Comparison of gastric emptying time between breast-fed and formula milk-fed infants less than 6 months old, using gastric ultrasound-An observational study.

BACKGROUND: Fasting before elective anesthesia care is a standardized practice worldwide. The aim is to decrease the risk of aspiration leading to pulmonary complications such as aspiration pneumonitis during anesthesia care. There are different guidelines for elective preoperative fasting in children. However, there is insufficient literature measuring gastric emptying time after breast milk or formula milk feeding in infants. OBJECTIVE: This study used gastric ultrasound to determine the gastric emptying time for breast milk and formula milk in children below 6 months of age. We also compared the calculated gastric volumes among breast-fed and formula milk-fed based on Schmitz's and Spencer's formula. MATERIALS AND METHODS: This prospective observational study was conducted at a tertiary care center in India between November (2017-2019). A total of 52 infants less than 6 months of age were recruited. The study population was divided into two groups (breast-fed and formula milk-fed) of 26 patients each. Ultrasound was used to measure the antral cross-sectional area of the stomach and to calculate the gastric volume using the two classical formulas (Schmitz and Spencer's). Gastric emptying was reported when the bull's eye appearance of the gastric antrum was seen or when the antral cross-sectional area was less than 3.07 cm2. RESULTS: The number of breast-fed children whose antral cross-sectional was greater than 3.07 cm2 (cut-off value for aspiration risk) beyond 1 h was 14/26 (53.84%) while none (0) children went beyond 3 h. The number of formula-fed children whose antral cross-sectional was greater than 3.07 cm2 beyond 1 h was 17/26 (65.38%) while one child (3.84%) went beyond 3 h. Using Schmitz's formula, mean (SD) gastric emptying times were 0.35 ± 0.68 h (95% CI 0.35 ± 0.185, range 0.165-0.535) for breast-fed patients and 0.35 ± 0.69 h (95% CI 0.35 ± 0.188, range 0.162-0.538) for formula-fed patients, and were thus neither clinically nor statistically different (p = .73) Using Spencer's formula, the mean gastric emptying times were 0.12 ± 0.33 h (95% CI 0.12 ± 0.09, range 0.03-0.21) for breast-fed patients and 0.04 ± 0.20 h (95% CI 0.04 ± 0.05, range -0.01 to 0.09) for formula-fed patients, and were also neither clinically nor statistically different p = .13. CONCLUSION: In our series, the gastric emptying times in breast-fed and formula-fed infants less than 6 months old were similar. Our results support the fasting guidelines of the European Society of Anaesthesiology and Intensive Care 2022, that is, 3 h for breastfeeding and 4 h for formula milk feeding. In addition, this shows that the Schmitz's and Spencer's formulae used to calculate the gastric volume based on ultrasound measurement of the antral cross-sectional area are not comparable in infants less than 6 months.

Evaluation of Electrical Cardiometry to Assess Fluid Responsiveness in Patients with Acute Circulatory Failure: A Comparative Study with Transthoracic Echocardiography.

Aim: Acute circulatory failure is commonly encountered in critically ill patients, that requires fluid administration as the first line of treatment. However, only 50% of patients are fluid-responsive. Identification of fluid responders is essential to avoid the harmful effects of overzealous fluid therapy. Electrical cardiometry (EC) is a non-invasive bedside tool and has proven to be as good as transthoracic echocardiography (TTE) to track changes in cardiac output. We aimed to look for an agreement between EC and TTE for tracking changes in cardiac output in adult patients with acute circulatory failure before and after the passive leg-raising maneuver. Materials and methods: Prospective comparative study, conducted at a Tertiary Care Teaching Hospital. Results: We recruited 125 patients with acute circulatory failure and found 42.4% (53 out of 125) to be fluid-responsive. The Bland-Altman plot analysis showed a mean difference of 2.08 L/min between EC and TTE, with a precision of 3.8 L/min. The limits of agreement (defined as bias ± 1.96SD), were -1.7 L/min and 5.8 L/min, respectively. The percentage of error between EC and TTE was 56% with acceptable limits of 30%. Conclusion: The percentage error beyond the acceptable limit suggests the non-interchangeability of the two techniques. More studies with larger sample sizes are required to establish the interchangeability of EC with TTE for tracking changes in cardiac output in critically ill patients with acute circulatory failure. How to cite this article: Sharma S, Ramachandran R, Rewari V, Trikha A. Evaluation of Electrical Cardiometry to Assess Fluid Responsiveness in Patients with Acute Circulatory Failure: A Comparative Study with Transthoracic Echocardiography. Indian J Crit Care Med 2024;28(7):650-656.

Secondary infections in COVID-19: Antemortem and postmortem culture study.

Background: Secondary bacterial infections during COVID-19 hospitalization have been reported in about 6-15% of patients. Aims: To study the secondary bacterial infections that affected the COVID-19 patients during their hospitalisation and to unearth the bacteriological profile of samples obtained after their demise. Settings and Design: This prospective study was carried out at a COVID-19 dedicated, apex tertiary care centre in North India from July 2020 to April 2021. Methods and Materials: Samples of 268 patients were considered for the study. Nasopharyngeal swab specimen, blood, and tissue (lung) were collected from the deceased body as early as possible and processed. Statistical Analysis: Statistical analyses were performed using STATA version 11.1 (Stata Corp., College Station, TX, USA). Results: A total of 170 samples were received from patients before their death, which included blood, urine, respiratory samples, pus, and cerebrospinal fluid. Forty-four pathogens were isolated, which consisted of Acinetobacter baumannii (43.1%), Klebsiella pneumoniae (36.3%), Escherichia coli (11.3%), and Pseudomonas aeruginosa (4.5%), Enterococcus faecium (4.5%). Two hundred fifty-eight samples were collected from the deceased bodies wherein the nasopharyngeal sample was highest, followed by tissue and blood. A total of 43 pathogens were isolated among them which included A. baumannii (44.1%), followed by K. pneumoniae (25.5%), E. coli (20.9%), P. aeruginosa (6.97%) and Enterobacter cloacae (2.3%). All these isolates were highly resistant to antimicrobials. Conclusions: In our study, bacterial profiles in antemortem and postmortem samples were found to be similar, suggesting that resistant pathogens may be the cause of mortality in COVID-19 infected hospitalised patients.

Comparison of KingVision videolaryngoscope channelled blade with Tuoren videolaryngoscope non-channelled blade in a simulated COVID-19 intubation scenario by non-anaesthesiologists and experienced anaesthesiologists: A prospective randomised crossover mannequin study.

Purpose: A videolaryngoscope has been recommended for intubation in the COVID-19 scenario but the videolaryngoscope providing optimal intubation conditions is not ascertained. We compared KingVision channelled blade with a non-Channelled videolaryngoscope for intubation times in a simulated COVID-19 intubation scenario by both anaesthesiologists and non-anaesthesiologists. Methods: This prospective randomised cross over mannequin study was conducted in a skill training lab. 25 anaesthesiologists and 25 non-anaesthesiologists donned in standard personal protective equipment performed 100 intubations with KingVision and Tuoren videolaryngoscopes in a mannequin covered with a transparent plastic sheet. The total intubation time, percentage of glottic opening scores, first attempt success rates were assessed. Results: The mean difference in intubation times in anaesthesiologists and non-anaesthesiologist less with KingVision videolaryngoscope (21.1s; 95% CI 9.6-32.6s vs. 35.9s; 95% CI 24.4-47.4 s; P = 0.001). Percentage of glottic opening score was significantly better with KingVision by non-anaesthesiologists (60; IQR 42.5 to 75 vs. 70; IQR 50 to 100; P = 0.019). KingVision provided superior first attempt success rate in non-anaesthesiologists (84% vs. 61.9%; P = 0.02) and anaesthesiologists (96% vs. 76%; P = 0.12). Conclusion: KingVision channelled videolaryngoscope provided faster intubation times, glottic views and first attempt success rates in a simulated COVID-19 scenario in manikins and might be preferred over videolaryngoscopes with non-channelled blade. The findings need to be further verified in humans. Trial registration: ctri.nic.in identifier: REF/2020/05/033338.

Dos casos de calambre refractario del escribano en la clínica de dolor: ¿está la respuesta en la toxina botulínica? / Two cases of refractory writer's cramp in pain clinic: Is botulinum the answer?

Introducción: El calambre del escribano es un trastorno doloroso refractario que suele manifestarse como enfermedad incapacitante tras un período corto de escritura. La terapia convencional con agentes neurogénicos como la carbamazepina muchas veces no beneficia a estos pacientes. En la literatura moderna se ha resaltado el uso de la toxina botulínica en distonías focales, de manera que su uso también podría extrapolarse a los pacientes con espasmo del escribano. Objetivo: Evaluar la eficacia y la seguridad de la toxina botulínica en casos de calambre refractario del escribano. Metodología: Presentamos 2 casos de calambre refractario del escribano. Se evaluó a los pacientes para determinar el grupo de los músculos de la mano que estaban comprometidos. Una vez identificados los músculos se inyectó en ellos la toxina botulínica y se utilizó la respuesta clínica como base para determinar la dosis total requerida. Se hizo seguimiento a los pacientes a fin de evaluar el grado de alivio y cualquier efecto adverso asociado. Resultados: Los 2pacientes presentaron un grado significativo de alivio clínico tras la aplicación de la toxina botulínica. El tiempo de escritura mejoró y los 2 pacientes refirieron un alivio significativo del dolor. En ambos casos fue necesario repetir la inyección después de 3-6 meses, aunque la afección fue menor en cada recaída y fue posible suspenderles la medicación oral. Uno de los pacientes presentó leve debilidad de la mano, que tuvo un impacto clínico menor y revirtió a la normalidad en un lapso de 2-3 semanas. Este hecho no afectó la satisfacción de los pacientes con el tratamiento, considerando que la enfermedad primaria era incapacitante y afectaba el trabajo profesional de todos los días. Conclusión: La toxina botulínica es una alternativa terapéutica segura y eficaz para tratar a los pacientes afectados con calambre refractario del escribano que consulten la clínica de dolor.

Introduction: Writer’s cramp is a refractory painful disorder, often presenting as a disabling disease while writing for a short duration. The conventional therapy in the form of neurogenic agents such as carbamazepine often fails to benefit these patients. Modern literature has highlighted the used of botulinum toxin in focal dystonisas and hence its use can also be extrapolated in patients of writer’s cramps. Aim: Evaluating the efficacy and safety of botulinum toxin in refractory writer’s cramps. Methodology:We present 2 cases of diagnosed refractory writer’s cramp. These patients were evaluated for group of handmuscles involved. Once themuscles were identified, botulinum toxin was injected into these muscles and clinical response was used to iterate the total dose of botulinum needed. These patients were followed up for degree of relief and any associated adverse effects. Results: Both patients showed significant clinical relief after the use of botulinum toxin. Their writing time improved and both patients reported a significant pain relief. The patients required repeat injection 3-6 months, however with each reoccurrence their ailment decreased and they could be taken off oral medication. Minor clinically insignificant reversible weakness was seen in one patient, which reverted to normal in 2-3 weeks time which did not affect patients’ satisfaction to treatment, as the primary disease was disabling for daily professional work. Conclusion: Botulinum toxin is a safe and effective therapeutic option for treating patients of refractory writer’s cramp presenting in the pain clinic.