Transurethral lidocaine (100 mg) bladder irrigation (TULI100) reduces the incidence of catheter related bladder discomfort in transurethral resection of bladder tumors: A randomized, double blind, controlled trial.

BACKGROUND: Transurethral resection of bladder tumors (TURBT) surgeries requires post-resection catheterization for continuous irrigation of the bladder. This indwelling catheter is associated with distressing catheter-related bladder discomfort (CRBD) and increases postoperative pain and agitation. OBJECTIVES: To prove the hypothesis that transurethral 100 mg lidocaine irrigation at the end of TURBT can reduce the frequency of moderate-to-severe postoperative CRBD. METHODS: 116 patients scheduled for TURBT were screened, 94 were recruited and completed the study. American Society of Anesthesiologists Physical Status I-II adult patients, 20-75 years of age undergoing elective TURBT surgery under general anesthesia were included. Transurethral normal saline with 0.01% lidocaine (100 mg in 1 L NS) was used for irrigation 30 min before the completion of surgery in group L, while only normal saline was used for transurethral irrigation in group N. The main outcomes were frequency of CRBD, pain and patient satisfaction at 0, 1, 2, and 6 h postoperatively. RESULTS: A total of 94 patients were analyzed in the study. The incidence of moderate-severe CRBD was significantly lower in group L as compared to group C at 0, 1, and 2 h (65.9% vs. 31.9%, p = 0.01; 31.9% vs. 10.6%, p = 0.012; 21.3% vs. 2.1%, p = 0.004, respectively). At the 6-h mark, the incidence of CRBD was lower in group L, although this did not achieve statistical significance (6.38% vs. 2.1%; p = 0.613). CONCLUSION: Irrigation with 0.01% lidocaine (100 mg) towards the end of TURBT reduces the incidence of moderate-severe CRBD by 52% and increases patient satisfaction.

Comparative evaluation of ultrasound guided supraclavicular and infraclavicular subclavian venous catheterizations in adult patients.

Background and Aims: Ultrasound-guided subclavian vein cannulation has two approaches: supraclavicular and infraclavicular. The aim of this study was to compare the ease of cannulation by recording the puncture time of the subclavian vein with the two approaches in adult patients. Material and Methods: This study was approved by our institutional ethics committee, and a written informed consent was obtained from the patients. This prospective randomized trial recruited patients aged 18 to 80 years with definite indications of subclavian vein cannulation. Real-time in-plane ultrasound-guided technique was used, and the subclavian vein was punctured at the junction of the brachiocephalic and IJV in supraclavicular approach (SC) and in oblique axis below the border of the clavicle in infraclavicular approach (IC). Results: A total of 96 patients were randomly allocated equally into two groups of 48 each, but only 45 patients in each group could be successfully cannulated. Median puncture times were comparable; 15 (9-39) s in SC and 21 (5-80) s in IC group. The first attempt success rate was 82.2% and 62.2%, and the mean total access time was 99.11 ± 34.66 s and 103.44 ± 50.27 s in SC and IC approaches, respectively and were comparable. The attempts of needle puncture were significantly higher in IC approach (1.40 ± 0.54 vs 1.20 ± 0.46 in SC approach; P = 0.04). The complication rates were comparable and less than 5%. Conclusion: Ease of cannulation of the subclavian vein using ultrasound-guided supraclavicular and infraclavicular approach is comparable as no statistically significant difference is noted in the puncture time and first-attempt success rate. The increased number of needle punctures reported in our study with the IC approach did not translate to an increased complication rate.

Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety.

BACKGROUND: Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS: This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS: Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION: Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.

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.

Comparative evaluation of optic nerve sheath diameter in patients undergoing laparoscopic cholecystectomy using low and standard pressures of gas insufflations.

Background and Aims: Intra-abdominal insufflation of CO2 is associated with an increase of intracranial pressure (ICP). We conducted this randomized control trial to compare the impact of low vs standard pressure pneumoperitoneum on ICP through the ultrasonographic estimation of the optic nerve sheath diameter (ONSD). Material and Methods: Patients of age group 18-80 years planned for laparoscopic cholecystectomy were randomly allocated into two groups; group S (standard pressure of 12-16 mmHg) and group L (low pressure of 8-10 mmHg) on the basis of intra-abdominal pressures used for the surgery. All were administered general anesthesia and end-tidal carbon dioxide (ETCO2) was maintained between 35 and 40 mmHg and peak airway pressures less than 35 cmH2O. ONSD was measured in either eye at a point 3 mm posterior to the globe at following time intervals; baseline, 5 min after induction, 10 min after insufflation, 10 min after reverse Trendelenburg, intraoperatively during surgery and after exsufflation in the supine position. Results: The demographic profile and operative times were comparable. ONSD was measured in 100 patients in each group for both the eyes and no patient had values above the cutoff value of 5.0 mm. No significant difference in the ONSD was observed at the above mentioned time intervals between the groups. There was a statistically significant lower value of the heart rate and mean arterial pressure in the low-pressure group. Conclusion: Intra-abdominal insufflation of CO2 at standard and low pressures does not increase ICP in short duration surgeries and thus both the pressures can be safely used in adult patients operated in reverse Trendelenburg position. Advantages of low pressure were limited to better hemodynamic control.

Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study.

INTRODUCTION: Extra vascular lung water (EVLW) is defined as the amount of fluid in the interstitial and alveolar spaces. Primary aim of this study was to assess EVLW using lung USG (B lines >3 per lung field) in critically ill head injured patients. MATERIALS AND METHODS: Intubated adult patients admitted in Trauma ICU with head injury (GCS 4-15) were assessed by daily chest X-ray and lung ultrasonography. Lung water content was graded based on the number of B lines per ICS with score ranging from 0-32 and categorized as low pulmonary fluid burden (0-10), moderate fluid burden (11-20) and high fluid burden (21-32). RESULTS: 140 critically ill head injured patients were assessed for eligibility and 20 excluded. Incidence of increased EVLW using lung USG was 61.66% (74/120) and the incidence reported using chest x ray was 40.83%(49/120) and the difference was statistically significant (p value <0.001). Increased EVLW significantly increased the duration of weaning, mechanical ventilation and ICU stay (p value <0.05). Significant association was observed between APACHE II, SAPS II and GCS at admission to ICU with presence of EVLW (p value ≤0.001). Mean delay in identification of EVLW by chest X-ray (CXR) compared to lung ultrasound was 1.42±0.76 days. CONCLUSION: Lung ultrasound is better than CXR for early detection of increased EVLW in critically ill head injured patients and has prognostic relevance as increased EVLW prolongs duration of mechanical ventilation and ICU stay. HOW TO CITE THIS ARTICLE: Gattupalli V, Jain K, et al. Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study. Indian J Crit Care Med 2019;23(3):131-134.

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 short-axis out-of-plane versus long-axis in-plane ultrasound-guided radial arterial cannulation in adult patients: a randomized controlled trial.

BACKGROUND: The current available literature is not unanimous in reporting the utility of short-axis and long-axis techniques for radial artery cannulation in both adults and children. This study was designed to compare short-axis out-of-plane (SA-OOP) and long-axis in-plane (LA-IP) techniques in ultrasound-guided radial artery cannulation in adults. METHODS: In this prospective randomized controlled trial, 150 adult patients of American Society of Anesthesiologists physical status I-III aged between 18 and 70 years were included. All patients were randomized into two groups (group SA-OOP) and (group LA-IP) of 75 each undergoing ultrasound-guided radial artery cannulation. The primary outcome was successful cannulation in the first attempt. Secondary outcomes included antero-posterior arterial diameter, skin-to-artery distance, ultrasonic localization time, cannulation time, no of attempts to cannulate artery, cannula insertion failure, and vascular complications. RESULTS: First-attempt arterial cannulation was successful in 80 % of patients in the SA-OOP group as opposed to 82.6 % patients in the LA-IP group (p = 0.67). The time to cannulate the artery was similar between the two groups, but the time to localize artery was significantly higher in the long-axis technique (p < 0.001). CONCLUSIONS: The first-attempt cannulation success rate and cannulation time in adult patients are similar in ultrasound-guided radial artery cannulation with both short-axis as well as long-axis techniques. Trial registration Clinical Trial Registry of India (CTRI/2015/02/005552).

Perioperative use of transthoracic echocardiography in a patient with congenitally corrected transposition of great arteries, atrial septal defect and severe pulmonary stenosis for lower segment cesarean section.

A 25-year-old female with congenitally corrected transposition of great arteries (CCTGAs), atrial septal defect, and severe pulmonary stenosis underwent lower segment cesarean section at 34 weeks of gestation using combined spinal epidural anesthesia (CSEA). We used transthoracic echocardiography (TTE) for intraoperative monitoring of the cardiovascular system because these patients are reported to have a high prevalence of myocardial perfusion defects, regional wall motion abnormalities, and impaired ventricular contractility. Scanning was done at four different time intervals; preoperatively, after initiation of CSEA, after delivery of child and postoperatively (6 and 24 h postdelivery) to detect regional wall motion and valvular abnormalities, calculate ejection fractions and optimize fluid administration. In this case report, we thus discuss the anatomical defects of CCTGA, physiologic concerns and emphasize on the use of TTE for perioperative management of such cases.

ASSIST - Patient satisfaction survey in postoperative pain management from Indian subcontinent.

INTRODUCTION: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. SETTINGS AND DESIGN: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. MATERIAL AND METHODS: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. STATISTICAL ANALYSIS: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. RESULTS: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1-10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). CONCLUSION: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.

Use of metabolic monitors in a multidisciplinary Intensive Care Unit: A prospective pilot study of 20 patients.

INTRODUCTION: Caloric intake of critically ill patients are usually calculated using predictive equations. Recent advances in gas exchange measurements have the potential to estimate energy expenditure at the bedside and at different time periods. MATERIALS AND METHODS: Energy needs of critically ill patients were estimated over a period of 3 months using simplistic formula of 25 kcal/kg/day estimated energy expenditure (EEE), Harris-Benedict equation (HBE) (Basal energy expenditure [BEE]) and M-COVX™ metabolic monitor resting energy expenditure (REE) on day 4 of Intensive Care Unit (ICU) admission. Calculations based on HBE were taken as standard, and percentage errors (PE) were calculated for each patient for values derived from simplistic formula and metabolic monitor. Adequacy of nutritional intake in ICU was also assessed. RESULTS: Metabolic monitor could be used in only 20/70 patients. The mean age of patients was 40 years, 65% were males, and average body mass index was 23.69 kg/m(2). Intermittent intolerance to feeds was reported in 50%. Values of REE and EEE were greater than BEE in 70% of patients. A significant difference was reported in values of PE of ≤20% and ≥30%; P = 0.0003 and 0.0001, respectively estimated using REE and EEE. CONCLUSIONS: It is not feasible to use metabolic monitors in all patients. Variability in readings is large and further studies are needed to establish the validity of its measurements. Calculations using simplistic formulas are much closer to values obtained using HBE.

Challenges in management of blast injuries in Intensive Care Unit: Case series and review.

Blast injuries are rare, but life-threatening medical emergencies. We report the clinical presentation and management of four bomb blast victims admitted in Intensive Care Unit of Trauma center of our hospital in 2011. Three of them had lung injury; hemothorax (2) and pneumothorax (1). Traumatic brain injury was present in only one. Long bone fractures were present in all the victims. Presence of multiple shrapnels was a universal finding. Two blast victims died (day 7 and day 9); cause of death was multi-organ failure and septic shock. Issues relating to complexity of injuries, complications, management, and outcome are discussed.

Role of oral melatonin in prevention of postoperative delirium in patients undergoing elective surgery under general anesthesia: A Randomized controlled trial.

Background: Postoperative delirium is a common complication in patients undergoing elective surgery under general anesthesia. We aimed to minimize the incidence with an oral dose of 3 mg of melatonin administered the night before surgery. Methods: Hundred and sixty-two patients aged 40-80 years posted for various urological and gastrointestinal surgeries under general anesthesia with no preoperative cognitive deficits were randomly distributed equally to melatonin or control groups. In the control group, routine premedication was done with tablet alprazolam (0.25 mg) and ranitidine (150 mg), but in the melatonin group, the patients were given 3 mg melatonin orally the night before surgery along with routine premedication. The CAM scale was used for diagnosis of postoperative delirium. Results: Incidence of delirium was significantly lower in the melatonin group, 23.5%, 8.6%, and 2.5% at 6, 24, and 48 hours, respectively, and the corresponding mean (SD) values of CAM scores were 1.37 (1.30), 1.07 (1.03), and 0.69 (0.80). In contrast, the incidence of delirium was 46.9%, 30.9%, and 16% at 6, 24, and 48 hours, respectively, in the control group. There was a significant reduction in anxiety, a lower incidence of cognitive dysfunction (i.e., MoCA score <26), and improvement in sleep quality in the melatonin group at 6, 24, 48, and 72 hours after the surgical intervention. The generalized estimating equations model (GEE) model was used to study change in MoCA and CAM scores over time between the two groups, and it showed a significant interaction between time and treatment groups (P < 0.001). Conclusions: Melatonin premedication reduced incidence of postoperative delirium and cognitive dysfunction and was associated with better sleep quality and anxiolysis.

Preeclamptic heart failure - perioperative concerns and management: a narrative review.

Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.

A Preliminary Feasibility Study on Hemodynamic Changes Following Feyh-Kastenbauer Retractor Insertion During Transoral Robotic Surgeries.

 Introduction Transoral robotic surgery (TORS) has become increasingly popular for the removal of pharyngeal and laryngeal cancers with the objective to improve functional and aesthetic outcomes. Feyh-Kastenbauer (FK) retractor is one such routinely used retractor during TORS. The setting up of this retractor has been seen to be accompanied by hemodynamic fluctuations. Methodology This prospective observational study was carried out on 30 patients undergoing TORS. All patients were administered general anesthesia using a pre-defined anesthesia protocol. The primary outcome was to compare hemodynamic fluctuations following endotracheal intubation with that after FK retractor insertion. Any requirement of a bolus dose of sevoflurane and fentanyl was recorded in response to hemodynamic fluctuations recorded in secondary outcomes. Results There was no statistically significant increase in mean heart rate, systolic, diastolic, and mean arterial blood pressure from baseline to endotracheal intubation and following retractor insertion (p=0.810, p=0.2, p=0.6, p=0.3 respectively). On subgroup analysis, hypertensive patients reported a greater rise in blood pressure following two minutes post FK retractor insertion compared to non-hypertensive patients (p=0.03). Out of 30 patients, five patients required a bolus dose of sevoflurane. Conclusion FK retractor insertion had a comparable hemodynamic response as endotracheal intubation during TORS. Hypertensive patients showed a rise in blood pressure at both endotracheal intubations and at FK retractor insertion.

Pre-Hospital Delays Represent Unnoticed Intervals That Affect Mortality Rates in Geriatric Hip Fractures: A Prospective Cohort Study.

Introduction Surgery is recommended within 24-48 hours for geriatric hip fractures. In developing countries. However, delayed presentation to the hospital due to various factors often precludes surgery from occurring within these recommended intervals. Therefore, our objective was to identify the hurdles that prevent early surgery for geriatric hip fractures and assess their effect on mortality. Methods A prospective cohort study was conducted with 78 geriatric patients (age > 60 years) who suffered hip fractures between September 2019 and November 2020. The demographic, American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), injury to admission, admission to surgery, and injury to surgery time were all recorded for each patient. A follow-up was conducted at one month and six months postoperatively for each patient. Mortality rate at 30 days and causes for delay in presentation to the hospital and delayed surgery were assessed. Multivariate logistic regression was done to assess the risk factors for 30-day mortality. Results The mean age of the patients was 74.2 years, and 64.1% of the patients were female. The mean (SD) injury-to-admission time was 3.45 (5.50) days, and the admission-to-surgery time was 4.28 (3.03) days. A total of 41% of patients had delayed presentation, commonly due to a lack of local healthcare infrastructure, financial constraints, and a lack of care providers. Furthermore, 65.3% of the patients underwent delayed surgery, and 44% faced organizational delays. Thus, the 30-day mortality rate was calculated at 19.2%, while the six-month mortality rate was 25.6%. The injury to admission time (OR 1.22 [1.03-1.44; p = 0.018]) and CCI were found to be risk factors in the 30-day mortality (OR 1.76 [0.93-3.33; p = 0.085]). Conclusions Pre-hospital delays and CCI are risk factors for short-term mortality following hip fractures. This underlines the need to generate awareness, improve the referral chain, and establish protocol-based care in hospitals. Further studies are required to assess the socioeconomic factors involved in the delayed treatment of geriatric hip fractures in developing countries.