COVID-19 pandemic and preparedness of anesthesia team in a stand-alone cancer centre in Eastern India.

India came under the grip of the coronavirus disease-2019 (COVID-19) pandemic and is now seeing rising graph. Cancer patients are specially in the high-risk group because of their immunocompromised status on one hand and progressive disease on the other hand. Hence, cancer care facility needs to prepare a clear strategy to manage their space, staff and supplies so that optimum patient care can be continued in the face of COVID-19 pandemic. In addition, infection prevention measures need to be robust to reduce in-hospital transmission. The working area of anesthesia and Critical Care is spread over the whole hospital such as operating room, ICU, isolation area, out-patient dept (OPD) area, various diagnostic areas and in-patient dept (IPD) to attend code blue calls. In this article, we describe the preparedness and initial response measures of the anesthesia and Critical Care department of a stand-alone tertiary level cancer care centre in eastern part of India. These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow, introduction and adequate supply of personal protective equipment for staff and formulation of clinical guidelines for anesthetic management. These containment measures are necessary to continue care of cancer patients, optimize the quality of care provided to COVID-19 positive cancer patients and to reduce the risk of viral transmission to other patients or healthcare providers.

Heating, ventilation and air conditioning (HVAC) in intensive care unit.

The aim of this review is to describe variation in standards and guidelines on 'heating, ventilation and air-conditioning (HVAC)' system maintenance in the intensive care units, across the world, which is required to maintain good 'indoor air quality' as an important non-pharmacological strategy in preventing hospital-acquired infections. An online search and review of standards and guidelines published by various societies including American Institute of Architects (AIA), American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Centers for Disease Control and Prevention (CDC), Department of Health Estates and Facilities Division, Health Technical Memorandum 2025 (HTM) and Healthcare Infection Control Practices Advisory Committee (HICPAC) along with various national expert committee consensus statements, regional and hospital-based protocols available in a public domain were retrieved. Selected publications and textbooks describing HVAC structural aspects were also reviewed, and we described the basic structural details of HVAC system as well as variations in the practised standards of HVAC system in the ICU, worldwide. In summary, there is a need of universal standards for HVAC system with a specific mention on the type of ICU, which should be incorporated into existing infection control practice guidelines.

Effect of Prone Positioning on Intraocular Pressure in Patients With Acute Respiratory Distress Syndrome.

OBJECTIVES: To evaluate the effect of prolonged duration of prone position (with head laterally rotated) on intraocular pressure in acute respiratory distress syndrome patients. DESIGN: Prospective observational study. SETTING: University hospital ICU. PATIENTS: Twenty-five acute respiratory distress syndrome patients, age 60 years (51-67 yr), Sequential Organ Failure Assessment score 10 (10-12), PaO2/FIO2 ratio of 90 (65-120), and all in septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intraocular pressure (in mm Hg) measured by hand-held applanation tonometer, at different time points. Before prone (in both eyes): at 30-45° head-end elevation position (THE pre-prone), in supine position just before turning prone (Tsupine pre-prone); during prone (in nondependent eye): at 10 minutes (T10 prone), 30 minutes (T30 prone), and at just before end of prone session (Tend-prone). After end of prone session (both eyes): at 5 minutes (T5 supine post-prone), 10 minutes (T10 HE post-prone), 15 minutes (T15 HE post-prone), and 30 minutes (T30 HE post-prone). Median duration of prone position was 14 hours (12-18 hr). Median intraocular pressure increased significantly (p ≤ 0.001) in both eyes. In dependent eye, from 15 (12-19) at THE pre-prone to 24, 21, 19, and 16 at T5 supine post-prone, T10 HE post-prone, T15 HE post-prone, and T30 HE post-prone respectively, whereas in nondependent eye from 14 (12-18.5) at THE pre-prone to 23, 25, 32, 25, 22, 20, and 17 at T10 prone, T30 prone, Tend-prone, T5 supine post-prone, T10 HE post-prone, T15 HE post-prone, and T30 HE post-prone respectively. Bland-Altman plot analysis showed significant linear relationship (r = 0.789; p ≤ 0.001) with good agreement between rise in mean intraocular pressure of the both eyes (dependent eye and nondependent eye) with their paired differences after the end of different duration of prone session (T5 supine post-prone). CONCLUSIONS: There is significant increase in intraocular pressure due to prone positioning among acute respiratory distress syndrome patients. Intraocular pressure increases as early as 10 minutes after proning, with increasing trend during prone position, which persisted even at 30 minutes after the end of post prone session although with decreasing trend.

Trans-Esophageal Doppler Assessment of Acute Hemodynamic Changes Due to Prone Positioning in Acute Respiratory Distress Syndrome Patients.

BACKGROUND: Effect of prone positioning on acute hemodynamic changes (within 10 min) in acute respiratory distress syndrome (ARDS) has not been studied. METHODS: In this prospective observational study, hemodynamic assessment by trans-esophageal Doppler (TED) was done with the primary aim of measuring early changes in cardiac index (CI), if any, after prone positioning in moderate to severe ARDS patients. A subgroup analysis was also done based on the response to passive leg raise (PLR). RESULTS: The baseline hemodynamic variables of 26 included patients were: CI 3.5 (3.1-4.3) L/min/m, peak velocity (PV) 83.2 (60.9-99.3) cm/s, flow time corrected (FTc) 341 (283-377) ms, mean acceleration (MA) 9.0 (7.04-11.7) m/s. After prone position, there were no statistically significant changes in CI, 3.5 (P=0.83), 3.75 (P = 0.96), 3.7 (P = 0.34), and 3.9 (P = 0.95) at 5, 10, 20, and 30 min respectively. FTc, mainly indicator of preload, showed decreasing trend to 315 (275-367) ms at 30 min post prone (P = 0.06). On the basis of PLR test also, CI did not change significantly in both PLR+ and PLR- groups. In PLR+ group, PV increased from 72.4 to 83 (P = 0.01), 74.9 (P = 0.03), 82 (P = 0.02), and 82 (P = 0.03) cm/s; while in PLR- group, MA increased from 8.8 to 9.7 (P = 0.03), 10.1 (P = 0.03), 9.3 (P = 0.04), and 10.6 (P = 0.01) m/s at 5, 10, 20, and 30 min respectively. CONCLUSIONS: In moderate to severe ARDS patients, there were no significant changes in CI during first 30 min after prone positioning, even in the subgroups on the basis of PLR response.

Submental intubation: A journey over the last 25 years.

Airway management in patients with faciomaxillary injuries is challenging due to disruption of components of upper airway. The anesthesiologist has to share the airway with the surgeons. Oral and nasal routes for intubation are often not feasible. Most patients have associated nasal fractures, which precludes use of nasal route of intubation. Intermittent intraoperative dental occlusion is needed to check alignment of the fracture fragments, which contraindicates the use of orotracheal intubation. Tracheostomy in such situations is conventional and time-tested; however, it has life-threatening complications, it needs special postoperative care, lengthens hospital stay, and adds to expenses. Retromolar intubation may be an option, But the retromolar space may not be adequate in all adult patients. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation allows intraoperative dental occlusion and is an acceptable option, especially when long-term postoperative ventilation is not planned. This technique has minimal complications and has better patients' and surgeons' acceptability. There have been several modifications of this technique with an expectation of an improved outcome. The limitations are longer time for preparation, inability to maintain long-term postoperative ventilation and unfamiliarity of the technique itself. The technique is an acceptable alternative to tracheostomy for the good per-operative airway access.