An analysis of emergency surgery on coronavirus disease positive patients and their outcomes during the coronavirus pandemic: A retrospective observational study.

Background: The primary objective of this study was to determine the outcome of emergency surgery in coronavirus disease 2019 (COVID-19) patients with regard to presently existing physical status, and highlight its subspecialty distribution. Methods: This retrospective observational study was done on all patients who underwent emergency surgery between March 2020 and Dec 2021 and were positive for COVID-19. Data collection included the age of the patients, gender, diagnosis, the type of surgery performed, and outcome. Physical status was assessed, as per Modified Medical Research Council Dyspnoea Scale (MMRC) and Metabolic Equivalent Scale (METS). Results: A total of 89 patients were analyzed from March 2020 to Dec 2021. There were 63 females and 26 males. The average age of the males was 53.8 ± 8.9 years and the average age of the females was 29.1 ± 4.6 years. The maximum number of surgeries done was lower segment cesarean section (57.3%). 55 out of 60 (91%) cases had a good grade on the MMRC scale (Grade 0 and 1). 3 patients had Grade 4 MMRC scale and all 3 were oncology cases. As per the METS scale, 56/60 (93.3%) patients had METS >10. Conclusion: This study has demonstrated that 55 out of 60 (91%) of cases had a good grade on the MMRC scale (Grade 0 and 1) 6 months to 1-year post-surgery. As per the METS scale, 56/60 (93.3%) patients had METS >10. Most of the cases were asymptomatic COVID-19-positive and presently have good physical status as determined by the study.

A novel approach to airway management in Pierre Robin syndrome-a case report.

Pierre Robin syndrome (PRS) neonates are one of the most difficult cases to intubate even for an experienced paediatric anaesthesiologist. We describe a case of a PRS-related anatomical anomaly that hindered attempts to manage the airway and the final approach that made it possible to insert an endotracheal tube (ETT). We describe the novel use of a video ureteroscope (Olympus URF-V2) as an airway endoscope. A 7-day-old, 2-kg boy was referred to our tertiary care hospital with diagnosed PRS. He was planned for correction of the mandible with mandibular distraction osteogenesis under general anaesthesia. Fibreoptic scope (Olympus, Japan) revealed the epiglottis lying on the posterior pharynx, which could not be manoeuvred. Due to repeated attempts, the patient developed laryngospasm, and his pulse arterial oxygen saturation (SpO2) was reduced to 70%. Following jaw thrust and slight pulling of the tongue with Magill's Forceps, a 150-cm long and 0.035-inch diameter atraumatic, Roadrunner® hydrophilic polyurethane-coated guidewire was introduced through the working channel of the video ureteroscope into the trachea under the vision (and a 3.5-mm ID ETT was railroaded over it and a definitive airway was established). A flexible fibreoptic ureteroscope may be useful in the management of a difficult airway and may become an important tool in the armoury of an anaesthesiologist. At our institute, which is a tertiary care centre, we are now training and utilising video-ureteroscope as an airway endoscope. To our knowledge, there is no documentary evidence of the use of a video ureteroscope for difficult airway management of a neonate.

Novel use of flexible video ureteroscope in airway management: A case series.

Fibreoptic bronchoscopes are vital for difficult airway management. However, many a times, it is not available. Also, the correct size may not be available, especially for use in paediatrics and neonates. We describe the use of a flexible fibreoptic video ureteroscope, as an alternative to a bronchoscope, for airway management. We include five cases of airway management using a 2.8 mm fibreoptic video ureteroscope. The use of a flexible video ureteroscope was successful in all the five cases, and all the patients tolerated the procedure well. No complications were encountered. We conclude that a video ureteroscope can be used for both elective and rescue airway management in small children as well as in adult patients.

Efficacy of evidence-based institutional protocol for prevention of postoperative nausea and vomiting: A prospective observational study.

BACKGROUND: Postoperative nausea and vomiting (PONV) is the second most common complaint in the postoperative period, often resulting in increased post anaesthesia care unit (PACU) and hospital stay. Translation of knowledge into consistent practice was considered a major gap. Hence, the present study was undertaken to test the efficacy of locally developed evidence-based institutional protocol for prevention of PONV. METHODS: Phase I consisted of determining the baseline incidence of PONV before introduction of the institutional protocol for PONV prophylaxis. In phase II, educational sessions for anaesthesiologists for PONV prevention and treatment were conducted, after which an institutional protocol was introduced. In phase III, this protocol was implemented, and the incidence of PONV was recorded using the same methodology as in phase I. The rate of adherence to the institutional protocol was also recorded. RESULTS: The incidence of postoperative nausea (PON) dropped significantly from 32.5% in phase I to 20% in phase III (p = 0.033). Similarly, the incidence of postoperative vomiting (POV) decreased from 20.5% in phase I to 9.1% in phase III (p = 0.016). Of all anaesthesiologists, 78.18% were noted to adhere to the protocol in phase III. Incidence of PON and POV was significantly less in patients in whom PONV prophylaxis was administered in adherence to protocol (8.3% vs 57.7%, p < 0.001; 3.6% vs 26.9%, p < 0.001, respectively). CONCLUSION: Evidence-based institutional protocols are effective in significantly reducing the incidence of PONV in adults undergoing noncardiac surgery under anaesthesia. CLINICAL TRIAL NUMBER AND REGISTRY URL: The trial was registered with Clinical Trials Registry of India (http:/ctri.nic.in) (CTRI/2015/12/006432).

Anaesthetic management of intraoperative tracheo-bronchial injury.

Intraoperative tracheobronchial injury (TBI) may manifest clinically as pneumothorax, pneumomediastinum, subcutaneous emphysema, cyanosis, and respiratory insufficiency and has serious implications if it remains undetected or is managed improperly. The outcome of such injuries is affected by the extent of the lesion, pulmonary status & the surgical reconstruction undertaken. The recommended airway management of an intraoperative tracheal tear is to bypass the injured side by intubating the healthy bronchus with a single lumen endotracheal tube (ETT) and the use of a bronchial blocker or double lumen endotracheal tube (DLT) and becomes a very challenging situation. We report successful anaesthetic management of an accidental traumatic rupture of the left main bronchus during surgical dissection in an elderly lady of Carcinoma Oesophagus who underwent a Video Assisted Thoracoscopic surgery (VATS), and was managed by one lung ventilation of the contralateral (right) side manipulating the same DLT and lung protective ventilation.

Analysis of platelet-activating factors in severe sepsis by flow cytometry and its correlation with clinical sepsis scoring system: A pilot study.

BACKGROUND: Sepsis is a major global healthcare concern. Platelets and leucocytes play a key role in sepsis. Whole blood flow cytometry (FCM) is a powerful new technique for the assessment of leucocyte and platelet parameters and their functional state. In the present study, we have used FCM to examine platelet and leucocyte functions and parameters in sepsis patients. METHODS: Prospective, non-interventional cohorts of all adult patients with sepsis and history of intensive care unit stay for more than 24 h at mixed surgical- medical ICU were evaluated. The Simplified Acute Physiology Score-3 (SAPS 3) admission score was obtained, and whole blood FCM analysis of select platelets and leukocyte parameters were performed using a combination of monoclonal antibodies in a predefined panel. We also evaluated the correlation between these parameters and the severity of the illness, based on SAPS 3 admission score. RESULTS: Total leucocyte count (TLC) was statistically and significantly different between all the study samples, but platelet count was not. SAPS 3 acted as the best discriminant between the study groups. With a cut-off score of 55.5, SAPS 3 score predicted hospital mortality with a sensitivity of 82.8% and a specificity of 83.9%, with an area under receiver operating curves (AUROC) of 0.888 (95% CI = 0.807-0.969, p < 0.000). Parameters for CD62P, platelet-leucocyte aggregates (PLAs) and CD11b showed statistically significant differences between the patients and healthy volunteers. CD62P expression was positively correlated to PLA variables in severe sepsis patients. The median fluorescence intensity was found to be more informative than mean fluorescence intensity. New "62P adhesion index (62P AI)" and "PLA adhesion index" are proposed and is likely to be more informative. CONCLUSION: SAPS 3 score was the most robust of the parameters evaluated. Our study suggest the idea that the incorporation of platelet and leucocyte activation parameters, rather than mere static counts, will add the existing prognostic model though we could not conclusively prove the same in this study.

Early Postoperative Malignant Subcutaneous Emphysema: Report and Review.

BACKGROUND: Subcutaneous emphysema is defined as presence of air or gas in subcutaneous tissue layer. It may be localized or generalized due to various aetiological factors. Although SE and pneumomediastinum are self-limiting conditions, life-threatening complications may develop. Escape of air into both pleural cavity causing bilateral pneumothorax and tension pneumothorax can be termed as malignant emphysema. PURPOSE: To report a case of malignant generalized subcutaneous emphysema in early postoperative phase following palatoplasty. CASE REPORT: A 25 year old female patient was operated for closure of residual oronasal communication using an anteriorly based tongue flap. The patient was reversed from general anesthesia and shifted to the post-operative room with the endotracheal tube in situ. Sudden swelling of the face and periorbital area was noticed which spread all over the body. A diagnosis of malignant post-operative subcutaneous emphysema was made and the patient was shifted back to the operation theatre. She was managed successfully by bilateral tube thoracotomy and tracheostomy. CONCLUSION: Close observation of the patient in early postoperative stage having endotracheal tube in situ is crucial to avoid such complication. Regardless of aetiology, early recognition of the clinical features of tension pneumothorax and timely intervention are necessary for the survival of the patient.

The handheld blood lactate analyser versus the blood gas based analyser for measurement of serum lactate and its prognostic significance in severe sepsis.

BACKGROUND: This study was done to compare the accuracy of the Lactate Pro LT 1710 (Arkray Inc., Kyoto, Japan) with the Combiline Plus (Eschweiler GmbH & Co. KG Holzkoppelweg, Kiel, Germany), and also, to analyze the prognostic significance of serum lactates and Simplified Acute Physiology Score 3 (SAPS 3) in patients of severe sepsis. METHODS: 106 patients of severe sepsis admitted to the ICU were screened. The serum lactate from an arterial sample analyzed in both the machines was recorded at admission and at 48 h. These patients were then followed up to the 28th day for mortality. RESULTS: The Lactate Pro LT 1710 handheld point of care lactate meter provides consistent results comparable to the Eschweiler Combiline blood gas analyser. Serum lactate concentration was significantly higher in nonsurvivors at the time of admission (3.30 ± 1.26) and at 48 h (4.34 ± 1.73). Lactate clearance at 48 h appears to be a better predictor of mortality than the lactate levels at 0 h and 48 h. The mean SAPS 3 at admission amongst survivors was significantly less as compared to nonsurvivors. The SAPS 3 had improved to 47.44 (±11.79) in survivors at 48 h, while in nonsurvivors it had worsened to 81.98 (±12.32) (p = 0.00); thus, a worsening SAPS 3 at 48 h had a poorer prognosis. CONCLUSIONS: The Lactate Pro LT 1710 provides similar results to the Combiline Eschweiler blood gas analyser and is a cheaper alternative. It would prove to be a boon in peripheral hospitals in the aggressive management of critically ill patients.

Acute renal failure in the ICU setting: A prospective observational study.

BACKGROUND: Acute renal failure (ARF) is a common entity in the intensive care unit (ICU) setting. There is scanty data regarding acute kidney injury (AKI) in ICUs from our country and no data from the service setting. METHODS: All patients admitted to the ICU of a tertiary care teaching hospital for six months were included in the study. They were divided into two groups: surg gr (admitted in surgical ICU) and med gr (admitted in medical ICU). During the stay in ICU, patients were observed for the development of AKI depending on the creatinine values and hourly urine output. Staging was done based upon the Risk Injury Failure Loss and End stage kidney (RIFLE) criteria. Relevant data associated with development of AKI was collected for correlation. RESULTS: 17.15% patients developed AKI after admission to the ICU 40% patients admitted with sepsis developed AKI. An increased susceptibility to develop AKI was found on day 4 of admission in both the groups. Of the patients who developed AKI, the surg gr of patients had a higher sequential organ failure assessment (SOFA) score both on day of admission (7.85 vs 5.65) and on the day of development of AKI (9.47 vs 6.18) as compared to the medical group. CONCLUSION: The incidence of ARF in our study was 17.2% with the patients of polytrauma/MODS being of major concern. The initial 3-4 days are the most critical and susceptible patients must be intensive monitored during this time for prevention of ARF. Medical ICU patients develop ARF at a low SOFA score in comparison to surgical ICU patients and thus need greater attention.

An evaluation of brachial plexus block using a nerve stimulator versus ultrasound guidance: A randomized controlled trial.

BACKGROUND AND AIMS: This study was carried out to evaluate the difference in efficacy, safety, and complications of performing brachial plexus nerve blocks by using a nerve locator when compared to ultrasound (US) guidance. MATERIAL AND METHODS: A total of 102 patients undergoing upper limb surgery under supraclavicular brachial plexus blocks were randomly divided into two groups, one with US and the other with nerve stimulator (NS). In Group US, "Titan" Portable US Machine, Sonosite, Inc. Kensington, UK with a 9.0 MHz probe was used to visualize the brachial plexus and 40 ml of 0.25% bupivacaine solution was deposited around the brachial plexus in a graded manner. In Group (NS), the needle was inserted 1-1.5 cm above mid-point of clavicle. Once hand or wrist motion was detected at a current intensity of less than 0.4 mA 40 ml of 0.25% bupivacaine was administered. Onset of sensory and motor block of radial, ulnar and median nerves was recorded at 5-min intervals for 30-min. Block execution time, duration of block (time to first analgesic), inadvertent vascular puncture, and neurological complications were taken as the secondary outcome variables. RESULTS: About 90% patients in US group and 73.1% in NS group, had successful blocks P = 0.028. The onset of block was faster in the Group US as compared to Group NS and this difference was significant (P 0.007) only in the radial nerve territory. The mean duration of the block was longer in Group US, 286.22 ± 42.339 compared to 204.37 ± 28.54-min in Group NS (P < 0.05). Accidental vascular punctures occurred in 7 patients in the NS group and only 1 patient in the US group. CONCLUSION: Ultrasound guidance for supraclavicular brachial plexus blockade provides a block that is faster in onset, has a better quality and lasts longer when compared with an equal dose delivered by conventional means.

Control of hospital acquired infections in the ICU: A service perspective.

BACKGROUND: The service setting has some unique strengths and weaknesses that must be kept in mind when organizing Hospital acquired infections (HAI) prevention interventions. METHODS: Following an initial study to gather data regarding HAI in the Surgical intensive care unit (ICU) we put into place various infection control interventions. The present study was carried out to analyse the effect of these interventions on the incidence of HAI in the ICU. RESULTS: The total admissions to the ICU were 253 patients. Eighty eight patients (34.78%) were admitted for more than 48 hr, 165 patients stayed for less than 48 h. The frequency of HAI was 7.95% (95% CI 3.54, 15). Hospital acquired pneumonia was observed in 2 of the 88 patients (2.27%) (95% CI 0.38, 7.30) which amounted to 9.70 infections per 1000 ventilator days. Bloodstream infection was detected in 3 out of 88 patients (3.4%) (95% CI 0.87, 8.99) amounting to 6.54 fresh infections per 1000 Central Venous Catheter days. Urinary tract infection was observed in 2 (2.27%) (95% CI 0.38, 7.30) at 2.86 fresh infections per 1000 catheter days. As compared to the previous study we found that there was a decline of HAI ranging from 60 to 70%. CONCLUSION: Our study demonstrated that by meticulously following infection control protocols especially tailored to the service setting the incidence of HAI's can be reduced. However, the challenge is in maintaining the gains achieved since there is a rapid turnover of manpower in the ICU and a lack of a structured ICU design model.

Dapsone-induced methemoglobinemia: "Saturation gap"-The key to diagnosis.

Two cases of Acquired Methemoglobinemia are presented. The significance of a high index of suspicion for diagnosisis emphasized, especially in the presence of a "saturation gap". The various causes of acquired methemoglobinemia are enumerated and the management reviewed.

Case series: Dexmedetomidine and ketamine for anesthesia in patients with uncorrected congenital cyanotic heart disease presenting for non-cardiac surgery.

The number of patients with uncorrected congenital cyanotic heart disease is less but at times some may present for non-cardiac surgery with a high anesthetic risk. Some of these may even be adults with compromised cardiopulmonary physiology posing greater challenges to the anesthesiologist. The authors have used a combination of dexmedetomidine and ketamine for anesthesia for non cardiac surgery in five patients with cyanotic heart disease and right to left shunt (3-Eisenmenger's syndrome, 2-Tetralogy of Fallot). The sympathoinhibitory effects of dexmedetomidine were balanced with the cardiostimulatory effects of ketamine, thereby maintaining good cardiovascular stability. The analgesia was good and there was no postoperative agitation. This drug combination was effective and safe for patients with cyanotic heart disease for non cardiac surgeries.

Management of a case of ankylosing spondylitis for total hip replacement surgery with the use of ultrasound-assisted central neuraxial blockade.

Management of a case of ankylosing spondylitis can be very challenging when the airway and the central neuraxial blockade, both are difficult. Ultrasound-assisted central neuraxial blockade may lead to predictable success in the field of regional anaesthesia. We present a young patient with severe ankylosing spondylitis where conventional techniques failed and ultrasound helped in successful combined spinal-epidural technique for total hip replacement surgery.

Ketodex, a combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopy in children: a preliminary report.

A combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopies (UGIE) was studied in 46 children aged 2-12 years over a 6-month period. Dexmedetomidine 1 µg/kg and ketamine 2 mg/kg were given as a bolus over 5 min. Heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and sedation scores were noted before induction as baseline and then every 5 min until recovery. The duration and ease of the procedure, time to recovery, and adverse effects, if any, were also recorded. UGIE could be performed with ease in 41 of the 46 cases. The HR, MAP, and SpO2 did not change significantly from the baseline. No airway intervention was required in any patient. There was no laryngospasm or shivering in any of the children, and one, four, and 11 children had hiccup, vomiting, and increased salivation, respectively. The Pediatric Anesthesia Emergence Delirium score was <4 in all except for two cases. The results of this case series show that this drug combination not only promises to be clinically effective but also safe for UGIE in children. Further randomized controlled trials with standard sedation protocols will be required to draw definite conclusions.