Coadministration of intravenous calcium along with neostigmine for rapid neuromuscular blockade recovery: A systematic review and meta-analysis.

Postoperative residual curarization (PORC) and the impact of the coadministration of intravenous calcium along with an acetylcholinesterase inhibitor on it are not well addressed. Extensive electronic database screening was done until October 7, 2022 after enlisting the protocol of this systematic review in PROSPERO (CRD42021274879). Randomized controlled trials (RCTs) evaluating the impact of intravenous calcium and neostigmine coadministration on neuromuscular recovery were included in this meta-analysis. Our search retrieved four RCTs with a total of 266 patients. The application of calcium shortened the neuromuscular recovery time (SMD = -2.13, 95% confidence interval [CI]: -2.66 to -1.59, I2 = 66%) and reduced the risk of PORC at 5 min (odds ratio [OR] = 0.21, 95% CI: 0.10-0.46, I2 = 0%), with an improved train-of-four (TOF) ratio at 5 min (mean difference [MD] = 9.28, 95% CI: 4-14.57, I2 = 66%). However, neither significant reduction in PORC at 10 min (OR = 0.41, 95% CI: 0.15-1.09, I2 = 0%) nor a better TOF ratio was associated with coadministration of calcium (MD = 0.40, 95% CI: -1.3-2.11). Coadministration of calcium along with neostigmine during the early period of neuromuscular blockade reversal can be used to enhance neuromuscular recovery.

Is EIT-guided positive end-expiratory pressure titration for optimizing PEEP in ARDS the white elephant in the room? A systematic review with meta-analysis and trial sequential analysis.

Electrical Impedance Tomography (EIT) is a novel real-time lung imaging technology for personalized ventilation adjustments, indicating promising results in animals and humans. The present study aimed to assess its clinical utility for improved ventilation and oxygenation compared to traditional protocols. Comprehensive electronic database screening was done until 30th November, 2023. Randomized controlled trials, controlled clinical trials, comparative cohort studies, and assessments of EIT-guided PEEP titration and conventional methods in adult ARDS patients regarding outcome, ventilatory parameters, and P/F ratio were included. Our search retrieved five controlled cohort studies and two RCTs with 515 patients and overall reduced risk of mortality [RR = 0.68; 95% CI: 0.49 to 0.95; I2 = 0%], better dynamic compliance [MD = 3.46; 95% CI: 1.59 to 5.34; I2 = 0%] with no significant difference in PaO2/FiO2 ratio [MD = 6.5; 95%CI -13.86 to 26.76; I2 = 74%]. The required information size except PaO2/FiO2 was achieved for a power of 95% based on the 50% reduction in risk of mortality, 10% improved compliance as the cumulative Z-score of the said outcomes crossed the alpha spending boundary and did not dip below the inner wedge of futility. EIT-guided individualized PEEP titration is a novel modality; further well-designed studies are needed to substantiate its utility.

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis.

Background: Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India. Methods: We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population. Results: We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%). Conclusions: Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Real-World Outcomes for the Fifth-Generation Balloon Expandable Transcatheter Heart Valve in the United States.

BACKGROUND: The fifth-generation SAPIEN 3 Ultra Resilia valve (S3UR) incorporates several design changes as compared with its predecessors, the SAPIEN 3 (S3) and SAPIEN 3 Ultra (S3U) valves, including bovine leaflets treated with a novel process intended to reduce structural valve deterioration via calcification, as well as a taller external skirt on the 29-mm valve size to reduce paravalvular leak (PVL). The clinical performance of S3UR compared with S3 and S3U in a large patient population has not been previously reported. OBJECTIVES: The aim of this study was to compare S3UR to S3/S3U for procedural, in-hospital, and 30-day clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR). METHODS: Patients enrolled in the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) Registry between January 1, 2021, and June 30, 2023, who underwent TAVR with S3UR or S3U/S3 valve platforms were propensity-matched and evaluated for procedural, in-hospital, and 30-day clinical and echocardiographic outcomes. RESULTS: 10,314 S3UR patients were propensity matched with 10,314 patients among 150,539 S3U/S3 patients. At 30 days, there were no statistically significant differences in death, stroke, or bleeding, but a numerically higher hospital readmission rate in the S3UR cohort (8.5% vs 7.7%; P = 0.04). At discharge, S3UR patients exhibited significantly lower mean gradients (9.2 ± 4.6 mm Hg vs 12.0 ± 5.7 mm Hg; P < 0.0001) and larger aortic valve area (2.1 ± 0.7 cm2 vs 1.9 ± 0.6 cm2; P < 0.0001) than patients treated with S3/S3U. The 29-mm valve size exhibited significant reduction in mild PVL (5.3% vs 9.4%; P < 0.0001). CONCLUSIONS: S3UR TAVR is associated with lower mean gradients and lower rates of PVL than earlier generations of balloon expandable transcatheter heart valve platforms.

Intraoperative Regional Cerebral Oxygenation During Pediatric Thoracoscopic Surgery: A Systematic Review.

Background: Ventilating a pediatric patient during thoracoscopy is challenging. Few studies have highlighted the impact of capnothorax in children by measuring regional cerebral oxygen saturation (rcSO2) with near infrared spectroscopy. In this systematic review, we aimed to summarize the data from relevant studies and assess whether thoracoscopy in children is associated with intraoperative pathological cerebral desaturation. Methods: The authors systematically searched four databases for relevant studies on the measurement of rcSO2 during pediatric thoracoscopic procedures. The primary outcome was the proportion of patients with pathological desaturation, that is, >20% decline in the intraoperative rcSO2. Risk of bias among the included studies was estimated using the Newcastle-Ottawa scale. Results: The systematic search resulted in 776 articles, of which 7 studies were included in the analysis. In total, 88 patients (99 procedures) with an age ranging from 0 days to 8.1 years were included. Of these, 43 (49%) patients were neonates. The included cohort had esophageal atresia and tracheoesophageal fistula (n = 26), long-gap esophageal atresia (n = 5), congenital diaphragmatic hernia (n = 14), and congenital pulmonary airway malformations and other conditions needing lung resection (n = 43). Of the total 99 procedures, pathological desaturation was noticed in 13 (13.1%, 95% confidence interval 7.2-21.4) of them. Upon quality assessment, most of the studies were weaker in the selection and comparability domains. Conclusion: In this review, pathological cerebral desaturation was noticed in 13.1% of the pediatric thoracoscopic procedures. However, due to limited methodological quality of the included studies, further randomized multicentric studies comparing rcSO2 in open versus thoracoscopic surgeries are needed to derive definitive conclusions.

Early Doffing among Frontline Healthcare Workers Working in the COVID Areas in Resource-Limited Settings: Lessons Learned and Interventions Taken.

Background: In the fight against the pandemic, personal protective equipment (PPE) has played a vital role. However, working with PPE has its own difficulties and problems. The aim of this study was to find out the reasons of early doffing, that is, in doffing in emergency situations before the shift among healthcare workers (HCWs) working in PPE in the COVID areas in resource-limited settings. Methods: This cross-sectional, survey-based study was carried out on healthcare workers involved in direct care of patients with COVID-19 in tertiary care COVID center, India. The questionnaire was sent as a Google form through email and social media platforms like WhatsApp and Facebook. The data was reported as the mean ± SD for continuous variables and as the percentage for categorical variables. Findings: Among 252 healthcare workers who participated in the survey, 145 (57.5%) participants doffed early on 300 occasions. Out of these 145, 50% doffed early only once and rest doffed early multiple times. The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%), and most commonly, breach was in mask or coverall/gown (32.6% each). Conclusion: Although PPE decreases the risk of infection, it is challenging for HCWs to work in PPE leading to instances of early doffing. The most common reason for early doffing in our study was the breach in PPE and the most common component of breach was found to be mask and coverall/gown. Therefore, we suggest that the proper sizes of the PPE should be made available and proper training in donning should be imparted to HCWs working in PPE.

Polygenic Risk Score for Cardiovascular Diseases in Artificial Intelligence Paradigm: A Review.

Cardiovascular disease (CVD) related mortality and morbidity heavily strain society. The relationship between external risk factors and our genetics have not been well established. It is widely acknowledged that environmental influence and individual behaviours play a significant role in CVD vulnerability, leading to the development of polygenic risk scores (PRS). We employed the PRISMA search method to locate pertinent research and literature to extensively review artificial intelligence (AI)-based PRS models for CVD risk prediction. Furthermore, we analyzed and compared conventional vs. AI-based solutions for PRS. We summarized the recent advances in our understanding of the use of AI-based PRS for risk prediction of CVD. Our study proposes three hypotheses: i) Multiple genetic variations and risk factors can be incorporated into AI-based PRS to improve the accuracy of CVD risk predicting. ii) AI-based PRS for CVD circumvents the drawbacks of conventional PRS calculators by incorporating a larger variety of genetic and non-genetic components, allowing for more precise and individualised risk estimations. iii) Using AI approaches, it is possible to significantly reduce the dimensionality of huge genomic datasets, resulting in more accurate and effective disease risk prediction models. Our study highlighted that the AI-PRS model outperformed traditional PRS calculators in predicting CVD risk. Furthermore, using AI-based methods to calculate PRS may increase the precision of risk predictions for CVD and have significant ramifications for individualized prevention and treatment plans.

Comparative evaluation of isoflurane and desflurane for postoperative cognitive decline in elderly patients: A prospective observational pilot study.

BACKGROUND: Approximately 16%-62% of patients undergoing non cardiac surgeries develop postoperative cognitive dysfunction. We compared the incidence of postoperative cognitive dysfunction in older adults aged 60-80 years who underwent open abdominal surgeries under general anaesthesia using isoflurane or desflurane and correlated it with the serum concentration of interleukin 1, interleukin 6, tumour necrosis factor alpha, amyloid ß and S100 on postoperative day 3. METHOD: Forty American Association of Anesthesiologists Physical Classification I or II patients were included after acquiring institutional ethics committee approval, registering in the Clinical Trials Registry - India, and informed written consent. They underwent open abdominal surgery under general anaesthesia and epidurals between 2017 and 2019. Patients with substance abuse or any disorder affecting cognition were excluded. Postoperative cognitive dysfunction was assessed by Stroop test, Wisconsin Card Sorting Test, Trail making test - B, Porteus Maze test, PGI memory scale, mini-mental state examination, and Bender Gestalt test the day before surgery and on the third postoperative day along with blood samples. RESULTS: Thirty-seven percent of the patients developed postoperative cognitive dysfunction. The risk was similar to isoflurane in comparison with desflurane (risk ratio: 0.65, 95% confidence interval: 0.30, 1.40). A significant percentage increase in reaction time for Porteus Maze test and Trail making test - B was noted with isoflurane (6.69 (4.20-8.94) and 8.01 (2.08-12.5), respectively) in comparison with desflurane group (13.01 (9.09-17.33), p = 0.003 and 11.62 (7.5-17.5), p = 0.017, respectively). CONCLUSION: Isoflurane and desflurane had a similar impact on the elderly for developing postoperative cognitive dysfunction and no correlation with any of the biomarkers used in the study on postoperative day 3.

Functional near-infrared spectroscopy guided mapping of frontal cortex, a novel modality for assessing emergence delirium in children: A prospective observational study.

INTRODUCTION: Despite an 18%-30% prevalence, there is no consensus regarding pathogenesis of emergence delirium after anesthesia in children. Functional near-infrared spectroscopy (fNIRS) is an optical neuroimaging modality that relies on blood oxygen level-dependent response, translating to a mean increase in oxyhemoglobin and a decrease in deoxyhemoglobin. We aimed to correlate the emergence delirium in the postoperative period with the changes in the frontal cortex utilizing fNIRS reading primarily and also with blood glucose, serum electrolytes, and preoperative anxiety scores. METHODS: A total of 145 ASA I and II children aged 2-5 years, undergoing ocular examination under anesthesia, were recruited by recording the modified Yale Preoperative Anxiety Score after acquiring the Institute Ethics Committee approval and written informed parental consent. Induction and maintenance were done with O2, N2O, and Sevoflurane. The emergence delirium was assessed using the PAED score in the postoperative period. The frontal cortex fNIRS recordings were taken throughout anesthesia. RESULTS: A total of 59 children (40.7%) had emergence delirium. The ED+ group had a significant activation left superior frontal cortex (t = 2.26E+00; p = .02) and right middle frontal cortex (t = 2.27E+00; p = .02) during induction, significant depression in the left middle frontal (t = -2.22E+00; p = .02), left superior frontal and bilateral medial (t = -3.01E+00; p = .003), right superior frontal and bilateral medial (t = -2.44E+00; p = .015), bilateral medial and superior (t = -3.03E+00; p = .003), and right middle frontal cortex (t = -2.90E+00; p = .004) during the combined phase of maintenance, and significant activation in cortical activity in the left superior frontal cortex (t = 2.01E+00; p = .0047) during the emergence in comparison with the ED- group. CONCLUSION: There is significant difference in the change in oxyhemoglobin concentration during induction, maintenance, and emergence in specific frontal brain regions between children with and without emergence delirium.

The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review.

Background: The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload. Methods: A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included. Results: We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32-0.95, I2 = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00-0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04-0.14, I2 = 89%), platelets (OR = 0.51, 95% CI 0.28-0.91, I2 = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55-0.88, I2 = 89%), and had better cost-effective treatment [Mean difference (MD) = -357.5, 95% CI - 567.75 to -147.25, I2 = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46-1.29, I2 = 82%). No mortality was detected across the studies. Conclusions: Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.

Utility of high-flow nasal oxygen in comparison to conventional oxygen therapy during upper gastrointestinal endoscopic procedures under sedation: A systematic review and meta-analyses.

BACKGROUND: Sedation and analgesia are the integral components of modern-day upper gastrointestinal (GI) endoscopic procedures. Irrespective of the sedative agent, hypoxia is the most commonly encountered unwarranted event with sedation. The current study intends to scrutinize whether high-flow nasal oxygen (HFNO) is advantageous for providing respiratory support during upper GI endoscopic procedures over other conventional low-flow oxygen delivery modalities, e.g. nasal cannula, facemask, etc. METHODS: An extensive screening of electronic databases was done till July 31, 2022, after enlisting in International prospective register of systematic reviews (PROSPERO) (CRD42021245409). Randomized controlled trials (RCT), comparative cohort studies, case series, cross-sectional studies and case-control studies evaluating the utility of HFNO during upper GI endoscopy under sedation were included in this meta-analysis. RESULTS: We retrieved eight randomized control studies and one longitudinal study with 3294 patients. The application of HFNO during endoscopy led to lesser incidence of desaturation spells (odds ratio [OR] = 0.23; 95% CI 0.11-0.48; I2 = 71%), reduced procedural interruption (OR = 0.11; 95% CI 0.02-0.60; I2 = 88%), better nadir SpO2 level during procedure (mean difference [MD] = 3.16; 95% CI 0.54-5.78; I2 = 73%), overall lesser incidence of sedation-related adverse events (OR = 0.63; 95% CI 0.42-0.93; I2 = 25%), with no significant impact on the duration of endoscopy (MD = 0.15; 95% CI - 0.02 to 0.31, I2 = 0%). CONCLUSION: HFNO is a novel option for upper GI endoscopy under sedation. CLINICAL TRIAL NUMBER AND REGISTRY URL: CRD42021245409 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021245409 ).

Impact of intravenous dexamethasone on the initiation and recovery of atracurium in children: A double-blinded randomized controlled trial.

BACKGROUND: Chronic steroid intake has been associated with attenuation of neuromuscular block. Despite some promising animal and adult studies, the effect of a single dose of intravenous dexamethasone on neuromuscular blockers is not well established. Thus, the present study aimed to demonstrate the effect of dexamethasone given at the time of induction for the prevention of PONV on the action of neuromuscular blockers in children undergoing elective surgery. METHOD: After obtaining approval from the Institute Ethics Committee and written informed parental consent, 100 ASA I and II children aged 4-15 years undergoing elective surgery randomized to receive either: 0.15 mg/kg (maximum of 5 mg) of dexamethasone diluted to a total volume of 2 ml with 0.9% saline (n = 50) or 2 ml of 0.9% saline (n = 50) at the time of induction. The time interval between application of atracurium and maximum T1 depression, 25% twitch height recovery of T1, amid 25% and 75% twitch height recovery of T1, amid the 25% twitch height recovery of T1 and recovery of the neuromuscular block to a TOF ratio of 0.9, and in between the initiation of atracurium injection till the recovery of the neuromuscular block to a TOF ratio of 0.9 was defined as onset time, clinical duration, recovery index, recovery time, and total recovery period, respectively, and recorded. RESULTS: The onset time and recovery index time were lower (1.96 ± 0.39, 8.04 ± 2.14, respectively) with dexamethasone in comparison with saline (2.01 ± 0.51, 8.9 ± 3.4, respectively) but not statistically significant. The clinical duration, recovery time, and total recovery period were similar. CONCLUSION: Application of a single bolus dose (0.15 mg/kg) of dexamethasone during induction does not attenuate atracurium-induced neuromuscular blockade in children.

Feasibility of anterior temporalis muscle ultrasound for assessing muscle wasting in ICU: a prospective cohort study.

PURPOSE: Skeletal muscle ultrasound is a valuable tool for assessing muscle wasting in ICU. Previous studies on skeletal muscle ultrasound in ICU have been performed on lower limb muscles. The current study is formulated to assess the feasibility and reliability of anterior temporalis (AT) muscle ultrasound for measuring muscle wasting in ICU. METHODS: In this prospective cohort study in 48 critically ill patients with sepsis, muscle layer thicknesses (MLTs) and mean grayscale (GS) values of anterior temporalis muscles and quadriceps femoris (Q) were measured at baseline and serially till 7 days. Correlation was made between baseline and change in MLT and GS values of AT and Q muscle and these parameters were compared between ICU survivors and non survivors. RESULTS: Baseline anterior temporalis MLTs or their longitudinal changes over 7 days did not correlate significantly with the corresponding parameters of quadriceps femoris muscles. The baseline GS values of two muscle groups correlated weakly at baseline, but the change in GS over 7 days showed no correlation. The baseline MLTs of both muscle groups and their longitudinal change over 7 days did not correlate with ICU length of stay. The change in MLT of AT over 7 days was significantly greater in ICU non-survivors compared to survivors. CONCLUSION: Measurement of ultrasonographic muscle layer thickness and grayscale parameters of anterior temporalis muscle did not show good correlation with that of quadriceps muscle.

Comparative evaluation of intraoperative dexmedetomidine versus lidocaine for reducing postoperative cognitive decline in the elderly: a prospective randomized controlled trial.

INTRODUCTION: Neuroinflammation, neuronal cytotoxicity, and apoptosis due to exposure to anaesthetic agents are often implicated in postoperative cognitive dysfunction (POCD). Lidocaine and dexmedetomidine have been shown to suppress the neuron-specific markers of inflammation, and we aimed to compare their neuroprotective efficacy in elderly patients. MATERIAL AND METHODS: This prospective randomized control study compared the incidence of POCD in ASA I/II patients aged 60 to 80 years without any history of substance abuse or any disorder affecting cognition. Dexmedetomidine and lidocaine were administered intraoperatively, and their effects on POCD were correlated with serum levels of IL-1, IL-6, TNF-a, amyloid-ß, and S100 on postoperative day 3. POCD was assessed by the Stroop test, Trail making test-B, Porteus Maze test, Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) on the day before surgery and the third postoperative day, along with blood samples. RESULTS: Demographic parameters, anaesthesia duration, exposure to anaesthetic gases, intraoperative opioid use, and blood transfusion were similar in the lidocaine ( n = 31) and dexmedetomidine ( n = 29) groups. The incidence of POCD was 29.03% in the lidocaine group and 24.1% in the dexmedetomidine group ( P = 0.77). On postoperative day 3, IL-1 levels increased by 449% with lidocaine and 202% with dexmedetomidine ( P = 0.03). TNF-a, IL-6, and S-100ß levels increased similarly in both groups. There was no significant correlation between percentage changes in neuropsychological tests and biomarkers. CONCLUSIONS: There was no significant difference in the incidence of POCD, but dexmedetomidine had a better anti-inflammatory effect in terms of lesser rise of postoperative IL-1 compared to lidocaine.

Ketamine and dexmedetomidine (Keto-dex) or ketamine and propofol (Keto-fol) for procedural sedation during endoscopic retrograde cholangiopancreatography: Which is safer? A randomized clinical trial.

BACKGROUND: Optimum procedural sedation is very essential for conducting non-operating room procedures such as endoscopic retrograde cholangiopancreatography (ERCP). The combination of ketamine and dexmedetomidine (KD) is expected to balance out the undesirable effects of either drug and provide smooth sedation. Together ketamine and propofol (KP) also provide synergistic sedation with stable hemodynamics. This prospective, single-blinded randomized study aimed to compare the effect of both the combinations during ERCP in terms of oxygen desaturation, respiratory depression, hemodynamic parameters, analgesia, recovery time, and ease with which the endoscopist could perform the endoscopy. METHODS: This prospective, single-blinded randomized study (CTRI/2019/08/020625) was conducted on 84, ASA (American Society of Anesthesiologists) physical status I or II patients, of age 18-65 years presenting for ERCP in a tertiary care center. They were randomized to receive either KD (n=42) or KP (n=42) combination during ERCP. Mean SPO2 at the end of the procedure was compared between the groups. Apart from these periprocedural hemodynamic and respiratory parameters, pain scores on arrival in the recovery room (t0), 15 minutes (t15), and 30 minutes (t30), recovery time, and endoscopist's satisfaction as per a Likert's scale were recorded. RESULTS: The mean SpO2 (SpO2 recorded every minute during the procedure and averaged over procedure time in minutes) in group KP (97.7 [96.1-98.6]) was significantly lower than group KD (98.5 [98.1-98.8]) (p=0.005). The post-procedure pain scores measured at t0 and t15 were higher in group KP (p<0.001 and p=0.043), and comparable at t30 in both the groups (p=0.711). The time to achieve Modified Aldrete score (MAS) ≥ 9 was significantly more in group KD (p<0.001). The lowest mean arterial pressure and heart rate in group KD were significantly lower than in group KP (p<0.001, p=0.006, respectively). The overall endoscopist satisfaction was better in group KP compared to group KD (p= 0.011). CONCLUSIONS: The combination of ketamine-dexmedetomidine for procedural sedation during ERCP is a safe alternative to ketamine-propofol with a better respiratory profile. CLINICAL TRIAL NUMBER AND REGISTRY URL: CTRI/2019/08/020625 ( www.ctri.nic.in ).

Respiratory vaccination.

Vaccinations are among the most cost-effective preventive health strategies to reduce healthcare costs and prevent morbidities. Every year, many adults and elderly encounter hospitalization because of infectious respiratory diseases. Among these, viral and bacterial pneumonia, tuberculosis, diphtheria and pertussis infections are some of the diseases that can be prevented and managed with fewer complications, with adequate preventive immunization. This review tries to outline the vaccines available for the prevention of these respiratory ailments along with their schedule and dosages.