Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study.

Background: With the provision of a small positive end-expiratory pressure (PEEP) effect, high-flow nasal oxygen (HFNO) therapy carries a risk of stomach distension. The present study was conducted to find out the air leak in the gastric antrum leading to gastric distension in adult patients with acute respiratory failure receiving HFNO therapy. Materials and methods: Adult patients with early hypoxemic respiratory failure requiring HFNO therapy were enrolled in this trial. Before initiation of HFNO therapy, baseline gastric volume (GV) and the average number of peristaltic contractions over one minute were measured using ultrasound. Once the patient was stabilized on HFNO therapy, a 2nd, 3rd, and 4th ultrasound scans were acquired at 10, 20, and 30 minutes respectively. Vitals and blood gas values were recorded at the baseline and after 30 min of initiation of HFNO therapy. Patient comfort, duration of HFNO therapy, and outcome were also recorded. Results: The GV at 10, 20, and 30 minutes were significantly larger (p < 0.001) compared to baseline. This increase in GV was associated with a significantly increased number of peristaltic contractions and had a significant positive correlation with the HFNO flow (r = 0.541; p < 0.001). The HFNO therapy was well tolerated by most of the patients and led to a significant improvement in the vitals and blood gas parameters at 30 minutes after initiation of HFNO therapy. Conclusion: In adult patients with hypoxemic respiratory failure, the use of HFNO therapy produces gas leaks into the stomach leading to increased gastric volume. The gastric distension increases the peristaltic contraction and higher flows result in more distension. How to cite this article: Ramachandran A, Bhatia P, Mohammed S, Kamal M, Chhabra S, Paliwal B. Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2024;28(4):393-398.

Hydrogen Evolution Activity of Nitrogen-Rich g-C3-xN4+x Synthesized by Solid-Gas Interface Method.

Synthesis of a metal-free carbon nitride (g-C3N4) photocatalyst in the form of nitrogen-rich g-C3-xN4+x derivatives is desirable for efficient solar to hydrogen conversion and remains a challenging task to achieve. Herein we report the development of homogeneous sheets of nitrogen-rich graphitic carbon nitride samples from melamine by a solid-gas interface approach. Using this method, pure g-C3N4 (CN), g-C3-xN4+x under ammonia flow (CN-NH3) and g-C3-xN4+x under nitrogen flow (CN-N2) are prepared. The g-C3-xN4+x (CN-NH3) sample shows better surface conductivity, wide optical absorbance in the visible region, reduced recombination and high electron donor density, and higher performance toward photoelectrochemical hydrogen evolution (HER). The g-C3-xN4+x (CN-NH3) generates a photocurrent of 2.06 µA cm-2, which is 2.5 times higher than that of the pure g-C3N4 (CN) sample (0.85 µA cm-2). It also shows higher photocatalytic water splitting ability compared to the CN and CN-N2 samples, generating 634 µmol g-1 hydrogen without cocatalyst and 1163 µmol g-1 of hydrogen with Pt cocatalyst. Density functional calculations suggest that the progressive band gap reduction with the increase in the N-dopant percentage can be attributed to the gradual increase in the partial π-occupations, which can lead to a significant stabilization of the conduction band minima. The theoretical modeling, however, indicates a saturation in the band gap effect after 75% of N-dopant. The onset potential of g-C3-xN4+x for HER appears at η = 0.43 V in dark and η = 0.34 V vs Ag/AgCl under solar light illumination of 1 sun.

α/ß-Stereo- and diastereoselective glycosylation with n-pentenyl glycoside donors, promoted by N-iodosuccinimide and catalyzed by chiral Brønsted acid.

A method involving stereoselective glycosylation catalyzed by (+)-isomenthol ester of pentacarbomethoxycyclopentadiene as a chiral Brønsted acid, with n-pentenyl glycosides in the presence of N-iodosuccinimide as the promoter is described; this method offered a chiral recognition of racemic substrates.

Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey.

Introduction: Appropriate implementation of a ventilator bundle (VB) is the key step in the prevention of ventilator-associated pneumonia (VAP). However, knowledge and compliance of critical care staff for VB are inconsistent in developing countries. This cross-sectional survey was planned to evaluate critical care practitioners' knowledge of, adherence to, and barriers toward implementation of VB in the ICUs of a tertiary care institute. Methodology: All registered nurses and resident doctors who are direct care providers to patients of the ICU were included. Two sets of questionnaires were given to access knowledge and to identify potential barriers in the implementation of VB. To determine compliance with the VB, direct observation was done for three nonconsecutive days, and mean compliance per component of the bundle and overall compliance to VB was determined. Data were analyzed using descriptive and analytic statistics. Results: Of these 75 participants, 43 (57.33%) were resident doctors and 32 (42.67%) were staff nurses. The median knowledge score of resident doctors and staff nurses for VB was 7 (range 3-10) and 6 (range 2-9), respectively, with an overall score of 7 (range 2-10). Self-reported adherence to individual components of VB ranged from 75% to 95%, among these, adherence to oral care protocol, including use of chlorhexidine oral rinse, was most, and adherence to DVT prophylaxis was least. The most common potential barriers identified were fear of potential adverse effects and unawareness of guidelines. Conclusion: Considerable gap is observed between knowledge and implementation of VB among critical care practitioners. Despite knowledge, fear of adverse events and lack of proper training are key barriers in implementation of VB. How to cite this article: Paliwal N, Bihani P, Mohammed S, Rao S, Jaju R, Janweja S. Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey. Indian J Crit Care Med 2023;27(4):270-276.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

Background and Aims: A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. Material and Methods: This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. Results: The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Conclusion: Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

The midpoint transverse process to pleura (MTP) block for postoperative analgesia in patients undergoing modified radical mastectomy: A case series.

Among the various regional anesthesia techniques used for postoperative analgesia in the modified radical mastectomy (MRM), thoracic paravertebral block (TPVB) is presently considered the technique of choice. Nevertheless, TPVB may lead to complications like inadvertent vascular puncture, hypotension, epidural or intrathecal spread, pleural puncture, or pneumothorax. Recently, a newer technique "midpoint transverse process to pleura" (MTP) block has been described in which the tip of the needle is placed at the midpoint between the transverse process and pleura. In this case series, we included ten patients of American Society of Anesthesiologist status I/II scheduled for MRM. Ultrasound-guided MTP block was performed and the catheter was inserted on the side of the surgery at the level of T4 level. The block was successful in the all patients as their median visual analogue score at rest and movement was 2 and 3, respectively, in first 24 h postoperatively. Only three patients required rescue analgesia in the first 24 h. No procedural-related complications were noticed in any patient. We concluded that MTP block provided effective perioperative analgesia with minimal rescue analgesia requirement and satisfactory safety profile.

Comparison of intranasal and nebulized dexmedetomidine for premedication in pediatric patients: A non-inferiority randomized controlled trial.

Background and Aims: Dexmedetomidine is a highly selective α-2 adrenoreceptor agonist and has been found to be an effective premedication agent when administered via the intranasal route. We aimed to compare the efficacy of dexmedetomidine premedication administered via intranasal route and through nebulization in pediatric patients. Material and Methods: This non-inferiority randomized controlled trial was conducted after getting approval from institutes ethics committee and informed written parental consent. Sixty-four children aged 2-8 years scheduled for elective surgery under general anesthesia were enrolled and were divided into two groups. Group I (Intranasal, n = 33) received 2 mcg/kg dexmedetomidine via intranasal route and group N (Nebulized, n = 31) received 2 mcg/kg dexmedetomidine through nebulization. The primary outcome was number of patients with satisfactory sedation 30 minutes after premedication at separation from parent. The secondary outcome included ease of medication acceptance, anxiety at parental separation, acceptance of anesthesia mask, perioperative hemodynamics, emergence agitation during recovery and adverse effects. Data collected was analyzed using Chi-square test, Student "t" test and Mann-Whitney U test with the help of SPSS 22. A one tailed P value < 0.025 was considered significant. Results: Demographic profile was comparable between groups. On arrival in OR 27 (81.8%) patients in group I and 21 (67.7%) patients in group N had satisfactory sedation score (P = 0.19). The median (IQR) sedation score was comparable between group I and group N (P = 0.057). Patients in Group I showed significantly better medication and mask acceptance scores (P < 0.0001, P = 0.001 respectively), parental separation anxiety score (P < 0.0001) and emergence agitation score (P = 0.001). There were no significant differences in hemodynamic parameters and adverse effects between the groups. Conclusion: Although nebulized dexmedetomidine is non-inferior to intranasal dexmedetomidine in providing desired level of sedation but intranasal administration had better acceptance of medication and anesthesia mask with lesser anxiety at parental separation and postoperative emergence agitation.

Gastric emptying time of two different quantities of clear fluids in children: A double-blinded randomized controlled study.

BACKGROUND: Perioperative pulmonary aspiration risk increases with increased preoperative gastric volume; hence traditionally, healthy children are kept fasted overnight before surgery. Current guidelines recommend 2-h clear fluids fasting prior to anesthesia. However, emerging evidence favors allowing 3 ml/kg clear fluids up to 1-h before anesthesia. We compared the gastric volume and gastric emptying time after ingestion of 3 ml/kg and 5 ml/kg of clear fluids. METHODS: The present study enrolled 44 children, aged between 6 and 14 years. On the day of surgery, baseline gastric volume was estimated using ultrasound and patients were randomly allocated into two groups of equal number, that is, Group 3 and Group 5 (patients received 3 ml/kg and 5 ml/kg 5% Dextrose respectively). Repeated gastric ultrasound was performed at every 5 min until the gastric volume reached baseline levels. The primary objective of the study was to compare gastric emptying time. Secondary objectives included comparison of antral cross-sectional area and gastric volume. RESULTS: The demographic profile, preoperative fasting duration for clear fluids, and baseline gastric volume were comparable between groups. In both groups, compared to baseline the antral cross-sectional area and gastric volume increased significantly following fluid ingestion and then decreased exponentially to reach baseline within 1-h. The median (IQR) (range) gastric emptying time (minutes) [35.0 (28.8, 40.0) (20.0-45.0) in group 3 and 40.0 (28.8, 45.0) (20.0-50.0) in group 5] and emptying half-time (minutes) [17.0 (15.7, 21.5) (14.4-24.0) in group 3 and 18.6 (16.0, 22.0) (15.1-23.8) in group 5] were comparable [median difference -5 (95% CI -7.8 to 2.1) and -1.5 (95% CI -2.3 to 1.0), respectively] (p = .16 and p = .44, respectively). CONCLUSION: As the gastric volume returned to baseline within 1-h even after ingesting 5 ml/kg clear fluids, the preoperative fasting time can be reduced to 1-h and healthy children undergoing elective procedure can be safely allowed to drink up to 5 ml/kg clear fluids.

Aspiration Pneumonia after Rapid Sequence Intubation: A Diagnostic Dilemma!

Rapid sequence intubation (RSI) is generally done in the patients requiring intubation in the emergency room. These patients are often full stomach and are at the risk of regurgitation and aspiration leading to aspiration pneumonia. The incidence of aspiration pneumonia during RSI is not known as the term "RSI" is poorly defined and the diagnosis of aspiration pneumonia is often clinical and circumstantial. How to cite this article: Bhatia PK, Mohammed S. Aspiration Pneumonia after Rapid Sequence Intubation: A Diagnostic Dilemma! Indian J Crit Care Med 2021;25(2):111-112.

Vertical integration in postgraduate teaching for anaesthesiology residents: A questionnaire based descriptive cross-sectional study.

BACKGROUND: Medical education has observed numerous reforms in the last hundred years. While most of the reforms are applied to the undergraduate teaching, postgraduate education and training have lagged behind in keeping the pace. Anesthesiology curriculum has witnessed a few new methods inducted into practice like problem-based learning, flipped classroom etc. We introduced vertical integration with anatomy at our department and assessed its impact. METHODS: After a five-week schedule of integrated anatomy classes, a self-structured questionnaire was circulated amongst the 41 anesthesiology residents to know their perceptions and attitudes towards the classes. Their suggestions were also sought. The responses were analyzed with descriptive statistics (percentages). RESULTS: Thirty-six responses were received leading to a response rate of 87.8%. Fourteen residents (38.9%) believed that the integrated classes would be very helpful in their clinical practice, 20 (55.5%) residents believed them to be helpful while two (5.5%) residents believed that the classes would be little helpful in clinical practice. Hundred percent of the residents recommended the classes to be continued for the future batches. Half of the residents wanted the classes to be conducted twice in the three-year tenure (in the first and last semester) while 11 (30.5%) residents wanted the classes to be conducted every year. Seven (19.4%) residents thought that it's enough to conduct the classes once during the three-year tenure. Resident's suggested that they would like to have integrated classes with other departments like physiology, radiology, emergency medicine etc. CONCLUSION: The integrated classes with anatomy were well perceived by the anesthesiology residents. Vertically integrated curriculum should be introduced in postgraduate training of various specialties for better education and hence, better patient care.

Pulmonary Hyperinfection with Strongyloides stercoralis in an Immunocompetent Patient.

Strongyloids stercoralis is a unique parasite as it has the capability of completing its life cycle entirely within the human host. The immune system of the host plays an important role in keeping the infection under control but when there is a breach in this system the infection may flare up and leads to hyperinfection. In immunocompetent patients, gastrointestinal manipulation could be an inciting trigger leading to translocation of larva into the systemic circulation and development of hyperinfection syndrome. We report a case where infection with S. stercoralis lead to hyperinfection in patient with intact immune system following laparotomy. HOW TO CITE THIS ARTICLE: Mohammed S, Bhatia P, Chhabra S, Gupta SK, Kumar R. Pulmonary Hyperinfection with Strongyloides stercoralis in an Immunocompetent Patient. Indian J Crit Care Med 2019;23(10):481-483.

Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature.

Physiological changes of pregnancy imposes higher risk of acute respiratory failure (ARF) with even a slight insult and remains an important cause of maternal and fetal morbidity and mortality. Although pregnant women have different respiratory physiology and different causes of ARF, guidelines specific to ventilatory settings, goals of oxygenation and weaning process could not be framed due to lack of large-scale randomized controlled trials. During the 2009 H1N1 pandemic, pregnant women had higher morbidity and mortality compared to nonpregnant women. During this period, alternative strategies of ventilation such as high-frequency oscillatory ventilation, inhalational of nitric oxide, prone positioning, and extra corporeal membrane oxygenation were increasingly used as a desperate measure to rescue pregnant patients with severe hypoxemia who were not improving with conventional mechanical ventilation. This article highlights the causes of ARF and recent advances in invasive, noninvasive and alternative strategies of ventilation used during pregnancy.