numeric pain score decreased from 7.22 +/- 0.83 to 2.33 +/- 1.67 on the second day after initiation of gabapentin therapy and remained low during the period of gabapentin therapy (2.06 +/- 0.63) (P < 0.001). There was a significant decrease in the need for fentanyl from Day 1 to Day 7 during the gabapentin therapy period (211.11 +/- 21.39 to 65.53 +/- 16.17 [ micro g]) in comparison to the placebo therapy period (319.44 +/- 25.08 to 316.67 +/- 24.25 [ micro g]) (P < 0.001). IMPLICATIONS: Gabapentin, an antiepileptic drug, has been used effectively for different types of pain management. This study demonstrates that gabapentin has minimal side effects and is an alternative to opioids and nonsteroidal antiinflammatory drugs for management of the bimodal nature of pain of Guillain-Barré Syndrome patients.

Bronchobiliary fistula: an anaesthetic point of view.

Bronchobiliary fistula is defined as the passage of bile in the bronchi and in the sputum (bilioptysis). This rare disorder is associated with significant morbidity. Authors review the anaesthetic management of bronchobiliary fistula and recommend the use of double lumen endotracheal tube even in cases with a closed/sealed bronchobiliary fistula.

Acupressure and ondansetron for postoperative nausea and vomiting after laparoscopic cholecystectomy.

PURPOSE: To compare the efficacy of acupressure wrist bands and ondansetron for the prevention of postoperative nausea and vomiting (PONV). METHODS: One hundred and fifty ASA I-II, patients undergoing elective laparoscopic cholecystectomy were included in a randomized, prospective, double-blind and placebo-controlled study. Patients were divided into three groups of 50. Group I was the control; Group II received ondansetron 4 mg iv just prior to induction of anesthesia; in Group III acupressure wristbands were applied at the P6 points. Acupressure wrist bands were placed inappropriately in Groups I and II. The acupressure wrist bands were applied 30 min prior to induction of anesthesia and removed six hours following surgery. Anesthesia was standardized. PONV were evaluated separately as none, mild, moderate or severe within six hours of patients' arrival in the postanesthesia care unit and then at 24 hr after surgery by a blinded observer. If patients vomited more than once, they were given 4 mg ondansetron iv as the rescue antiemetic. Results were analyzed by Z test. A P value of < 0.05 was taken as significant. RESULTS: The incidence of PONV and the requirement of rescue medication were significantly lower in both the acupressure and ondansetron groups during the first six hours. CONCLUSION: Acupressure at P6 causes a significant reduction in the incidence of PONV and the requirement for rescue medication in the first six hours following laparoscopic cholecystectomy, similar to that of ondansetron 4 mg iv.

Tuberculous brain abscess: clinical presentation, pathophysiology and treatment (in children).

BACKGROUND: Tubercular brain abscess (TBA) is a rare manifestation of CNS tuberculosis. It is characterised by an encapsulated collection of pus, containing viable tubercular bacilli without evidence of tubercular granuloma. PRESENTATION AND HISTORY: Patients may present with features of raised intracranial pressure and focal neurological deficit commensurate with the site of the abscess. A history of pulmonary tuberculosis may be present, as documented in one of our six cases; three of our six children developed TBA despite 3-weeks to 12-month courses of antitubercular chemotherapy prescribed for post-TBM hydrocephalus. DIAGNOSIS: Contrast CT head, MRI, MR spectroscopy is helpful in making the diagnosis and planning the treatment. TBA may be unilocular or multilocular on contrast CT scan. A relatively long clinical history and an enhancing capsule with thick wall are suggestive of TBA. Pyogenic abscess, however, has a thin rim on contrast CT. The capsule of TBA is formed of vascular granulation tissue containing acute and chronic inflammatory cells, particularly polymorphs. Proof of tubercular origin must be demonstrated either by presence of acid fast bacilli in culture or staining of pus or wall. TREATMENT: Treatment options include simple puncture, continuous drainage, fractional drainage, repeated aspiration through a burr hole, stereotactic aspiration and total excision of the abscess. Total excision usually becomes necessary in multilocular noncommunicating and thick-walled abscesses. Antitubercular therapy is the mainstay of management. The development of fulminant tubercular meningitis is sometimes problematic following surgical excision of TBA, as seen in one of our four operated cases. Mortality is reported to be high despite progress in treatment, while five of the six children treated by us responded well to the treatment.

Perioperative management of a patient presenting with a spontaneously ruptured esophagus.

PURPOSE: To report a case of spontaneous rupture of the esophagus and its anesthetic management. CLINICAL FEATURES: A 52-yr-old male presented with a seven day history of chest pain, respiratory distress, and swelling in the neck following forceful vomiting. Examination revealed hypotension, decreased air entry in the right lower lung field with crepitations, epigastric tenderness with abdominal distension and guarding of both right and left hypochondria. A contrast esophagogram showed extravasation of contrast material from the lower third of the esophagus into the mediastinum without pleural cavity involvement. Reinforced primary closure of a 5-cm transmural tear in the right anterolateral wall of the esophagus 5 cm above the gastro-esophageal junction was performed along with right-sided chest drainage. The anesthetic drugs and technique in this case were selected to avoid any increase in intra-abdominal pressure to prevent further spillage of gastric contents into the mediastinum through the perforation. Invasive monitoring was used to assess early hemodynamic changes and to administer fluid therapy and vasoactive drugs. Due to prolonged surgery, lung congestion, large fluid shifts, a long surgical incision and abnormal arterial blood gases, the patient was ventilated mechanically in the intensive care unit. Subsequently he developed an esophageal leak, septic shock, and multiple organ failure and died. CONCLUSION: In a patient with a spontaneous rupture of esophagus, the anesthetic considerations include avoidance of further aggravation of the esophageal tear, and resuscitation from a morbid inflammatory condition.