Development of a preoperative Early Warning Scoring System to identify highly suspect COVID-19 patients.

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) is spreading at an unprecedented speed. Lack of resources to test every patient scheduled for surgery and false negative test results contribute to considerable stress to anesthesiologists, along with health risks to both caregivers and other patients. The study aimed to develop an early warning screening tool to rapidly detect 'highly suspect' among the patients scheduled for surgery. METHODS: Review of literature was conducted using terms 'coronavirus' OR 'nCoV 2019' OR 'SARS-CoV-2' OR 'COVID-19' AND 'clinical characteristics' in PUBMED and MedRxiv. Suitable articles were analysed for symptoms and investigations commonly found in COVID-19 patients. Additionally, COVID-19 patient's symptomatology and investigation profiles were obtained through a survey from 20 COVID-19 facilities in India. Based on literature evidence and the survey information, an Early Warning Scoring System was developed. RESULTS: Literature search yielded 3737 publications, of which 195 were considered relevant. Of these 195 studies, those already included in the meta-analyses were not considered for independent assessment. Based on the combined data from meta-analyses and survey, risk factors of COVID-19 disease identified were as follows: history of exposure, fever, cough, myalgias, lymphocytopaenia, elevated C-reactive protein (CRP)/lactate dehydrogenase (LDH) and radiographic infiltrates. CONCLUSION: Development of this Early Warning Scoring System for preoperative screening of patients may help in identifying 'highly suspect' COVID-19 patients, alerting the physician and other healthcare workers on the need for adequate personal protection and also to implement necessary measures to prevent cross infection and contamination during the perioperative period.

Development and validation of a questionnaire for a survey on perioperative fasting practices in India.

BACKGROUND AND AIMS: Perioperative fasting guidelines have been published and updated to standardise practices. Hence, Indian Society of Anaesthesiologists decided to conduct a survey to assess the fasting practices and the food habits across India, which would be subsequently used for developing preoperative fasting guidelines for the Indian population. We detail and discuss herewith the content validity of the questionnaire developed for the survey. METHODS: Thirty-six questions related to perioperative fasting practices were framed based on the collected evidence and relevance to regional diet and concerns. Subsequently, an information sheet was prepared and sent to 10 experts to grade each question. The responses were tabulated, and item-wise content validity index (I-CVI), scale-wise content validity index (S-CVI) and modified kappa statistic were calculated in Microsoft Excel™ sheet. RESULTS: Seven of the 10 experts completed the assessment and grading as per the instructions provided and submitted a completed proforma. S-CVI for relevance, simplicity, clarity and ambiguity was 0.72, 0.86, 0.72 and 0.72, respectively. S-CVI/average or average congruency percentagewas 0.95, 0.97, 0.95 and 0.95 for relevance, simplicity, clarity and ambiguity, respectively. Question 2 received an I-CVI of 0.71 in terms of clarity and question 23 received an I-CVI of 0.71. They were modified as persuggestions of the experts. CONCLUSION: We conclude that our questionnaire designed to ascertain the preoperative fasting practices for a surveymet the content validity criteria both by qualitative and quantitative analyses.

Clinical trial registration: A practical perspective.

The increase in the number of clinical trials, driven mainly for career advancement mandated by regulatory bodies such as Medical Council of India risks output of substandard publications and also wastage of resources. There are also concerns of inadequate reporting and wilful concealment of results. The quality and quantity of the output become questionable evidences for medical practice. Lack of transparency can lead to disillusionment of the public in the medical field. Clinical trials registration seeks to regulate and streamline the clinical trials by mandating registration in various registries, through free for registration sites such as Clinical Trials Registry of India (CTRI). The guidelines are based on the World Health Organisation's International Clinical Trials Registry Platform (ICTRP). This review aims to highlight the types of registries, the registration process, the data that need to be registered, the guide to use the CTRI and the search options in CTRI and ICTRP. The role of International Committee of Medical Journal Editors is also highlighted in regard to not only registration but also on the publication of trial registration number in the manuscript.

Consensus statement on anaesthesia for day care surgeries.

The primary aim of day-care surgery units is to allow for early recovery of the patients so that they can return to their familiar 'home' environment; the management hence should be focused towards achieving these ends. The benefits could include a possible reduction in the risk of thromboembolism and hospital-acquired infections. Furthermore, day-care surgery is believed to reduce the average unit cost of treatment by up to 70% as compared to inpatient surgery. With more than 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hence, there is an immense opportunity for expansion in day-care surgery in India to ensure faster and safer, cost-effective patient turnover. For this to happen, there is a need of change in the mindset of all concerned clinicians, surgeons, anaesthesiologists and even the patients. A group of nine senior consultants from various parts of India, a mix of private and government anaesthesiologists, assembled in Mumbai and deliberated and discussed on the various aspects of day-care surgery. They formulated a consensus statement, the first of its kind in the Indian scenario, which can act as a guidance and tool for day-care anaesthesia in India. The statements are derived from the available published evidence in peer-reviewed literature including guidelines of several bodies such as the American Society of Anesthesiologists, British Association of Day Surgery and International Association of Ambulatory Surgery. The authors also offer interpretive comments wherever such evidence is inadequate or contradictory.

Intrathecal Dexmedetomidine for Anaesthetic Management of a Patient with Chronic Inflammatory Demyelinating Polyneuropathy.

Chronic demyelinating disorders have multifactorial origin but common important physiologic and anaesthetic considerations. Choice of anaesthesia technique and the drugs used, undertanding the pros and cons of using central neuraxial blocks will help in successful management of such patients. We describe the anaesthetic management of a 34-year-old male with chronic inflammatory demyelinating polyneuropathy posted for cystolithotripsy.

Does C-MAC® video laryngoscope improve the nasotracheal intubating conditions compared to Macintosh direct laryngoscope in paediatric patients posted for tonsillectomy surgeries?

BACKGROUND AND AIMS: C-MAC® video laryngoscope (VL) with Macintosh blade has been found to improve Cormack-Lehane (C-L) laryngoscopic view as well as intubating conditions for orotracheal intubation. However, studies done on the performance of C-MAC® VL for nasotracheal intubation (NTI) are very few in number. Hence, we compared laryngoscopy and intubating conditions between Macintosh direct laryngoscope and C-MAC® VL for NTI. METHODS: Sixty American Society of Anesthesiologists Physical Status I, II patients, aged 8-18 years, posted for tonsillectomy surgeries under general anaesthesia with NTI were randomised, into two groups. Patients in group 1 were intubated using Macintosh direct laryngoscope and group 2 with C-MAC® VL. C-L grading, time required for intubation, need for additional manoeuvres and haemodynamic changes during and after intubation were compared between the groups. RESULTS: C-L grade 1 views were obtained in 26 and 29 patients in group 1 and group 2, respectively (86.7% vs. 96.7%). Remaining patients were having C-L grade 2 (13.3% vs. 3.3%). Duration of intubation was less than a minute in group 2 (93.3%). Need for additional manoeuvres (M1-M5) were more in group 1 (97% vs. 77%). M1 (external manipulation) was needed more in group 2 compared to group 1 (53.3% vs. 30%). Magill's forceps alone (M4) and M4 with additional external manipulation (M5) were needed more in group 1 compared to group 2 (60% vs. 16%). CONCLUSION: The overall performance of C-MAC® VL was better when compared to conventional direct Macintosh laryngoscope during NTI in terms of glottis visualisation, intubation time and need for additional manoeuvres.

Methodology for research II.

Research is a systematic process, which uses scientific methods to generate new knowledge that can be used to solve a query or improve on the existing system. Any research on human subjects is associated with varying degree of risk to the participating individual and it is important to safeguard the welfare and rights of the participants. This review focuses on various steps involved in methodology (in continuation with the previous section) before the data are submitted for publication.

Basic statistical tools in research and data analysis.

Statistical methods involved in carrying out a study include planning, designing, collecting data, analysing, drawing meaningful interpretation and reporting of the research findings. The statistical analysis gives meaning to the meaningless numbers, thereby breathing life into a lifeless data. The results and inferences are precise only if proper statistical tests are used. This article will try to acquaint the reader with the basic research tools that are utilised while conducting various studies. The article covers a brief outline of the variables, an understanding of quantitative and qualitative variables and the measures of central tendency. An idea of the sample size estimation, power analysis and the statistical errors is given. Finally, there is a summary of parametric and non-parametric tests used for data analysis.