Effect of N95 Filtering Facepiece Respirator on Venous Blood Carbon Dioxide Levels and Hemodynamic Changes in Health Care Workers.

Background: N95 filtering facepiece respirators (FFR) are used by health care workers for prevention of airborne infection, and its use has increased manifolds during COVID-19 pandemic. Prolonged use may result in carbon dioxide (CO2) accumulation, affect hemodynamics, and blood gas values. Although arterial blood gas values accurately measure the blood CO2 levels, venous blood gas values also show acceptable correlation. Aim: To evaluate the physiological impact of N95 FFRs on health care workers, including hemodynamic changes and venous blood levels of CO2 during a period of 6 h. Settings and Design: Prospective observational study in a tertiary care hospital. Methods: The study was conducted on 30 health care workers who performed routine duties while wearing N95 FFR. Venous blood gas values (CO2, pH, and bicarbonate) and vitals (respiratory rate, heart rate, blood pressure, and saturation) were noted at baseline, 2 (T2), and 6 h (T6) after wearing the mask. Discomfort level was also measured on a Visual Analogue Scale (VAS) of 1-10. Statistical Analysis: Repeated measures analysis was done using repeated measures ANOVA or Friedman's test. Group comparisons for continuously distributed data were made using independent sample "t" test or Wilcoxon test. Results and Conclusion: Hemodynamic and blood gas values did not change over time. The VAS for discomfort because of respirator use was 1.33 (1.42) at T2 and 2.77 (1.91) at T6. This was a significant increase in discomfort over time (P = 0.001). About 80% of participants experienced discomfort during this period. N95 FFR did not lead to significant alteration in hemodynamics or change in blood gas values after 6 h of continuous usage. However, discomfort significantly increased over time.

Current practice of Rapid Sequence Induction (RSI) in pediatric anesthesia: A survey from India.

Background and Aims: Rapid Sequence Induction (RSI) is an established technique to secure the airway in patients who are at risk of aspiration. The practice of RSI in the pediatric population is highly variable due to numerous patient factors. We conducted a survey to find the prevalent practices and adherence of anesthesiologists to the practice of RSI in different pediatric age groups and whether it differs with the experience of the anesthesiologist or the age of the child. Material and Methods: The survey was conducted among residents and consultants attending the pediatric national anesthesia conference. The questionnaire consisted of 17 questions on anesthesiologist's experience, adherence, conduct of pediatric RSI, and the reason for nonadherence. Results: The response rate was 75% (192/256). Anesthetists having less than 10 years of experience adhered to RSI more often as compared to respondents with more experience. Succinylcholine was the most commonly used muscle relaxant for induction, with use increasing in higher age groups. The application of cricoid pressure increased with increasing age groups. Anesthetists with >10 years of experience used cricoid pressure more often in age groups of <1 year (P < 0.05). In a scenario of intestinal obstruction, adherence to RSI was low in pediatrics as compared to adults, with 82% of respondents agreeing to this. Conclusion: This survey on the practice of RSI in the pediatric population demonstrates wide variation in the practice among individuals and the reasons for nonadherence as compared to adults. It highlights the need felt by almost all the participants for more research and protocol in the practice of pediatric RSI.

Correlation of preoperative inferior vena cava diameter and inferior vena cava collapsibility index with preoperative fasting status, patient demography and general anaesthesia associated hypotension: A prospective, observational study.

Background and Aims: A definitive cutoff of inferior venacava (IVC) diameter in expiration (dIVCmax) and inferior vena cava collapsibility index (IVCCI) for predicting general anaesthesia associated hypotension (GAAH) is not yet determined. Primary objective of this study was to determine the correlation of dIVCmax and IVCCI, with GAAH. Other objectives were to determine the correlation of these IVC parameters with preoperative fasting duration, temperature and humidity. The correlation of dIVCmax with patient demography was also studied. Methods: A total of 110 adult patients undergoing elective surgery under general anaesthesia were included in the study. IVC ultrasonography was done in the preoperative room, 20 to 30 minutes before shifting the patient to the operating room. Hypotension at (hypo@) 2 minutes and 10 minutes after administering vecuronium was recorded. Results: Hundred and seven patients were analysed. A significant positive correlation was present between patient height and dIVCmax (r = 0.25, P = 0.009). Area under receiver operating characteristics curve was 0.595 (95% confidence interval (CI) 0.485-0.705) and 0.568 (95% CI 0.458-0.679) for dIVCmax and IVCCI for predicting hypo@2 min, with a diagnostic accuracy of 54% and 53%, respectively. dIVCmax ≤1.14 cm had a sensitivity of 31% and specificity of 87% in predicting GAAH. IVCCI ≥63.3% could predict GAAH with 31% sensitivity and 84% specificity. No significant correlation was found between preoperative IVC parameters and preoperative fasting or environmental factors. Conclusion: Both dIVCmax and IVCCI have poor diagnostic accuracy, with good specificity and low sensitivity in predicting GAAH. A steady formula for calculating baseline IVC diameter adjusted for patient demography is needed.

Study comparing different airway assessment tests in predicting difficult laryngoscopy: A prospective study in geriatric patients.

BACKGROUND AND AIMS: Limited studies are available comparing diagnostic accuracy of various airway predictors in geriatric patients. We conducted this study with primary aim to evaluate and validate the predictive value of 'standard airway predictors' like modified Mallampati test, thyromental distance (TMD), sternomental distance, neck movement (NM), mouth opening (MO), dentition and 'new airway predictors' like upper lip bite test (ULBT), ratio of height to thyromental distance and thyromental height test (TMHT) for predicting difficult laryngoscopy in geriatric patients. METHODS: This prospective, observational study was conducted on 140 patients above 65 years of age of either sex, scheduled for elective surgery under general anaesthesia requiring endotracheal intubation. The age, weight, height, body mass index (BMI) and airway parameters were recorded. The laryngoscopic view was assessed by modified Cormack-Lehane scale. Standard formulae were used to calculate validity indexes. RESULTS: The incidence of difficult larygoscopy found in our study was 25%. The mean age of our study population was 69.37 ± 4.23 years. TMD exhibited the highest sensitivity (80%) and negative predictive value (NPV) (91.86%) as compared to other studied airway predictors. The positive predictive value (PPV) of ULBT was 100%. Moreover, ULBT exhibited highest accuracy (82.14%) and odds ratio (86.88) and high specificity (91.30%) for predicting difficult laryngoscopy in geriatric patients. NM and TMHT also exhibited high accuracy (77.85%, 77.14%) and PPV (59.09%, 52.94%). CONCLUSIONS: TMD and ULBT both showed good predictive value in diagnosing difficult laryngoscopy in geriatric patients. Furthermore, NM and TMHT also exhibited higher diagnostic accuracy in predicting difficult airway in these patients.

Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study.

BACKGROUND AND AIMS: The role of cervical epidural analgesia in head and neck cancer surgery is not fully explored. The aim of this study was to evaluate cervical epidural analgesia in terms of opioid and anesthetic requirements and stress response in patients undergoing head and neck cancer surgery. MATERIAL AND METHODS: After institutional ethical committee approval and written informed consent, 30 patients undergoing elective head and neck cancer surgery were randomized into two groups: Group E (cervical epidural analgesia with general anesthesia), and group G (general anesthesia alone). In group E, an 18 gauge epidural catheter was placed at cervical (C) 6 - thoracic (T) 1 level. After test dose, a bolus of 10 ml of 0.2% ropivacaine was given followed by continuous infusion. Technique of general anesthesia and post-operative management was standardized in both the groups. Opioid and anesthetic drug requirement was observed. Blood glucose and serum cortisol levels were measured at baseline; post-incision and after surgery. RESULTS: There was significant reduction in the requirement of morphine (P < 0.001), isoflurane (P = 0.004) and vecuronium (P = 0.001) in group E. Post-operative, blood glucose and serum cortisol levels were significantly reduced (P = 0.0153 and 0.0074, respectively). Early post-operative pain was reduced with the lesser requirement of post-operative morphine. CONCLUSIONS: The use of combined cervical epidural analgesia with general anesthesia reduces opioid, anesthetic drug requirement and stress response as compared to general anesthesia alone in patients undergoing head and neck cancer surgery.

Comparison of thyromental height test with ratio of height to thyromental distance, thyromental distance, and modified Mallampati test in predicting difficult laryngoscopy: A prospective study.

BACKGROUND AND AIMS: Preoperative airway assessment to predict patients with difficult laryngoscopy is always crucial for anesthesiologists. Several predictive tests have been studied by various authors in quest of finding the best airway predictor. Recently, a new airway predictor, thyromental height test (TMHT) has been reported to have good predictive value in assessing difficult airway. We conducted this study with primary aim to evaluate the diagnostic accuracy of TMHT and to compare it with other established airway predictors, such as ratio of height to thyromental distance (RHTMD), thyromental distance (TMD), and modified Mallampati test (MMT) for predicting difficult laryngoscopy. MATERIAL AND METHODS: This prospective, observational study was conducted in 550 patients of either sex aged >18 years scheduled for elective surgery under general anesthesia. The patients' airway was assessed preoperatively by two anesthetists. Standard anesthetic protocol was followed in all the patients. The laryngoscopic view was graded according to Cormack-Lehane scale. The receiver operating characteristic (ROC) curve was used to calculate the ideal cut off values for TMHT and RHTMD. Standard formulae were used to calculate validity indexes. RESULTS: The incidence of difficult laryngoscopy was 10%. The cut-off value for TMHT and RHTMD were 5.1 cm and 19.5, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TMHT were 78.18%, 93.94%, 58.90%, and 97.48%, respectively. The highest sensitivity, PPV, and NPV were observed with TMHT as compared with RHTMD, TMD, and MMT (P < 0.0001). CONCLUSIONS: TMHT is the best predictive test with highest accuracy and odds ratio for predicting difficult airway out of all predictive tests evaluated.

A prospective survey on knowledge, attitude and current practices of pre-operative fasting amongst anaesthesiologists: A nationwide survey.

BACKGROUND AND AIMS: Pre-operative fasting is a routine practice to minimise the risk of pulmonary aspiration. The leading societies of anaesthesia have adopted more liberal fasting guidelines to avoid the adverse effect of prolonged fasting. This survey was conducted to assess the knowledge, attitude and current practice of fasting guidelines among Indian anaesthesiologists and to analyse the reasons for non-compliance of these guidelines. METHODS: A questionnaire consisted of 11 questions was distributed via 'Survey Monkey' software to 621 anaesthesiologists who attended the annual conference of the Indian Society of Anaesthesiologists held in Ludhiana, in 2016. American Society of Anaesthesiologists (ASA) practice guidelines for fasting were the standard of assessment. RESULTS: The response rate to the survey was 52%. Of the respondents, 69% described correctly the practice guidelines to pre-operative fasting. Only seven percent respondents were aware of the benefits of liberalised fasting. More than 2/3rd of the respondents advised fasting as per ASA guidelines during pre-anaesthetic check-up (PAC). However, only about 50% respondents confirmed that these guidelines are actually followed in their institution. Not having control on scheduling of cases in operation theatre and poor knowledge of ward nurses and surgeons were the common reasons for non-compliance of these guidelines. Twenty four percent respondents did not use routinely any drug for aspiration prophylaxis. CONCLUSION: Majority of the respondents were aware of the ASA fasting guidelines. However, the implementation of the guidelines and knowledge regarding benefits of liberalised fasting is poor among respondents.

Gabapentinoids as a Part of Multi-modal Drug Regime for Pain Relief following Laproscopic Cholecystectomy: A Randomized Study.

BACKGROUND: Gabapentinoids have been used as preemptive analgesics for pain management following laparoscopic cholecystectomy. Recently, multimodal analgesic techniques have been found superior to preemptive analgesia alone. AIM: The aim of this study is to evaluate and compare a single preoperative dose of pregabalin 150 mg and gabapentin 300 mg for pain relief following laparoscopic cholecystectomy as a part of multimodal drug regime. SETTINGS AND DESIGN: This randomized, single-blind study was conducted after Ethical Committee approval and written informed consent from the patients. MATERIALS AND METHODS: Fifty patients undergoing laparoscopic cholecystectomy under general anesthesia were randomly allocated to receive either 150 mg pregabalin (Group PG), or 300 mg gabapentin (Group GB) orally, 2 h before surgery. Standard anesthesia induction and maintenance were done. For intraoperative pain management, injection fentanyl 2 µg.kg-1 intravenous (IV) along with injection voveran 75 mg IV and port site infiltration was used. Postoperatively, injection diclofenac 75 mg intramuscular TDS was continued. Severity of postoperative pain (visual analog scale [VAS]), postoperative fentanyl requirement and incidence, and severity of side effects were assessed. When VAS >40 mm or on patient's request, a Fentanyl bolus at an increment of 25-50 µg IV was given as rescue analgesia. RESULTS: Intraoperative fentanyl requirement was 135 ± 14 µg in Group PG and 140 ± 14 µg in Group GB (P = 0.21). Postoperative, fentanyl requirement was 123 ± 18 µg in Group PG and 131 ± 23 µg in Group GB (P = 0.17) There was no statistically significant difference in the VAS score for static and dynamic pain. Time to the first requirement of analgesic was 5.4 ± 1.1 h in Group PG and 4.6 ± 1.6 h in Group GB (P = 0.015). No side effects were observed. CONCLUSION: We conclude that a single preoperative dose of pregabalin (150 mg) or gabapentin (300 mg) are equally efficacious in providing pain relief following laparoscopic cholecystectomy as a part of multimodal regime without any side effects.