Author Response: Oxygen Delivery Devices in Postoperative Patients: Proper Selection of Patients Matters!

How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S. Author Response: Oxygen Delivery Devices in Postoperative Patients: Proper Selection of Patients Matters! Indian J Crit Care Med 2024;28(8):803.

Ultrasound-guided short-axis out-of-plane versus long-axis in-plane technique of Posterior Tibial Artery Cannulation in adult patients: The POTACUT (POsterior Tibial Artery Access with Ultrasound Trial) Randomized Trial.

BACKGROUND: No research has been conducted to compare long-axis in-plane and short-axis out-of-plane techniques for ultrasound-guided posterior tibial artery cannulation in adults. This study compared these two procedures for cannulating the posterior tibial artery. METHODS: This prospective randomized trial included 236 adult patients undergoing general anesthesia who required arterial cannulation. The posterior tibial artery was cannulated using either the long-axis in-plane technique (group LAIP) or the short-axis out-of-plane method (group SAOP) with an ultrasound machine. First-attempt cannulation success, the number of cannulation attempts required to achieve successful cannulation, ultrasound localization time, cannulation time, and perioperative complications in these two groups were analyzed. RESULTS: The LAIP group demonstrated a significantly higher first-attempt success rate (40.7% vs 18.6%, p < 0.001), shorter ultrasound localization time (36.5 [30, 60] s vs 50 [35, 80] s, p < 0.001), and faster cannulation time (80 [55, 100] s vs 110 [70, 180] s, p < 0.001). LAIP group showed a significantly higher overall success rate (92.4% vs 81.4%, p = 0.012). The median number of cannulation attempts in the LAIP and SAOP groups were 2 [1, 2] and 2 [2, 3], respectively (p < 0.001). Complications were comparable between groups (p = 0.248). CONCLUSIONS: The LAIP group demonstrated higher first-attempt and overall success rates compared to the SAOP group for ultrasound-guided posterior tibial artery (PTA) cannulation in adult patients.

'Effectiveness of various Sulbactam based Combination Antibiotic Therapy in Management of Ventilator-Associated Pneumonia caused by Carbapenem-Resistant Acinetobacter baumannii in a Tertiary Care Health Centre.'

OBJECTIVE: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a common cause of ventilator-associated pneumonia (VAP). Some in vitro data favour various combination antibiotic therapy. However, there is a need for more in vivo studies for the management of VAP caused by CRAB. This retrospective study was done to evaluate the effectiveness of various combination antibiotic therapy including sulbactam on outcomes of VAP caused by CRAB. METHODS: Adult patients (age ≥ 18 years) diagnosed with VAP caused by CRAB were included. Patients with polymicrobial infections were excluded from the study. Patients with CRAB associated VAP who were given sulbactam based antibiotic combinations were observed for outcomes. The primary outcome was 28-day mortality after diagnosis of VAP caused by CRAB. Reduction in serum HsCRP (High sensitivity C-reactive protein) during treatment and requirement of inotropes were the secondary outcomes. Outcomes were compared between various sulbactam based antibiotic combination therapies. RESULTS: A total of 103 patients were included. A total of 44 (42.7%) patients received sulbactam and minocycline or sulbactam and polymyxin B dual antibiotic combination, and 59 (57.3%) patients received sulbactam, polymyxin B and minocycline triple antibiotic combination. The percentage difference in 28 days mortality was 27.51% (95% CI 8.03% to 44.06%; p=0.005) in dual vs triple sulbactam based antibiotic combination therapy. The percentage difference in requirement of inotropes during therapy and HsCRP reduction after 7 days of therapy was 23.65% (95% CI 6.43% to 38.3%; p=0.007) and 25.1% (95%CI 10.1% to 38.2%; p<0.001) respectively when compared between dual vs triple sulbactam based antibiotic combination therapy. CONCLUSION: Treatment with sulbactam, polymyxin B and minocycline combination antibiotic therapy was associated with significantly lower 28-day mortality. Moreover, the lower requirement of inotropes during treatment and a significant reduction in HsCRP level favours this combination antibiotic therapy in VAP caused by CRAB.

Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia.

How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod DK, Meshram T, et al. Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia. Indian J Crit Care Med 2024;28(6):626-627.

Artificial intelligence in pediatric airway - A scoping review.

Artificial intelligence is an ever-growing modality revolutionizing the field of medical science. It utilizes various computational models and algorithms and helps out in different sectors of healthcare. Here, in this scoping review, we are trying to evaluate the use of Artificial intelligence (AI) in the field of pediatric anesthesia, specifically in the more challenging domain, the pediatric airway. Different components within the domain of AI include machine learning, neural networks, deep learning, robotics, and computer vision. Electronic databases like Google Scholar, Cochrane databases, and Pubmed were searched. Different studies had heterogeneity of age groups, so all studies with children under 18 years of age were included and assessed. The use of AI was reviewed in the preoperative, intraoperative, and postoperative domains of pediatric anesthesia. The applicability of AI needs to be supplemented by clinical judgment for the final anticipation in various fields of medicine.

Safety and complications of labour epidural analgesia in obese parturients: worrying is not worth the weight!

The physiological transformations accompanying pregnancy, compounded by the implications of obesity, pose intricate challenges for anaesthesiologists attending to obese parturients. Obesity makes it harder to successfully provide epidural analgesia to a parturient. This narrative review explains the most recent data on the safety and complications of providing labour epidural analgesia in obese expectant mothers. We have emphasised the evidence-based approaches that are the most effective for obese pregnant mothers receiving labour epidural analgesia.

Aerosol drug therapy in critically ill patients (Aero-in-ICU study): A multicentre prospective observational cohort study.

BACKGROUND: In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). METHODS: After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. RESULTS: From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. CONCLUSION: Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

Comparison of Oxygen Delivery Devices in Postoperative Patients with Hypoxemia: An Open-labeled Randomized Controlled Study.

Background: Acute hypoxemic respiratory failure is among the more commonly occurring complications in postoperative patients. Supplemental oxygen and addressing the primary etiology form the basis of its treatment. Materials and methods: We conducted an open-labeled randomized control trial with 90 adult patients and compared three oxygen delivery vehicles (ODV), i.e., noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and venturi mask (VM) in postoperative hypoxemic patients. The primary outcome variable was a change in the P/F ratio after 2 hours of use of ODV. Results: It was observed that the change in P/F ratio after 2 hours was similar in all three ODV groups (p = 0.274). The mean values of the post-ODV P/F ratio were comparable with the pre-ODV P/F ratio in all three modalities. The P/F ratio after HFNC was 358.08 ± 117.95; after NIV was 357.60 ± 220.67; and after VM was 355.47 ± 101.90 (p = 0.997). Conclusion: Among HFNC, NIV, and VM, none of the devices proved superior to the other for use in postoperative hypoxemia. How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod D, Meshram T, et al. Comparison of Oxygen Delivery Devices in Postoperative Patients with Hypoxemia: An Open-labeled Randomized Controlled Study. Indian J Crit Care Med 2024;28(3):294-298.

Comparison of procedural time with two different ultrasound-guided approaches for dorsalis pedis artery cannulation in adult patients: A randomized trial.

BACKGROUND: In adult patients, there has never been an evaluation of short-axis out-of-plane versus long-axis in-plane approaches of ultrasound-guided dorsalis pedis artery cannulation. This research was conducted to compare these two techniques to cannulate the dorsal pedis artery. METHODS: In this trial, 128 adult patients undergoing surgery and necessitating arterial cannulation were examined. Dorsalis pedis artery cannulation was performed utilizing an ultrasound by long-axis in-plane approach (group L) or short-axis out-of-plane (group S) techniques. RESULTS: Group S had a higher first attempt success rate than group L (46.9% vs 28.6%, p = 0.039). The S group had a lower assessment time than the L group (11.48 ± 3.07 vs 19.68 ± 2.79 s; p = 0.000). Cannulation time was higher in the S group (18.91 ± 1.92 s) compared to the L group (12.48 ± 1.61 s; p = 0.000). Nevertheless, the total procedure time was comparable between the L group and the S group (32.16 ± 2.95 vs 30.42 ± 4.07 s; p = 0.107). CONCLUSIONS: In adults, both views of ultrasonography can be used to guide DPA cannulation. The cannulation time for the DPA in L group was less than the S group, whereas the assessment time was less in S group. The total procedure time, however, was similar between both the groups.

An observational study on carbapenem-resistant Enterobacterales (CRE) colonisation and subsequent risk of infection in an adult intensive care unit (ICU) at a tertiary care hospital in India.

Background: Carbapenem-resistant Enterobacterales (CRE) are a global health problem with a growing prevalence. India has a high prevalence of CRE. CRE infections are difficult to treat, and are associated with significant morbidity and mortality. Colonisation is generally a prerequisite for infection and the prevention of CRE colonisation is key to the prevention of CRE infection. Objectives: To determine the prevalence of CRE colonisation and subsequent infections in an adult intensive care unit (ICU) in India. Methods: We conducted a prospective observational study in which perirectal swabs were obtained along with relevant clinical details of consenting adult patients upon ICU admission between January 2019 and August 2020. Rectal screening was performed using MacConkey agar plates with ertapenem disks and further identification was performed using conventional microbiological techniques. Ertapenem minimum inhibitory concentration (MIC) was determined using an epsillometer (E) test. The modified carbapenem inactivation (mCIM) test and EDTA carbapenem inactivation test (eCIM) were performed to confirm carbapenem resistance using the Clinical Laboratory Standards Institute (CLSI) 2020 guidelines. Results: 192 ICU patients were screened for CRE. 37 patients were found to be colonised with CRE. Klebsiella pneumoniae (N=25; 67.6%) was the most frequent CRE isolate, followed by Escherichia coli (N=11; 29.7%) and one Enterobacter species (N=1; 2.7%). 89.2% (33/37) patients developed CRE infection. Pneumonia was the most common CRE infection identified in 12/33 (36.4%) patients.during the hospital stay. The median duration of hospital stay was longer (17 days) for CRE colonised compared to CRE non-colonised patients (9 days) (P<0.001). Death occurred in 27 % (N=10/37) of CRE-colonised patients during the hospital admission. Conclusion: CRE colonisation is associated with high risk of subsequent CRE infection and longer ICU and hospital admission.

Medication errors in the practice of paediatric anaesthesia - a narrative review.

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Comparison of Caudal Dexmedetomidine and Midazolam as an Adjuvant to Ropivacaine for Postoperative Pain Relief in Children Undergoing Infra-Umbilical Surgeries: A Randomized Controlled Trial.

BACKGROUND: We explored the analgesic efficacy of two non-opioid adjuvants (midazolam and dexmedetomidine) with ropivacaine in children undergoing infraumbilical surgeries. METHODS: In this parallel group randomized controlled trial, 135 children aged between 2 and 8 years were recruited. Children were randomly allocated to one of three groups: RD received 1 mL/kg of ropivacaine (0.2%) with dexmedetomidine 1 µg/kg, RM received 1 mL/kg of ropivacaine (0.2%) with midazolam 30 µg/kg, and R received 1 mL/kg of ropivacaine (0.2%) with 1 mL normal saline. The primary outcome of the present study was to determine the duration of postoperative analgesia. Secondary outcomes were assessing postoperative face, leg, activity, cry, consolability (FLACC) pain score, rescue analgesics, hemodynamics, sedation scores, and adverse effects. RESULTS: The analgesia duration was significantly prolonged in the RD and RM group (600.0 [480.0-720.0] minutes and 600.0 [480.0-720.0] minutes, respectively) compared to the R group 360.0 (300.0-480.0) minutes (P < 0.001). The FLACC score was comparatively higher in the R group compared to the RD and RM groups postoperatively. Time for the first rescue analgesia was more prolonged in RD and RM groups when compared with the R group. Postoperative sedation was higher in the RM group up to 120 minutes postoperatively compared to the RD and R groups. CONCLUSION: The combination of dexmedetomidine or midazolam with local anesthetics significantly increases the analgesia duration while minimizing adverse effects.

Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study.

How to cite this article: Sahoo P, Kothari N, Sharma A, Goyal S. Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2023;27(8):603-604.

Comparison of intranasal dexmedetomidine-midazolam, dexmedetomidine-ketamine, and midazolam-ketamine for premedication in paediatric patients: a double-blinded randomized trial.

BACKGROUND: Paediatric patients are a population with a high level of anxiety. The prevention of perioperative stress in a frightened child is important to render the child calm and cooperative for smoother induction. Intranasal premedication is easy and safe, and the drug is rapidly absorbed into the systemic circulation, ensuring early onset of sedation in children and good effectiveness. METHODS: 150 patients in the age group 2-4 years, ASA class I, undergoing elective surgical procedures were enrolled. The patients were randomly divided into 3 groups: a DM group (receiving intranasal dexmedetomidine 1 µg kg -1 and midazolam 0.12 mg kg -1 ), a DK group (receiving intranasal dexmedetomidine 1 µg kg -1 and keta-mine 2 mg kg -1 ), and an MK group (receiving intranasal midazolam 0.12 mg kg -1 and ketamine 2 mg kg -1 ). After 30 minutes of administration of the drugs, the patients were assessed for parent separation anxiety, sedation, ease of IV cannulation, and mask acceptance. RESULTS: The comparison among the 3 groups showed a statistically significant difference for ease of IV cannulation and mask acceptance at 30 minutes, with a P -value of 0.010 with CI of 0.0-0.02, and P -value 0.007 with CI 0.0-0.02, respectively. The parent separation anxiety and sedation score at 30 minutes was statistically insignificant with a P -value of 0.82 with CI of 0.03-0.14 and P -value 0.631 with CI of 0.38-0.58, respectively. CONCLUSIONS: The combination of midazolam and ketamine had a better clinical profile for premedication as compared to other combination drugs used in our study in terms of IV cannulation and acceptance of masks with a comparable decrease in separation anxiety from parents and adequate sedation.

Anesthetic challenges for pheochromocytoma surgery in pediatric patients: A case series.

Pheochromocytoma in children is an exceptionally uncommon cause of hypertension in this age group. These tumors pose a significant threat of adverse cardiovascular events during the perioperative phase. In this article, we describe three cases of pediatric pheochromocytoma to shed light on the difficulties associated with administering anesthesia to patients with this condition. The foundations for successful perioperative outcomes include preoperative blood pressure control, extensive intraoperative hemodynamic evaluation, and appropriate coordination with surgeons.

Comparison of ultrasound-guided dynamic needle tip positioning and acoustic shadowing technique with palpation technique for radial arterial cannulation by experienced clinicians: A randomized controlled trial.

BACKGROUND: Radial artery cannulation is usually done for monitoring invasive blood pressure during intraoperative period. The dynamic needle tip positioning approach allows continuous visualization of the needle tip during ultrasound-guided cannulation. The acoustic shadowing technique, using two lines on the ultrasound probe, might be used to facilitate radial artery puncture. We aimed to compare these two ultrasound-guided techniques of radial artery cannulation with the traditional palpation method in adult patients. METHODS: In this trial, 180 adult patients requiring arterial cannulation were randomized into three groups (Traditional palpation (TP), Dynamic needle tip positioning (DNTP), and acoustic shadow technique (AST)). All cannulations were carried out by experienced anesthetists. Data was analyzed for the success rate of arterial cannulation in the first attempt, total number of attempts in 5 min, time taken to cannulate, number of cannulas used, and complications related to the procedure. RESULTS: The first attempt success rates among TP, DNTP, and AST were 66.7%, 66.7%, and 71.7%, respectively (p = 0.794). The median time taken for cannulation was 60.5 (37.0, 129.5) s, 71.0 (50.0, 170.0) s, and 108.0 (58.0, 181.0) s, respectively (p = 0.066) and the median number of cannulation attempts was 1, in all the three groups (p = 0.684). There was also no difference in the total number of cannulas used, the overall success rate of cannulation, and complications related to the procedure in the three groups. CONCLUSION: The TP, DNTP, and AST technique for radial artery cannulation had comparable first attempt success rate, the time taken for cannulation, the number of cannulas used, and overall complications. We conclude that radial arterial cannulation by palpation, as well as ultrasound-guided DNTP and AST techniques performed by experienced clinicians in hemodynamically stable adult patients are equally advantageous.

Comparison of Diagnostic Accuracy of Presepsin and Procalcitonin for Sepsis in Critically Ill Patients: A Prospective Observational Study.

Objective: Early diagnosis of sepsis is crucial to institute appropriate therapy and then to avert a possible negative outcome. We planned this study to evaluate the diagnostic value of presepsin, its sensitivity and specificity for diagnosing sepsis in critically ill patients, and its ability to prognosticate the outcome of sepsis. Methods: In this prospective observational study, adult patients admitted to the intensive care unit (ICU) at our institute were screened, and those with features suggestive of sepsis were recruited into the study. Procalcitonin (PCT) and presepsin were assessed on the day of admission and day 7 of the ICU stay, apart from routine investigations. Patients were followed for outcome in terms of mortality till 28 days. Results: The study comprised 82 patients who satisfied the inclusion criteria. Presepsin sensitivity for sepsis diagnosis was determined to be 78%, while that of PCT was determined to be 69%. This gave a combined sensitivity of presepsin and PCT of 93% when used in parallel for the diagnosis of sepsis. Conclusion: A combination of PCT and presepsin provides higher sensitivity and can be used to screen for sepsis in the ICU. How to cite this article: Roy S, Kothari N, Sharma A, Goyal S, Sankanagoudar S, Bhatia PK, et al. Comparison of Diagnostic Accuracy of Presepsin and Procalcitonin for Sepsis in Critically Ill Patients: A Prospective Observational Study. Indian J Crit Care Med 2023;27(4):289-293.