Role of handgrip strength testing in pre-anaesthetic check-up: A prospective cross-sectional study.

Background and Aims: Frailty has been known to be associated with postoperative adverse events and longer hospital length of stay (LOS). Hand grip strength (HGS) is one of the parameters of measuring frailty. The aim of the study was to correlate preoperative handgrip strength and 30-day outcome of patients undergoing major abdominal surgery. It also aimed to evaluate the role of the standard preoperative variables like metabolic equivalents, revised cardiac risk index (RCRI), serum albumin, and serum creatinine along with their association with HGS testing in determining the postoperative outcome in surgical patients. Material and Methods: This prospective observational study included 149 American Society of Anesthesiologists class III/IV patients presenting for major abdominal surgery. A mean of three measurements of dominant HGS using Camry hand dynamometer was measured. The patients were divided into groups: weak, normal, and strong depending on grip strength. Patients were followed for 30 days and postoperative outcome in terms of ventilatory support, admission to intensive care unit, cardiac complications, in-hospital mortality, and LOS were recorded. Observational data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney Rank test. Associations between RCRI, serum albumin, and LOS with HGS were evaluated using logistic regression. Results: The hospital LOS was significantly longer in patients with weak HGS (15.11 ± 11.03 days versus 10 ± 5.71 days, P = 0.001). Patients with weak HGS had significantly lower mean serum albumin levels compared to normal HGS (P = 0.0001) and a statistically significant RCRI score (P = 0.013). Conclusion: HGS can be used as a preoperative test in predicting hospital LOS after major surgery.

A comparative study of desflurane versus sevoflurane in obese patients: Effect on recovery profile.

BACKGROUND AND AIMS: Anesthesia in obese patients is difficult due to associated comorbidities and altered physiology. Desflurane and sevoflurane have a low fat-blood solubility coefficient and are better suited in these patients to achieve a rapid emergence. We studied BIS guided drug titration to compare the postoperative recovery characteristics and cognitive function of desflurane versus sevoflurane in obese patients undergoing laparoscopic abdominal surgeries. MATERIAL AND METHODS: After institutional ethics committee approval and written informed consent, sixty obese patients (BMI ≥30 kg/m2) were randomized to receive either BIS guided desflurane or sevoflurane. Recovery was assessed by time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person after discontinuation of volatile anesthetic agent. For cognitive function, time taken to complete Mini mental state examination (MMSE) score to baseline was compared in both study groups. RESULTS: Difference of time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person was not significant between both anesthetic groups. Patients in sevoflurane group took significantly (P-value = 0.001) less time (40.07 ± 13 min) to achieve preoperative MMSE score than desflurane group (51.2 ± 11.7 min). CONCLUSION: Both desflurane and sevoflurane have similar recovery profile in obese patients when anesthetic concentration is carefully titrated. Reversal of cognitive function is significantly earlier in obese patients anesthetized with sevoflurane.

A rational approach to manage surgical procedures in COVID Era - A perspective based on experience in a private referral hospital.

BACKGROUND AND AIMS: COVID-19 disease has imposed challenges in caring for non-Covid elective surgical patients. As elective surgeries become essential, we propose to evaluate our approach and outcomes of surgical procedures performed during the initial period of COVID-19 pandemic so as to provide a road-map for safer approach. MATERIAL AND METHODS: We retrospectively evaluated outcomes in patients who underwent essential elective and emergency surgeries during the 5-week period between April 18, 2020 and May 28, 2020. All patients were screened at the front desk on their arrival to identify possible exposure to SARS- CoV-2. Nasopharyngeal swab of patients requiring hospital admission was tested for COVID-19 by quantitative RT-PCR. Patients needing essential elective surgery were taken up for surgery if they tested negative for COVID-19. Emergency procedures were undertaken in a demarcated theatre for COVID after taking level-3 protection without delay. The clinical data was reviewed and analysed. RESULTS: A total of 764 surgical procedures were conducted, of which 70.7% were elective essential surgeries, with 95.4% of these patients being discharged in stable healthy condition. Approximately 23% of the elective and 26% of the emergency surgeries was categorised in the surgical difficulty category III and majority of these were performed under general anesthesia. Postoperative mortality was 1.04%, but the overall mortality rate was approximately 2.5%. Only two patients (0.3%) tested positive for COVID-19 in our series. CONCLUSION: A robust preoperative screening and testing can enable safe scheduling of essential elective surgeries.

Comparison of opioid-based and opioid-free TIVA for laparoscopic urological procedures in obese patients.

BACKGROUND AND AIMS: Perioperative pain management in an obese patient is challenging. The incidence of respiratory depression is higher in obese patients and is exaggerated with opioids. We evaluated the efficacy of opioid-free anesthesia with propofol, dexmedetomidine, lignocaine, and ketamine in obese patients undergoing urological laparoscopic procedures with reference to postoperative analgesic consumption, hemodynamic stability, and respiratory depression. MATERIAL AND METHODS: In this prospective, randomized, blinded controlled study, patients were randomized to receive either opioid-based (opioid group) or opioid-free (opioid-free group) anesthesia. Postoperative pain was assessed using visual analog score (VAS) 30 min after recovery, hourly for 2 h and every 4 hourly for 24 h. The primary outcomes studied were respiratory depression, mean analgesic consumption and time to rescue analgesia. Intraoperative hemodynamic parameters, mean SpO2, respiratory rate and postanesthesia care unit (PACU) discharge time were secondary objectives. RESULTS: There were no differences in the demographic and intraoperative hemodynamic profile between the groups. Incidence of respiratory depression, defined as fall in saturation, was more in opioid-based group. Postoperative analgesic requirement (225 ± 48.4 vs 63.6 ± 68.5 mg of tramadol with P value of <0.001) and PACU discharge times (18.1 ± 5.4 vs 11.7 ± 4.3 hours with P value of <0.001) were significantly less in the opioid-free group. CONCLUSIONS: Opioid-free anesthesia is a safer and better form of anesthesia in obese patients undergoing laparoscopic urological procedures as there is a lower requirement of postoperative analgesia.

Influence of hemodynamics and intra-operative hydration on biochemical outcome of renal transplant recipients.

BACKGROUND AND AIMS: Early graft function is crucial for successful kidney transplantation. The aim of our study was to evaluate the effect of intra-operative central venous pressure (CVP) and mean arterial pressure (MAP) on early graft function and biochemical outcome. MATERIAL AND METHODS: This was a retrospective study carried out on patients undergoing renal transplant only from live-related donors between March 2011 and May 2013. We mainly divided the patients into two groups based on CVP and mean MAP. One group had CVP more than 12 and other with CVP <12 mmHg at the time of declamping. Further one group was with mean MAP >100 mmHg and other with mean MAP of <100 mmHg. The graft outcome of genetically related and genetically unrelated donors was also evaluated in early postoperative period. The trend in fall of serum creatinine was studied during the first five post-operative days. The effect of age, dry weight, sex, relation with donor and intraoperative factors like MAP and CVP on early graft function were analysed. Correlation analysis, analysis of variance test (ANOVA) and multivariate analysis technique were used in this study for statistical computation. RESULTS: The mean CVP at the time of declamping was 13.91 mmHg. The minimum CVP was 6 mmHg in one patient who had ischemic heart disease with low ejection fraction. All 5 days mean serum creatinine values were comparable in two groups on 1(st), 2(nd), 3(rd) and 4(th) postoperative days. The mean MAP at the time of declamping was 111.22 mmHg. Mean MAP varied from a minimum of 95 mmHg to maximum of 131 mmHg. There was no significant difference in two groups on 1(st), 2(nd), 3(rd), 4(th) and 5(th) postoperative days. CONCLUSION: A CVP around 12 mmHg and mean MAP >95 mmHg with good perioperative fluid hydration is associated with good early graft function.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange Versus Conventional Facemask Breathing for Preoxygenation During Rapid Sequence Induction.

INTRODUCTION: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), if used for pre-oxygenation and apnoeic oxygenation, has the propensity to extend the safe apnoea time and thereby decrease the incidence of desaturation during rapid sequence induction (RSI) for emergency surgeries. Hence, we proposed to evaluate the comparative efficacy of pre-oxygenation with the use of conventional facemask breathing versus THRIVE during RSI in patients undergoing general anaesthesia (GA) for emergency surgeries. MATERIALS AND METHODS: Eighty patients undergoing RSI under GA for emergency abdominopelvic surgery were divided randomly into two groups. Patients were preoxygenated for three minutes with 100% oxygen via either a high-flow nasal cannula at a flow of 60 L/minute using THRIVE or a tightly-held, snuggly-fitting facemask at a flow of 12L/minute using a circle system. RSI was administered followed by laryngoscopy and endotracheal intubation. Arterial partial pressure of oxygen (PaO2) measured immediately after successful endotracheal intubation was our primary outcome. The lowest peripheral oxygen saturation (SpO2), apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and any adverse event were also recorded. Data thus collected were statistically analysed. RESULTS: No statistically significant difference in PaO2 value was observed after successful intubation, lowest SpO2, apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and adverse event between both the groups (p>0.05). CONCLUSION: We conclude that though not superior to conventional facemasks, THRIVE is a safe, practicable, and efficient pre-oxygenation tool during RSI of GA for patients undergoing emergency surgeries.

Conventional versus reverse insertion of i-gel® in overweight and obese patients - Interventional randomised controlled trial.

Background and Aims: The supraglottic airway device, i-gel, is used in obese patients for short- to medium-duration surgical procedures. Insertion techniques have contributed to the successful and proper placement of i-gel in the first attempt. This study aims to compare two techniques for successfully inserting i-gel in the first attempt in overweight and obese patients as measured by oropharyngeal leak pressure (OLP). Methods: This interventional, randomised, controlled study was conducted after ethical approval, and trial registration in overweight and obese patients. Patients were randomised into two groups: In Group C, the conventional technique was used, while in Group R, the reverse technique was used to insert i-gel. OLP, successful placement, required manipulations, time taken for insertion, number of attempts, and intraoperative and postoperative complications were studied. The collected data were analysed statistically. Results: The mean OLP (30.46 ± 3.76 vs. 32.12 ± 3.10 mmHg, P = 0.018) and the mean time of insertion (16.42 ± 1.86 vs. 13.98 ± 1.97 s, P = 0.001) for conventional and reverse techniques, respectively, were statistically significant and favourable for Group R compared to Group C. Successful placement of i-gel at the first attempt, ease of insertion, number of attempts and all the manipulations except withdrawal and advancement were comparable in both the groups. No postoperative complications were noted. Conclusion: The reverse technique significantly favoured the actual OLP values and the mean insertion time. Successful placement of i-gel at the first attempt was observed with both conventional and reverse techniques.

Analgesic efficacy of dexamethasone versus dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided transversus abdominis plane block for post-operative pain relief in caesarean section: A prospective randomised controlled study.

BACKGROUND AND AIMS: Transversus abdominis plane (TAP) block is commonly used to treat post-operative pain after lower abdominal surgeries. The aim of this randomised controlled study was to assess the efficacy of addition of dexmedetomidine or dexamethasone to ropivacaine in TAP block and compare the two for post-operative pain relief in caesarean section. METHODS: A hundred parturients (18-45 years) undergoing caesarean section under spinal anaesthesia received ultrasound-guided (USG) bilateral TAP block with 50ml of 3mg/kg ropivacaine along with 0.1mg/kg dexamethasone (Group A) or 1µg/kg dexmedetomidine (Group B) in this prospective, randomised, double-blind study. Time to initial self-reporting of post-operative pain, time to first rescue analgesic demand, visual analogue scale (VAS) for pain haemodynamic parameters and adverse effects if any were noted, anda P value < 0.005 was considered as statistically significant. RESULTS: Time to initial self-reporting of post-operative pain (411.35 vs. 338.20 min, P < 0.005) and time to first rescue analgesic (474.30 vs. 407.30 min, P < 0.005) were significantly longer in group B as compared to group A. VAS score at the time of initial self-reporting of pain was significantly lower in group B. No significant haemodynamic changes or side-effects were noted. CONCLUSION: Addition of dexmedetomidine to ropivacaine as compared with dexamethasone in bilateral TAP block following caesarean section prolongs the time to initial post-operative pain and time to first rescue analgesic consumption.

A Cross-Sectional Study on Knowledge, Attitude, and Practices of Donning and Doffing of Personal Protective Equipment: An Institutional Survey of Health-Care Staff during the COVID-19 Pandemic.

BACKGROUND: Personal protective equipment (PPE) is used to protect the health-care professional from bacterial, viral, or other hazards during this COVID-19 pandemic, and they should be made aware of proper usage of this equipment. AIMS: The aim was to evaluate how adequate knowledge, attitude, and practices (KAP) of health-care worker toward the appropriate use of PPE, which can prevent them and the community from virus contamination. METHODOLOGY: This study was conducted in a tertiary care hospital during the COVID-19 pandemic in a span of approximately 50 days. This cross-sectional questionnaire-based survey was done in 155 health-care providers posted in the COVID-19 area. STATISTICAL ANALYSIS: Data were described in terms of range; mean ± standard deviation, frequencies (number of cases) and relative frequencies (percentages) as appropriate. RESULTS: Health-care workers (HCWs) were aware of the importance and criticality of donning and doffing procedure, but they lack the knowledge about dispersion of virus as 62% responded that virus dispersion occurs more during donning than doffing. Gaps were found in attitude as 51% of HCWs found it inconvenient to don PPE that they sometimes think of compromising their own safety. Nearly 33.5% of HCWs move out of the doffing area without removing gloves and N-95, which needs serious correction in their practice. CONCLUSION: There were major gaps in KAP at institutional level among the health-care providers with regard to donning and doffing of PPE during the beginning of this pandemic.

A comparative study on postoperative pain relief in laparoscopic cholecystectomy: Intraperitoneal bupivacaine versus combination of bupivacaine and buprenorphine.

CONTEXT: To assess the analgesic efficacy of the combination of bupivacaine and buprenorphine in alleviating postoperative pain following laparoscopic cholecystectomy. AIMS: Laparoscopic cholecystectomy is comparatively advantageous as it offers less pain in the postoperative period and requires a shorter hospital stay. There are only a few studies performed to evaluate the analgesic efficacy of intraperitoneal instillation of buprenorphine and bupivacaine during laparoscopic cholecystectomy. SETTINGS AND DESIGN: The present research is a randomized, double-blind controlled study conducted in the Department of Anaesthesiology, Dayanand Medical College and Hospital Ludhiana, Punjab after formal ethical approval from Hospital's Ethics Committee. SUBJECTS AND METHODS: This study analyzed 90 adults admitted for elective laparoscopic cholecystectomy. After the procedure, subjects were divided into three equal groups to conduct the study. Three Groups A, B, and C had intraperitoneal instillation of the 25 ml of physiological saline (0.9% normal saline), 0.25% of bupivacaine, 0.25% bupivacaine, and 0.3 mg buprenorphine, respectively. Necessary vitals were monitored and recorded. Visual analog scale (VAS) and verbal rating scale (VRS) scores were recorded and analyzed systematically. STATISTICAL ANALYSIS USED: All observations were analyzed using analysis of variance and Student's t-test. RESULTS: The mean pain scores were highest in Group A compared to Group B and Group C. Mean VAS and VRS scores were highest in Group C comparatively and lowest in Group A. CONCLUSION: Combination of buprenorphine and bupivacaine intraperitoneally is comparatively more effective in relieving postoperative pain in comparison to intraperitoneal instillation of bupivacaine alone for postoperative pain management after laparoscopic cholecystectomy.

Bilateral Infraorbital Nerve Block Versus Intravenous Pentazocine: A Comparative Study on Post-operative Pain Relief Following Cleft Lip Surgery.

BACKGROUND AND OBJECTIVES: Infra orbital nerve block is utilized for postoperative pain control in children undergoing cleft lip repair. This study was conducted to compare the effectiveness, advantages and disadvantages of infra orbital nerve block and opioids for postoperative pain relief following cheiloplasty. MATERIALS AND METHODS: Sixty paediatric patients aged 3 months - 13 years undergoing cheiloplasty were selected by simple random sampling and were divided into two groups. All the children received standardized premedication with midazolam, were operated upon under general anaesthesia and the block was performed at the end of surgery before reversal. Group B patients were administered bilateral infra orbital nerve block with 0.25% Bupivacaine (upto 2 mg/kg). Group O patients received Pentazocine 0.5 mg / kg IV. Postoperatively, the heart rate and respiratory rates were recorded every 15 minutes for the first 60 minutes, half hourly till 4 hours and then at 12 and 24 hours. Behavioural assessment for pain / discomfort was done at intervals of ½, 1, 2, 3, 4, 12 and 24 hours. Need for supplementary analgesics and duration between the administration of block/opioid and the first dose of supplementary analgesics were noted. Side effects such as nausea and vomiting, pruritus, respiratory depression and bradycardia during each of these periods were noted. RESULTS: Both the groups were comparable for age, sex, weight and operative time with no statistical difference. The mean duration of analgesia for infra orbital nerve block was 357.5 minutes i.e. 5 hours 58 minutes and that for opioid was 231 minutes i.e. 3 hours 51 minutes which was significantly lower than the hours of analgesia provided by the block. Further, at the 4th hour, 76.6% of the patients in Group O required supplementary analgesics, in contrast to only 16.6% in Group B. The incidence of nausea and vomiting and pruritus was also higher in Group O. CONCLUSION: The results indicate that bilateral infra orbital nerve block provides effective analgesia in the postoperative period, lasting for 6 hours in comparison to 3½ - 4 hours following the administration of intravenous Pentazocine, with no major untoward effects.

Hemodynamic responses with different dose of ketamine and propofol in day care gynecological surgeries.

BACKGROUND: Day care gynaecological surgeries mandate use of hemodynamically stable combination of commonly used intravenous agents, propofol & ketamine. Hence we proposed to evaluate the hemodynamic profile of different dose combination of propofol & ketamine as induction agents in ambulatory gynecological surgeries. MATERIAL & METHODS: Thirty adult patients scheduled for day care gynecological surgeries were randomly divided into five Groups. Group I received inj. propofol 2mg/kg i.v + inj. Normal saline (NS); Group II received ketamine 2mg/kg i.v + inj. NS; Group III was given inj. Propofol 2mg/kg i.v followed by inj. Ketamine 1 mg/kg i.v.; Group IV received inj. Ketamine 2 mg/kg i.v followed by inj. propofol 1 mg/kg i.v; Group V received combination of inj. Propofol 1 mg/kg i.v and inj. Ketamine 1 mg/kg i.v. After administration of the drug, non invasive systolic, diastolic and mean arterial pressures, heart rate, respiratory rate, arterial oxygen saturation and ECG were recorded every minute for five minutes. RESULTS: Statistically significant hemodynamic alterations were observed in Group I & II, with Group I having the highest incidence of apnea (23.3%). No significant changes in hemodynamics were seen in Group V. CONCLUSION: We conclude that the combination of 1mg Propofol and 1mg ketamine produced better hemodynamic stability in comparison to other Groups.