Assessment of residual gastric volume using point-of-care ultrasonography in adult patients who underwent elective surgery.

BACKGROUND: Aspiration pneumonitis remains a dreaded complication that may lead to almost 9% of anaesthesia-related deaths. The presence of gastric contents has always been a contributing factor to an increased risk of aspiration. Preoperative gastric ultrasound has been suggested as a modality for determining residual volume in special populations and conditions. We conducted an observational study to determine the gastric residual volume in preoperative patients of elective surgery with gastric ultrasound and to study its correlation with patient factors. METHODS: We enrolled 411 patients in the age group of 18-80 with ASA-PS I and II having BMI less than 35 kg/m2. Patients with prior gastrointestinal surgery and parturients were excluded from the present study. Gastric antrum in both supine and right lateral decubitus positions was measured using USG in the immediate preoperative period, and gastric residual volume was calculated, which was subsequently correlated with various patient factors. RESULTS: On qualitative assessment, 97 and 118 patients were observed to have distended stomachs in the supine and right lateral decubitus positions, respectively. On quantitative assessment, 336 had safe GRV, 60 patients were classified as having a low risk of aspiration (GRV < 1.5 ml/kg) while 13 had a high risk of aspiration (> 1.5 ml/kg). Eight patients with a fasting duration of more than ten hours and five who fasted between 6 and 10 h had a gastric residual volume of more than 1.5 ml/h. Patients who were premedicated with histamine blockers had a statistically significant higher antral cross-sectional area (p-value - 0.022*) and GRV (p-value - 0.018*) in the right lateral decubitus position compared to patients who had taken proton pump inhibitors (PPIs). As BMI increased, there was a statistically significant (p-value < 0.001) increase in mean antral CSA in both supine and right lateral decubitus positions. There was a statistically significant association found between type 2 diabetes (p-value 0.045*) with antral grade. DISCUSSION: Patients can have significant residual volume (> 1.5 ml/kg) despite adequate fasting, and preoperative gastric ultrasound can help in assessing the same and guiding perioperative airway management. PPIs are more effective in reducing gastric residual volume as compared to histamine blockers. Patients with a BMI of more than 30 and type 2 diabetes mellitus have significant correlation with increased gastric residual volume mandating preoperative gastric ultrasound assessment for effective management. CONCLUSIONS: Patients with BMI over 30 and type 2 diabetes may benefit from POCGUS to guide perioperative airway management by stratifying GRV. Trial registration Name of registry-Clinical Trial Registry of India. Trial registration number-2020/03/024083. Date of registration-19.3.2020. URL- http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=39961&EncHid=&userName=.

Awake videolaryngoscopic orotracheal intubation in patients with laryngeal tumour using the C-MAC D-Blade.

Background and Aims: This study assessed the applicability of C-MAC videolaryngoscope (VL) D-blade for awake intubation in patients with laryngeal tumour. The primary study objective was to determine the rate of successful intubation in the first attempt. The other parameters recorded were number of attempts required for intubation, duration of different stages of intubation, haemodynamics, ease of intubation and patient comfort on visual analogue scale (VAS) postoperatively. Methods: Thirty patients were studied. Patients were sedated with dexmedetomidine and fentanyl as a slow bolus (over 20 min) and Ramsay sedation score was assessed. Topicalisation of the oropharynx, tonsillar pillars and base of the tongue was done with lignocaine 10% spray. Four ml of 4% lignocaine using MADgic atomiser was used for anaesthetising the glottis and the tracheal lumen. Results: Successful intubation was achieved in 86.6% patients in first attempt and 13.3% in two attempts. Total time for all intubations was less than 30 seconds. Fremantle score was F-1-C-MAC D-blade (easy intubation with full view) in 60% patients, while 23.3% had F-2-C-MAC D-blade (full view and either required more than one attempt or a modified technique), 13.3% had P-1-C-MAC D-blade (partial view with easy intubation) and 3.3% had P-2-C-MAC D-blade (partial view and required more than one attempt or a modified technique). The VAS score for anaesthesiologist's ease and for patient's experience was 85.83 ± 7.20 and 86.66 ± 14.46, respectively. Conclusion: C-MAC VL D-blade-assisted awake intubation is an effective and safe method to manage the airway of patients with laryngeal tumour once adequate topicalisation is ensured before the procedure.

Topical vs. intravenous administration of tranexamic acid to minimize blood loss in abdominal hysterectomy perioperatively: A randomized controlled study.

Background and Aims: Topical application of tranexamic acid (TXA) to bleeding wound surfaces is rapidly gaining recognition and currently a topic of further research in patients undergoing abdominal hysterectomy. The aim of the study was to compare the efficacy of topical vs. intravenous (i.v.) administration of TXA in reducing perioperative blood loss in patients undergoing abdominal hysterectomy. Material and Methods: A double-blinded parallel-group randomized controlled study was conducted in a tertiary teaching institute. Group 1 (n = 25) received 10 mg.kg-1 i.v. bolus of TXA after induction followed by infusion of 1 mg.kg-1.h-1 of TXA, in 50 ml of normal saline (NS), till the completion of surgery and just before closure of peritoneum 100 ml of NS was applied topically over the raw surface. Group 2 (n = 25) received 50 ml of NS over 10 min after induction, followed by infusion of 50 ml of NS, till the completion of surgery and just before closure of peritoneum, 1.5 g of TXA mixed in 100 ml of NS was applied topically over the raw surface. The primary outcome was total perioperative blood loss (intraoperative plus 24 h postoperative). The secondary outcomes included change in hemoglobin concentration postoperatively at 12 h, 24 h; need for blood/blood product transfusion; amount of blood/blood product transfused and side effects of TXA. Results: Total perioperative blood loss was 312 ± 106.65 ml in group 1 and 325 ± 89.90 ml in group 2 (p = 0.659). It was found that the mean reduction in hemoglobin was 0.7 g.dl-1 and 0.54 g.dl-1 in group 1 and 0.67 g.dl-1 and 0.44 g.dl-1 in group 2 at 12 h and 24 h respectively, with no significant intergroup difference. Conclusion: Administration of TXA topically is as efficacious as TXA administered i.v. to minimize perioperative blood loss in patients undergoing abdominal hysterectomy.

Contrasting Photochromic and Acidochromic Behaviors of Pyridyl- and Pyrimidylethynylated Mono- and Bis-Benzopyrans.

Investigation of photochromic and acidochromic behaviors of a set of pyridyl- and pyrimidylethynylated mono- and bis-benzopyrans reveals an intriguing influence of the N-heteroaryl ring on spectrokinetic properties of the photogenerated o-quinonoid colored reactive intermediates. While the absorption maxima of the pyridylethynylated bis-benzopyran and its photogenerated o-quinonoid colored species undergo bathochromic shifts by ca. 40 and 22 nm, respectively, in the presence of an acid (e.g., trifluoroacetic acid (TFA)), the same remain unaffected for the analogous pyrimidylethynylated bis-benzopyran and its photogenerated o-quinonoid colored species under similar conditions. Modification of the photochromic behavior of these benzopyrans and, hence, spectrokinetic properties of their photogenerated o-quinonoid species in the presence of H+ is a consequence of relative proton affinities of N-heteroaryl rings, i.e., pyridyl/pyrimidyl, and the resonance effects relayed through the ethynyl spacers in a push-pull π-delocalized-type skeleton; the mesomeric effects operate in a contrasting manner depending on the N-heteroaryl ring in the absence and in the presence of an acid. These molecular systems offer a unique opportunity to modulate both photochromic and acidochromic properties of benzopyrans and their photogenerated colored o-quinonoid intermediates by leveraging N-heteroaromatic rings.

Comparative evaluation of Air-Q blocker and Proseal laryngeal mask airway in patients undergoing elective surgery under general anaesthesia: A randomised controlled trial.

BACKGROUND AND AIMS: The Air-Q blocker (Cook gas LLC, Mercury Medical, Clearwater, FL, USA) is a relatively new supraglottic airway device (SAD) with capability to serve as a conduit for intubation. As there is limited data on Air-Q blocker, the present study was performed to compare the efficacy of Air-Q blocker and Proseal laryngeal mask airway (PLMA) in patients undergoing elective surgery. METHODS: A total of 90 American Society of Anesthesiologists (ASA) physical status I and II patients were randomly allocated to Air-Q blocker or PLMA group. Oropharyngeal leak pressure (OLP), insertion success, insertion time, ease of orogastric tube (OGT) insertion, fibreoptic visualisation of the glottis, haemodynamic and ventilation parameters, and complications at emergence and postoperatively were investigated. RESULTS: OLPs were higher in PLMA group as compared to Air-Q blocker group (P = 0.002). Still, the OLP (27.5 ± 5.8 cm H2O) was clinically effective in Air-Q blocker group. The mean time for successful insertion was significantly shorter for Air-Q blocker than PLMA (P = 0.019). The number of attempts to insert both the devices was comparable (P ≥ 0.05). Air-Q blocker provided a significantly better fibreoptic score than PLMA (P = 0.038). The two groups were comparable in terms of ease of OGT insertion, haemodynamics and ventilation parameters, and complications at emergence and postoperatively. CONCLUSIONS: Air-Q blocker provides a clinically effective OLP though PLMA provides a slightly better sealing function in patients undergoing laparoscopic and non-laparoscopic surgeries under general anaesthesia requiring neuromuscular blockade. Air-Q blocker has shorter insertion time and a better fibreoptic view of glottis as compared to PLMA.

Does an acute pain service improve the perception of postoperative pain management in patients undergoing lower limb surgery? A prospective controlled non-randomized study.

BACKGROUND AND AIM: An acute pain service (APS) has been running in our institute since April 2013 and is managed by the Department of Anesthesia and Intensive Care. However, it is not clear to what extent the patients feel benefited from the APS. The aim of the study was to compare the perception of postoperative pain management in patients receiving care under APS with those receiving routine postoperative pain relief following lower limb surgery. MATERIAL AND METHODS: This was a prospective, hospital-based, controlled non-randomized study. American Society of Anesthesiologists (ASA) grades I-III patients with age 18-75 years undergoing lower limb orthopedic surgery were prospectively recruited into APS (index group) or routine postoperative care (control group) (n = 55 each). Postoperatively, American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) and Short Form (SF-12) were used to evaluate the outcome of postoperative pain management at 24 h and health-related quality of life after 4 weeks respectively. RESULTS: Both groups were comparable in terms of demographic data. Patients in the index group had statistically significant better perception of care than the control group. Index group scored significantly higher than control group on median patient satisfaction score (9; interquartile range [IQR] [7-10] vs. 5 [3-6]; P < 0.001). In index group, there was significant reduction of worst pain in first 24 h along with decreased frequency of severe pain. CONCLUSION: Implementation of acute pain service plays an important role in improving the quality of postoperative pain relief, perception of care, and patient satisfaction.

Serotonin Syndrome in ICU-A Road Less Traveled.

A potentially life-threatening adverse drug reaction, serotonin syndrome (SS) may occur in patients on serotonin agonist medications. Medications responsible for SS include commonly prescribed antidepressants, anxiolytics, analgesics and antiemetics. This syndrome has been mentioned in various scenarios in perioperative setting but rarely acknowledged in intensive care unit (ICU) setting. Multiple comorbities leading to polypharmacy and serotoninergic medications place elderly patients, particularly at higher risk of SS. We wish to report a case of SS in an elderly male with depression who developed SS and required ICU admission. Most crucial point is to be able to recognize this entity whenever a patient on multiple drugs with altered sensorium is admitted to ICU. HOW TO CITE THIS ARTICLE: Jindal S, Gombar S, Jain K. Serotonin Syndrome in ICU-A Road Less Traveled. Indian J Crit Care Med 2019;23(8):376-377.

A Randomized Double Blinded Trial Comparing Dexmedetomidine With Dexamethasone as an Adjunct to Ropivacaine in Ultrasound Guided Interscalene Block for Arthroscopic Shoulder Surgery.

OBJECTIVE: To evaluate the analgesic effi cacy of dexamethasone (DXA) vs. dexmedetomidine (DXM) as an adjunct to ropivacaine in ultrasound-guided interscalene block (USG-ISB) for arthroscopic shoulder surgery. METHODS: In this randomized double-blinded controlled trial, 60 American Society of Anesthesiologists grade 1-2 patients, 18-65 years, scheduled for arthroscopic shoulder surgery were randomly allocated to either group 1 (USG-ISB given with 0.5% ropivacaine 20 mL with 2 mL of saline containing DXM 0.5 mcg/kg) or group 2 (same protocol but DXA 8 mg instead of DXM). ISB was performed with in-plane technique under USG. Following surgery under general anesthesia, the patients received intravenous patient-controlled analgesia with fentanyl. Data were collected at 2-hourly intervals up to 24 hours after USG-ISB. The primary outcome was the duration of analgesia. Secondary outcomes consisted of pain ratings, total cumulative postoperative fentanyl consumption, patient satisfaction, and adverse effects. RESULTS: The groups were comparable regarding baseline demographic and clinical characteristics including onset of sensory and motor block. The duration of postoperative analgesia for group 2 was signifi cantly longer than for group 1 (22.40 ± 2.16 h vs. 19.30 ± 3.80 h; p < 0.001). Group 2 also required less total median number of boluses than group 1 (0 vs. 3; p < 0.001), less total fentanyl consumption (10.00 mcg ± 24.20 vs. 40.33 mcg ± 38.70; p < 0.001), less pain scores, and greater satisfaction (99.30 ± 2.53 vs. 93.30 ± 11.50; p=0.007). Adverse effects were few and comparable in both groups. CONCLUSION: Greater postoperative analgesia and opioid sparing effect was observed in patients receiving 8 mg DXA as adjunct for USG-ISB.

Perioperative management of an elderly patient of hypertrophic obstructive cardiomyopathy for knee arthroplasty and the role of peripheral nerve blocks.

This case report exemplifies how the anaesthetic technique of general anesthesia with continuous bilateral femoral nerve block for bilateral knee arthroplasty was well chosen for the management of perioperative complications in an elderly patient with hypertrophic obstructive cardiomyopathy (HOCM). A 69-year-old female patient of HOCM was scheduled for bilateral total knee replacement. Echocardiography revealed severe left ventricular outflow tract obstruction with peak systolic gradient of 56 mmHg. The surgery was conducted under general anaesthesia with invasive monitoring and bilateral continuous femoral nerve blocks for postoperative analgesia. Postoperatively, she developed pulmonary oedema due to the liberal administration of fluids. This complication was successfully managed without interrupting the management of pain. Management of patients with HOCM for noncardiac surgery requires knowledge of variable presentation of two forms of disease. Also, this case report highlights the practical advantage of continuous femoral nerve block (CFNB)s over epidural anaesthesia.

Acinetobacter indicus sp. nov., isolated from a hexachlorocyclohexane dump site.

The taxonomic position of a Gram-negative, non-motile, oxidase negative and catalase positive strain, A648(T), isolated from a hexachlorocyclohexane (HCH) dump site located in Lucknow, India, was ascertained by using a polyphasic approach. A comparative analysis of a partial sequence of the rpoB gene and the 16S rRNA gene sequence revealed that strain A648(T) belonged to the genus Acinetobacter. DNA-DNA relatedness values between strain A648(T) and other closely related members (16S rRNA gene sequence similarity greater than 97%), namely Acinetobacter radioresistens DSM 6976(T), A. venetianus ATCC 31012(T), A. baumannii LMG 1041(T), A. parvus LMG 21765(T) A. junii LMG 998(T) and A. soli JCM 15062(T), were found to be less than 8%. The major cellular fatty acids of strain A648(T) were 18:1ω9c (19.6%), summed feature 3 (15.9%), 16:0 (10.6%) and 12:0 (6.4%). The DNA G+C content was 40.4 mol%. The polar lipid profile of strain A648(T) indicated the presence of diphosphatidylglycerol, phosphatidylethanolamine, followed by phosphatidylglycerol and phosphatidylcholine. The predominant polyamine of strain A648(T) was 1,3-diaminopropane and moderate amounts of putrescine, spermidine and spermine were also detected. The respiratory quinone consisted of ubiquinone with nine isoprene units (Q-9). On the basis of DNA-DNA hybridization, phenotypic characteristics and chemotaxonomic and phylogenetic comparisons with other members of the genus Acinetobacter, strain A648(T) is found to be a novel species of the genus Acinetobacter, for which the name Acinetobacter indicus sp. nov. is proposed. The type strain is A648(T) ( = DSM 25388(T) = CCM 7832(T)).

Sphingobium lactosutens sp. nov., isolated from a hexachlorocyclohexane dump site and Sphingobium abikonense sp. nov., isolated from oil-contaminated soil.

The taxonomic position of a yellow-pigmented bacterial strain, designated DS20T, isolated from a hexachlorocyclohexane dump site at Lucknow, India was determined based on a polyphasic taxonomic characterization. A neighbour-joining tree based on 16S rRNA gene sequences showed that strain DS20T occupied a distinct phylogenetic position in the Sphingobium cluster, showing highest similarity with 'Pseudomonas abikonensis' IAM 12404 (98.8%), followed by Sphingobium rhizovicinum CC-FH12-1T (97.4%) and Sphingobium olei IMMIB HF-1T (97.2%). Therefore, the taxonomic characterization of 'P. abikonensis' NBRC 16140 was also undertaken. Phylogenetic, chemotaxonomic and morphological analyses, based on signature sequences, DNA-DNA hybridizations, fatty acid profiles, physiological characterizations and polar lipid profiles confirmed that both strains DS20T and 'P. abikonensis' NBRC 16140 represent two distinct species of the genus Sphingobium. Therefore, two novel Sphingobium species are proposed, Sphingobium lactosutens sp. nov. (type strain, DS20T=CCM 7540T=MTCC 9471T) and Sphingobium abikonense sp. nov. (type strain, NBRC 16140T=IAM 12404T=KCTC 2864T).