Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study.

BACKGROUND: Lung interstitial edema is a clinically silent pathology that develops before overt pulmonary edema among pre-eclamptic women with severe features. Point-of-care lung ultrasonography (LUS) has been suggested as an accessible bedside tool that may identify lung interstitial edema before developing clinical signs and symptoms. Thus, we planned to use bedside LUS as a diagnostic tool in admitted pre-eclamptic women with severe features, with the aim of identifying alveolar-interstitial fluid, seen as B-lines. Our primary objective was to assess the incidence of interstitial alveolar syndrome on lung ultrasonography. METHODS: We conducted a prospective, single-center, observational study on parturients with pre-eclampsia with severe features over a period of 15 months. LUS in 4 intercostal spaces (ICS) was performed on all eligible patients. The number of single or confluent B-lines in each space was recorded by an independent observer. A scoring system was used to grade the lung fluid content based on the number of single and confluent B-lines per ICS, with scores ranging from 0 to 32 (low, 0-10; moderate, 11-20; and high, 21+). The incidence of B-lines at admission and before and after delivery was calculated. In addition, bedside 2D echocardiography was performed to assess left ventricular systolic and diastolic function. Any correlation between presence of B-lines on LUS and blood pressure, clinical symptoms, or echocardiography findings was assessed. RESULTS: Seventy patients were enrolled in the study. On LUS, B-lines were seen in 64.3% patients at admission (45/70 vs 25/70 without B-lines; P = .02), 65.7% patients before delivery (46/70 vs 24/70 without B-lines; P = .01), and 58.6% patients 24 hours postpartum (41/70 versus 29/70 without B-lines; P = .15). Nearly all patients (94.3%) exhibited low to moderate severity of pulmonary fluid burden at admission. Echocardiography revealed diastolic dysfunction in 47.1% (n = 33/70) patients with associated B-lines in the majority (n = 32/33). The total B-line score and E/e' ratio among patients with diastolic dysfunction was found to be strongly correlated (r = 0.848; P < .001). All pre-eclamptic women with presence of breathlessness (11/11; 100%) and facial puffiness (16/16; 100%) on admission had B-lines on LUS. CONCLUSIONS: We conclude that ultrasonographic pulmonary interstitial syndrome is present in more than half of the women with pre-eclampsia with severe features and correlates with diastolic dysfunction, high blood pressure records, and acute-onset breathlessness.

A Prospective, Randomized Comparison of the Classical Altemir's Method With the Newer Seldinger's Technique of Submental Intubation.

BACKGROUND: Submental intubation performed using the classical Altemir's technique is a well-accepted, safe technique for providing optimal operating field to the maxillofacial surgeon, in cases where either nasotracheal or orotracheal intubation is impossible. We propose a new, percutaneous Seldinger's technique of submental intubation as an interesting alternative to the classical Altemir's technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract, instead of bluntly dissecting it. We hypothesized that Seldinger's technique would be associated with reduced procedure time and minimal scar formation in patients with maxillofacial fractures. METHODS: We enrolled 60 patients scheduled to undergo maxillofacial injury fixation under general anesthesia. After consent, the cohort was randomly allocated to undergo submental intubation by either the classical Altemir's technique or Seldinger's technique. As our primary objective, we noted the time taken to complete the procedure of submental intubation. Our secondary objectives were the components of primary outcome, such as disconnection/apnea time, bleeding, and technical difficulties during the procedure. We also observed for complications such as presence of salivary fistula/infection at hospital discharge and scar characteristics at 1- and 3-month follow-up. RESULTS: The median time for performing submental intubation in the Seldinger group was significantly lower than that in the Altemir group (170.5 [136.5-256.0] seconds vs 220.0 [205.5-289.0] seconds; P value, .040). The median disconnection time was also significantly lower in the Seldinger group (12.0 [10.8-20.0] seconds vs 19.0 [15.0-23.0] seconds; P value, .036). Furthermore, significant bleeding was absent in nearly 53.8% of the study participants in the Seldinger group as compared to 25.9% in the Altemir group. At follow-up, there was no evidence of differences in scar characteristics between the 2 groups. CONCLUSIONS: Seldinger's technique is associated with shorter procedure time and reduced apnea time due to easier and better tract formation, thus minimizing the effort required to exteriorize the endotracheal tube. Furthermore, as dilation reduces tissue damage, Seldinger's technique is associated with significantly less procedural bleeding. Thus, Seldinger's technique can be safe, easy, and faster to perform compared with the classical Altemir's technique of submental intubation in patients with maxillofacial trauma.

Conformational spread and dynamics in allostery of NMDA receptors.

Allostery can be manifested as a combination of repression and activation in multidomain proteins allowing for fine tuning of regulatory mechanisms. Here we have used single molecule fluorescence resonance energy transfer (smFRET) and molecular dynamics simulations to study the mechanism of allostery underlying negative cooperativity between the two agonists glutamate and glycine in the NMDA receptor. These data show that binding of one agonist leads to conformational flexibility and an increase in conformational spread at the second agonist site. Mutational and cross-linking studies show that the dimer-dimer interface at the agonist-binding domain mediates the allostery underlying the negative cooperativity. smFRET on the transmembrane segments shows that they are tightly coupled in the unliganded and single agonist-bound form and only upon binding both agonists the transmembrane domain explores looser packing which would facilitate activation.

The effect of Bacillus coagulans Unique IS-2 supplementation on plasma amino acid levels and muscle strength in resistance trained males consuming whey protein: a double-blind, placebo-controlled study.

PURPOSE: The aim of the present study was to assess the effect of Bacillus coagulans Unique IS-2 supplementation on absorption and utilization of protein in resistance-trained males. METHODS: In this double blind, placebo-control trial, resistance-trained males (21.08 ± 2.84 years) were randomized to consume, either 20 g of whey protein powder {80% whey protein concentrate (WPC80), amounting to 15.4 g protein} with 2 billion CFU Bacillus coagulans Unique IS-2 (supplemental group) or 20 g of whey protein powder and lactose instead of Bacillus coagulans (placebo group) once daily for 60 days with a controlled resistance exercise protocol. The whey protein concentrate (WPC-80) given to both groups had a lactose content of 6.8%. Plasma-free amino acids (PFAAs) were determined at baseline, at 30 and 60 days of supplementation. Muscle strength, hypertrophy, VO2 max, and body composition, and other biochemical parameters were assessed at baseline and end line. RESULTS: A positive effect of probiotic Bacillus coagulans Unique IS-2 supplementation was observed on protein absorption as evidenced by an increase in total PFAA by + 16.1% (p = 0.004). Branched chain amino acids (BCAA) comprising isoleucine (p = 0.016), leucine (p = 0.001), and valine (p = 0.002) were increased by + 33.1% in ITT analysis as compared to placebo after 60 days. At 30 days an increase in isoleucine by + 35% (p = 0.113), leucine by + 43% (p = 0.032), and valine by + 32% (p = 0.017) was observed in ITT analysis. Probiotic effect was shown on exercise performance as evidenced by an increase in one RM of leg press and vertical jump power by + 16.61% (p = 0.024) and + 7.86% (p = 0.007), respectively. CONCLUSION: Significantly increased absorption of BCAA with supplementation of B. coagulans Unique IS-2 along with whey protein and improvement in leg press and vertical jump power was noted indicating the positive effect of the probiotic on muscle power in the lower body. TRIAL REGISTRATION NUMBER: CTRI/2017/03/008117; Date:16.03.2017.

Prone cardiopulmonary resuscitation: Relevance in current times.

The most common and recommended position for performing cardiopulmonary resuscitation (CPR) is the supine position. However, clinicians may encounter situations when patients suffer cardiac arrest in prone position. Prone CPR has been described previously in a number of settings, most commonly intraoperative. In the current COVID-19 era, with more patients being nursed in prone position, an increase in the incidence of cardiac arrests requiring prone CPR is expected. Hence most of the resuscitation guidelines have made prone CPR a vital component of their recommendations. To date, most of our health-care workers have limited knowledge about prone resuscitation and the literature surrounding it. Nonetheless, with the current evidence at hand, it seems to be a reliable method of providing resuscitation and all health-care workers should be well versed with it. Thus, the goal of this narrative review is to try and fill the gaps in our knowledge about prone CPR. Literature search was done on PubMed, Medline, EMBASE using keywords 'CPR', 'Resuscitation', 'Prone Position', 'Prone', 'Prone CPR'.

Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review.

Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed.

Activity Dependent Inhibition of AMPA Receptors by Zn2.

Zn2+ has been shown to have a wide range of modulatory effects on neuronal AMPARs. However, the mechanism of modulation is largely unknown. Here we show that Zn2+ inhibits GluA2(Q) homomeric receptors in an activity- and voltage-dependent manner, indicating a pore block mechanism. The rate of inhibition is slow, in the hundreds of milliseconds at millimolar Zn2+ concentrations; hence, the inhibition is only observed in the residual nondesensitizing currents. Consequently, the inhibition is higher for GluA2 receptors in complex with auxiliary subunits γ2 and γ8 where the residual activation is larger. The extent of inhibition is also dependent on charge at site 607, the site that undergoes RNA editing in GluA2 subunits replacing glutamine to arginine, with the percent inhibition being lower and IC50 being higher for the edited GluA2(R) relative to unedited GluA2(Q) and to GluA2(Q607E), a mutation observed in the genetic screen of a patient exhibiting developmental delays. We also show that Zn2+ inhibition is significant during rapid repetitive activity with pulses of millimolar concentrations of glutamate in both receptors expressed in HEK cells as well as in native receptors in cortical neurons of C57BL/6J mice of either sex, indicating a physiological relevance of this inhibition.SIGNIFICANCE STATEMENT Zn2+ is present along with glutamate in synaptic vesicles and coreleased during synaptic transmission, modulating the postsynaptic ionotropic glutamate receptors. While Zn2+ inhibition of the NMDA subtype of the ionotropic glutamate receptors is well characterized, the mechanism of modulation of the AMPA subtype is much less known. Here we have systematically studied Zn2+ inhibition of AMPARs by varying calcium permeability, auxiliary subunits, and activation levels and show that Zn2+ inhibits AMPARs in an activity-dependent manner, opening up this pathway as a means to pharmacologically modulate the receptors.

Median Effective Volume of 0.5% Ropivacaine for Ultrasound-guided Costoclavicular Block.

BACKGROUND: The median effective dose of ropivacaine required for producing an effective costoclavicular block has not yet been determined. The authors conducted this dose-finding study with the objective of determining the median effective dose of 0.5% ropivacaine required to produce a successful costoclavicular block for surgical anesthesia in 50% of the patients (ED50) as well as the calculated dose required for effective blockade in 95% of the patients (ED95). METHODS: This single-armed prospective study was conducted on 40 American Society of Anesthesiologists physical status I or II patients, aged 18 to 60 yr, with a body mass index of 18 to 30 kg/m2, scheduled to undergo forearm and hand surgeries under ultrasound-guided costoclavicular block. A volume of 0.5% ropivacaine administered in the costoclavicular space was determined using the sample up-and-down sequential allocation study design of binary response variables. The first patient received a volume of 26 ml of 0.5% ropivacaine. After a successful or unsuccessful block, the volume of local anesthetic was decreased or increased, respectively, by 2 ml in the next patient. Evaluation of sensory and motor block was performed every 5 min for 30 min and graded using a 3-point scale. Surgical anesthesia was considered to be successful if a minimum score of 14 was achieved and the surgeon was able to proceed with surgery without needing to supplement anesthesia. RESULTS: The volume of local anesthetic administered ranged from 8 to 26 ml. Centered isotonic regression with a bias-corrected Morris 95% CI derived by bootstrapping showed ED50 of 13.5 ml (95% CI, 11.5 to 15.4 ml) and ED95 of 18.9 ml (95% CI, 17.9 to 27.5 ml). CONCLUSIONS: A 19-ml dose of 0.5% ropivacaine is likely to produce an effective ultrasound-guided costoclavicular block for providing adequate surgical anesthesia to 95% of the patients.

Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis.

BACKGROUND: Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures. OBJECTIVE: We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department. METHODS: Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4 h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome. RESULTS: Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4 h with mean difference of 1.59 (95% CI, 0.59-2.59, p = 0.002) with I2 = 96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30 min and lasted till 4 h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay. CONCLUSIONS: FICB is associated with significant pain relief both at rest and on movement lasting up to 4 h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary.

Sonographic Optic Nerve Sheath Diameter Following Seizure Prophylaxis in Pre-Eclamptic Parturients With Severe Features: A Prospective, Observational Study.

OBJECTIVES: Neurological manifestations, including raised intracranial pressures, are a hallmark of worsening pre-eclampsia. Invasive methods for measuring intracranial pressure, though a gold standard, are not always a viable option. Maternal ocular sonography is a promising bedside tool, which serves as a noninvasive, cost-effective means for measuring optic nerve sheath diameter (ONSD), a surrogate marker of raised intracranial pressures. We studied the ultrasonographically measured ONSD in severely pre-eclamptic women, and the effect of magnesium sulfate therapy on its values. METHODS: Thirty severely pre-eclamptic women at ≥28 weeks gestation were included. We recorded baseline ONSD values, serum magnesium levels, neurological symptoms, vitals, and repeated them at 4 and 12 hours following magnesium sulfate therapy, and then at 24 hours postpartum. An ONSD value >5.8 mm was suggestive of raised intracranial pressure. Primary outcome measure was to evaluate changes in ultrasonographically measured ONSD following seizure prophylaxis with magnesium sulfate. RESULTS: Women, 73.3%, had baseline ONSD >5.8 mm, with mean diameter being significantly high (6.02 ± 0.77 mm). There was a statistically nonsignificant decline in mean ONSD values at 4 and 12 hours, as well as at 24 hours postpartum. Patients with neurological symptoms declined significantly (from 70 to 10%; p value <.001) following magnesium sulfate therapy. CONCLUSIONS: Majority of severely pre-eclamptic parturients had high ONSD value suggestive of raised intracranial pressures, which persisted in the postpartum period and was unaffected by magnesium sulfate therapy. Ultrasound can thus serve as a point-of-care, cost-effective, easily available bedside tool for indirectly measuring intracranial pressures in this high-risk population.

The analgesic effectiveness of ilioinguinal-iliohypogastric block for caesarean delivery: A meta-analysis and trial sequential analysis.

BACKGROUND: An effective analgesia strategy following caesarean delivery should be designed to improve fetomaternal outcomes. Much recent research has focused on the efficacy of ilioinguinal-iliohypogastric (II-IH) block for providing such analgesia. DESIGN: A systematic review and meta-analysis of randomised controlled trials. OBJECTIVES: To investigate the effectiveness of II-IH block in patients undergoing caesarean delivery. The primary outcome was the cumulative parenteral morphine equivalents at 24 h. Pain scores at 4 to 6 and 24 h postsurgery, time to first rescue analgesia and adverse effects were the secondary outcomes analysed. DATA SOURCES: Two reviewers searched independently PubMed, Embase, Google Scholar and the Cochrane central registers of a controlled trial from their inception until June 2020. METHODOLOGY: Prospective randomised control trials comparing II-IH block with either systemic analgesia alone or a placebo block (non-active controls) were eligible for inclusion. Only trials that reported their methods comprehensibly and transparently were included. Cochrane methodology was used to assess the risk of bias. Data are presented as mean difference with 95% confidence interval (CI). RESULTS: Thirteen trials comprising a total of 858 patients were included. Opioid (intravenous morphine equivalents) consumption was reduced by 15.57 mg (95% CI -19.87 to -11.28; P < 0.00001; I2 = 95%) during the first 24 h in patients receiving II-IH block when compared with placebo or no block. Patients receiving general anaesthesia showed a greater reduction in morphine requirement at 24 h than those receiving neuraxial anaesthesia. Adequate 'information size' for the above outcome was confirmed with trial sequential analysis to rule out the possibility of a false-positive result. II-IH also significantly reduced pain scores at rest more so at 4 to 6 h than at 24 h. CONCLUSIONS: Our study suggests that the use of II-IH blocks is associated with a lower 24 h requirement for intravenous morphine equivalents in patients undergoing caesarean delivery. However, given the methodological limitations, data should be interpreted with caution until more studies are available.

Containment of varicella outbreak in intensive care unit of a tertiary level hospital.

BACKGROUND: Varicella-Zoster virus (VZV) infection in healthcare organizations, especially in intensive care units (ICU), having admitted immunocompromised patients, is of serious concern as well as poses threat to healthcare workers working in such critical areas. The present report defines the transmission and infection control measures initiated to curtail VZV infection spread in the trauma ICU of a tertiary care hospital of North India. OUTBREAK REPORT: At the infection outset, there were 12 patients admitted in ICU and 54 healthcare workers were posted to manage these critical patients. After confirmation of VZV infection, all susceptible patients as well as healthcare workers were quarantined and fresh intake of patients was restricted. Out of the total healthcare workers, 14 (25.92%) were found susceptible (as per protective VZV IgG titers) and were vaccinated. Of the 12 patients admitted in the ICU, six patients were discharged and sent home directly, four patients expired due to their critical disease state, one patient left against medical advice, and one patient remained admitted in ICU till the incubation period was over. Epidemiologically, line listing for index case reporting was done. The efficacy of control measures was re-evaluated to strengthen existing infection control practices and general measures viz. strict hand washing, adherence to aseptic protocols and intensification of environmental cleaning. CONCLUSIONS: Established varicella surveillance measures ensure VZV outbreaks are identified in a timely manner and control measures implemented to prevent further transmission. Also, vaccination policy among HCWs is the utmost requirement despite having huge financial implications.

Allosteric Changes in the NMDA Receptor Associated with Calcium-Dependent Inactivation.

N-methyl-D-aspartate (NMDA) receptors mediate synaptic excitatory signaling in the mammalian central nervous system by forming calcium-permeable transmembrane channels upon binding glutamate and coagonist glycine. Ca2+ influx through NMDA receptors leads to channel inactivation through a process mediated by resident calmodulin bound to the intracellular C-terminal segment of the GluN1 subunit of the receptor. Using single-molecule FRET investigations, we show that in the presence of calcium-calmodulin, the distance across the two GluN1 subunits at the entrance of the first transmembrane segment is shorter and the bilobed cleft of the glycine-binding domain in GluN1 is more closed when bound to glycine and glutamate relative to what is observed in the presence of barium-calmodulin. Consistent with these observations, the glycine deactivation rate is slower in the presence of calcium-calmodulin. Taken together, these results show that the binding of calcium-calmodulin to the C-terminus has long-range allosteric effects on the extracellular segments of the receptor that may contribute to the calcium-dependent inactivation.

Tranexamic Acid Is Associated With Improved Operative Field in Orthognathic Surgery.

PURPOSE: In the past, both tranexamic acid and dexmedetomidine have been used separately to decrease intraoperative blood loss during orthognathic surgery. However, their combined use in the same setting has never been prospectively evaluated. The present study was conducted to evaluate the effect of tranexamic acid on operative field visibility and blood loss during orthognathic surgery after dexmedetomidine-induced hypotensive anesthesia. PATIENTS AND METHODS: The present prospective, randomized clinical trial included patients who had undergone orthognathic surgery under general anesthesia. The patients were divided into 2 groups. The dexmedetomidine and tranexamic (DT) group received an intravenous bolus of tranexamic acid (15 mg/kg) and intravenous dexmedetomidine (0.25 to 0.7 µg/kg/hr) as maintenance infusion. The dexmedetomidine (DS) group received only intravenous dexmedetomidine at the same dosage. All the patients received a bolus dose of intravenous dexmedetomidine (1 µg/kg) before the start of anesthesia induction. The operating surgeon rated the quality of the surgical visual field every 15 minutes using the Fromme ordinal scale. Intraoperative blood loss was estimated using the modified gross formula. The operating surgeon's satisfaction was assessed using a Likert scale. Data were analyzed using SPSS, version 22.0 (IBM Corp, Armonk, NY). Kolmogorov-Smirnov tests were used to assess the normality of the measured data, and categorical variables were analyzed using the χ2 or Fischer exact test. RESULTS: The study sample included 36 patients, with a mean age of 23.67 ± 11.298 years in the DS group and 20.28 ± 3.286 years in the DT group. Of the patients in the DS and DT groups, 66.66 and 61.11% were male, respectively. No statistically significant differences were found in the baseline characteristics between the 2 treatment groups. The surgeon reported a significantly better surgical visual field in the DT group compared with that in the DS group (P = .001). Also, the intraoperative blood loss significantly less in the DT group (231.11 ± 137.64 mL vs 360.17 ± 187.86 mL; P = .025). CONCLUSIONS: Tranexamic acid improved surgical field visibility and reduced intraoperative blood loss when administered in conjunction with dexmedetomidine during orthognathic surgery under controlled hypotensive anesthesia.

Management of pregnant laboring women during COVID-19 pandemic.

Since its first outbreak in December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has become a global public health threat. In the midst of this rapidly evolving pandemic condition, the unique needs of pregnant women should be kept in mind while making treatment policies and preparing response plans. Management of COVID-19 parturients requires a multidisciplinary approach consisting of a team of anesthesiologists, obstetricians, neonatologists, nursing staff, critical care experts, infectious disease, and infection control experts. Labor rooms as well as operating rooms should be in a separate wing isolated from the main wing of the hospital. In the operating room, dedicated equipment and drugs for both neuraxial labor analgesia and cesarean delivery, as well as personal protective equipment, should be readily available. The entire staff must be specifically trained in the procedures of donning, doffing, and in the standard latest guidelines for disposal of biomedical waste of such areas. All protocols for the management of both COVID-19 suspects as well as confirmed patients should be in place. Further, simulation-based rehearsal of the procedures commonly carried out in the labor room and the operation theaters should be ensured.

Maternal hyperuricemia as a marker of post-spinal hypotension and uterine tone during cesarean delivery: a prospective observational study.

PURPOSE: Raised serum uric acid, a marker of oxidative stress, is known to increase vascular tone and depress myometrial contractility. A rise in serum uric acid levels has also been reported during labor, warranting its correlation with post-spinal hypotension and uterine tone. METHODS: Serum UA sample was drawn from enrolled healthy, laboring parturients. Of these, 100 women who required emergency cesarean delivery were re-sampled prior to surgery. Following spinal anesthesia we recorded episodes of hypotension (MAP < 80% of baseline), use of vasopressors and supplemental uterotonics. The primary outcome was maternal hyperuricemia (1SD > appropriate for gestation age) and its correlation with post-spinal hypotension. Secondary outcomes were total vasopressors used, duration of labor and its effect on uric acid levels, uterine tone and neonatal outcome. RESULTS: Hyperuricemia was observed in 33% of parturients. On comparing with women showing normal uric acid levels, hyperuricemic parturients experienced significantly lower incidence of post-spinal hypotension (45.5% vs. 67.2%; p value = 0.04) and lower vasopressor usage (p value = 0.06). Clinically, an increased use of supplemental uterotonics in these parturients was noted (p = 0.20). The duration of labor had no impact on uric acid levels. Neonatal outcome was unaffected. CONCLUSIONS: In healthy, normotensive parturients undergoing emergency cesarean delivery, maternal hyperuricemia is associated with lower incidence of post-spinal hypotension and reduced need of vasopressors. Elevated serum uric acid levels may also be associated with decreased uterine tone, necessitating greater requirement of supplemental uterotonics. However, further prospective trials are needed to strongly establish this association.

Ultrasound guided superior laryngeal nerve block as an adjuvant to generalanesthesia during endoscopic laryngeal surgery: A prospective, randomized, double-blind trial.

INTRODUCTION: Blindly administered bilateral (B/L) superior laryngeal nerve (SLN) blocks, have been used to decrease the perioperative stress response of endoscopic laryngosurgeries. Use of ultrasound (USG) for giving these blocks is more likely to be successful, with fewer complications. We evaluated the efficacy of USG guided B/L SLN block in decreasing perioperative cough, sore-throat and hoarseness of voice. MATERIAL AND METHODS: This study was conducted on forty patients undergoing endoscopic laryngosurgery under GA. Patients were randomized into two groups of 20 patients each. Patients in group C received GA, whereas those in group L received USG-guided SLN block bilaterally with 2.5 ml of 2% lignocaine, along with GA. Postoperative cough, sore throat and hoarseness of voice was measured at 30 min, 2 h, 4 h and 24 h following transfer to post-anesthesia care unit. RESULTS: Patients receiving SLN block had significantly lower incidence of perioperative cough (20% in group L vs 90% in group C; p value - 0.0001) as well as sore throat (5% in group L vs 95% in group C; p value - 0.0001). In these patients, severity of hoarseness of voice was greater in the early postoperative period (100% in group L vs 70% in group C; p value - 0.027), while it decreased significantly at 24 h postoperatively(0.0% in group L vs 30% in group C; p value - 0.027). CONCLUSION: USG guided SLN block as an adjuvant to GA resulted in better recovery profile of the patients with significant reduction in postoperative cough, sore throat and hoarseness of voice.

Effect of dexamethasone on analgesic efficacy of transverse abdominis plane block in laparoscopic gynecological procedures: A prospective randomized clinical study.

BACKGROUND AND AIMS: Dexamethasone has been increasingly used as an adjuvant to local anesthetics in peripheral nerve blocks with various studies showing an opioid sparing the effect of intravenous (IV) dexamethasone as well in a multimodal analgesia technique. It is not clear whether this effect of dexamethasone is because of its peripheral action or because of its systemic absorption. In our study, we compared the effectiveness of dexamethasone on duration of analgesia when used as an adjuvant with local anesthetic in transverse abdominis plane block (TAP) versus when given systemically by IV route along with block only, in patients undergoing laparoscopic gynecological procedures under general anesthesia (GA). MATERIAL AND METHODS: This is a prospective, randomized, parallel treatment, double-blinded study. The primary outcome of our study was the time to administration of first rescue analgesia. Forty patients were randomly assigned to perineural (PN) and IV Group using a computer-generated random numbers table and allocated using sealed opaque envelopes technique. After induction of GA, PN group received ultrasound guided TAP block with 15 ml of 0.25% levobupivacaine plus 4 mg (1 ml) dexamethasone on each side. Patients in IV group received TAP block on both sides with 15 ml of 0.25% levobupivacaine and 8 mg IV dexamethasone. RESULTS: Time to request for first rescue analgesia was 6.63 ± 1.5 h in PN group and 5.04 ± 1.7 h in IV group. Pain scores were comparable in both the groups. CONCLUSION: Dexamethasone administered in either of the routes has comparative effect on quality of analgesia of TAP block with 0.25% levobupivacaine.

Primary Cutaneous Mucormycosis in a Trauma Patient with Morel-Lavallée Lesion.

Mucormycosis is an aggressive fungal infection caused by zygomycetes from the order of Mucorales. Immunocompromised patients or patients with comorbidities are susceptible to this infection. There are many forms of mucormycosis such as rhino-orbito-cerebral, cutaneous, gastrointestinal, and pulmonary. Cutaneous mucormycosis is rare in trauma patients with no comorbidities. Morel-Lavallée lesions are rare degloving injuries in trauma patients. We report a case of cutaneous mucormycosis in a trauma patient with the Morel-Lavallée lesions.

Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study.

BACKGROUND: Children undergoing computerized tomography (CT) frequently require sedation to allay their anxiety, and prevent motion artifacts and stress of intravenous (IV) cannulation. AIMS: The aim of this trial was to compare the effectiveness of oral midazolam and intranasal dexmedetomidine as sole premedicants in children for carrying out both IV cannulation as well as CT scanning, without the need for additional IV sedatives. METHODS: Fifty-nine children, aged 1-6 years, scheduled to undergo CT imaging under sedation were randomized to receive either 0.5 mg·kg-1 oral midazolam (group M) or 2.5 mcg·kg-1 intranasal dexmedetomidine (group D). After 20-30 min, intravenous cannulation was performed and response to its placement was graded using the Groningen Distress Rating Scale (GDRS). After cannulation, children were transferred on the CT table, and assessed using the Ramsay sedation score (RSS). CT imaging was performed without any further sedative if the RSS was ≥4. If there was movement or decrease in sedation depth (RSS ≤ 3), ketamine 1 mg·kg-1 IV was given as an initial dose, followed by subsequent doses of 0.5 mg·kg-1 IV if required. RESULTS: A Significantly higher proportion of children in group D (67%) achieved RSS ≥ 4 as compared to group M (24%) (P-0.002). The risk ratio (95% CI) was 2.76 (1.38-5.52). Significantly lower GDRS scores were noted in group D (1(1-2)) as compared to group M (2(1-2)) at the time of venipuncture (P = 0.04). CONCLUSION: In the doses and time intervals used in our study, intranasal dexmedetomidine (2.5 µg·kg-1 ) was found to be superior to oral midazolam (0.5 mg·kg-1 ) for producing satisfactory sedation for CT imaging.