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.

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.

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.

Comparison of midpoint transverse process to pleura (MTP) block and erector spinae plane block (ESP) for postoperative analgesia in modified radical mastectomy patients: A double-blinded, randomized control trial.

Background and Aims: Modified radical mastectomy (MRM) is associated with moderate severity of postoperative pain. Besides intravenous (IV) analgesics, various nerve blocks are being described for pain relief of MRM patients. We compared erector spinae plane (ESP) block with midpoint transverse process to pleura (MTP) block in these patients for postoperative analgesia. Material and Methods: After receiving ethical committee approval from the institutional ethics committee (AIIMS, Jodhpur) and written informed consent from study participants, 66 patients who were assigned American Society of Anesthesiologists (ASA) physical status I and II, aged 18-75 years, and were scheduled to undergo MRM were enrolled and randomly allocated into two groups. Unilateral block was given before surgery at T3 or T4 level and with 15 ml of 0.5% ropivacaine in both the groups. Infusion of 0.5% ropivacaine (Neon laboratories limited, Mumbai, India) and 0.2% ropivacaine at a rate of 5 ml/h was maintained intraoperatively and postoperatively, respectively. Pain was assessed using the Visual Analogue Scale (VAS) for the next 24 hours. The total number of patients needing rescue analgesia, the total amount of rescue analgesics consumed in the next 24 hours, and patient satisfaction score were also compared between groups. Results: Demographics and baseline vitals were comparable in the groups. On comparing VAS scores in both the groups during rest and movement at different time intervals, there was no difference in pain scores during the initial two hours. From the third hour, there was a statistically significant difference (P < 0.001) in pain VAS scores in both groups. The ESP group had lower VAS scores compared to the MTP group when followed for the next 24 hours. There was a statistically significant difference in patient satisfaction. Conclusion: ESP block is more efficacious when compared to MTP block for postoperative analgesia in MRM patients.

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.

Comparison of the effects of dexmedetomidine and nitroglycerin on cerebral oxygen saturation using near-infrared spectroscopy in patients undergoing controlled hypotensive anaesthesia: A randomised controlled non-inferiority trial.

Background and Aims: There is limited literature wherein the hypotensive drugs have been compared to know the cerebral effects by monitoring regional cerebral oxygen saturation (rScO2). This study aimed to compare the effects of dexmedetomidine and nitroglycerin on rScO2 during controlled hypotensive anaesthesia using near-infrared spectroscopy (NIRS). The primary objective was to evaluate the non-inferiority of dexmedetomidine versus nitroglycerin in the occurrence of cerebral desaturation events (CDEs) during hypotensive anaesthesia. Methods: Adult patients scheduled to undergo head and neck surgery under general anaesthesia randomised to receive either dexmedetomidine or nitroglycerin infusion for controlled hypotensive anaesthesia. Cerebral oximetry was monitored with NIRS, and data regarding CDEs, bilateral rScO2, and peri-operative haemodynamics were collected. Continuous data were analysed using unpaired Student's t-tests except for intra-group analyses, which were analysed using paired t-tests. Categorical data were analysed using the Chi-square test. For comparison of time to CDEs, Kaplan-Meier survival analysis with log-rank test was performed. Results: Of the 82 patients in both groups, CDEs were observed in 15 patients each. A decrease from baseline by 20% was observed in three patients: one in Group N and two in Group D. Statistically, there was an equal risk of getting CDEs in the groups. The time to CDE was comparable (P > 0.05). The difference in heart rate was statistically significant (P < 0.001). Conclusion: Dexmedetomidine is non-inferior to nitroglycerin in terms of the occurrence of cerebral desaturation events when used for controlled hypotensive anaesthesia in head and neck surgeries.

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.

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.

Count in Time So All is Fine.

Dislodgement of surgical sponge into airway during the intraoperative period is uncommon as the airway, in most cases secured by an endotracheal tube. We report such an unusual case during micro laryngeal surgery and direct laryngoscopy assessment under general anaesthesia. This shows early suspicion and quick action to avoid disaster.

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.

Assessment of the use and Safety of Protection Box for Intubation and Extubation Among Anaesthesiologists During COVID-19 Pandemic- A Cross-sectional Survey.

Introduction: Covid 19 epidemic has affected the people making them undergo emergency procedures requiring intubation. A protective box was innovated at our tertiary care centre to safeguard the HCW during intubation and/or extubation and the study was planned to assess its use and safety among the anaesthesiologists. Methods: A cross sectional, questionnaire base survey was done among anaesthesiologists in various strata of residency. The intubation box was used on the patient for intubation and extubation. The experience of participants was recorded via a Google Form and one response per participant was restricted. Participants were divided into two groups, Group 1(1stand 2nd year junior residents) and Group 2 (Senior resident and 3rd year junior resident). A valid response, was received from 25 anaesthesiologists who were either performing or assisting the intubation. The residents were evaluated based on the ease of use and safety features of the box. Results: There was a significant difference in the time taken to intubate between the two groups (p = 0.048) and it was found that Group 2 with more experience took less time to intubate than Group 1. Also, more respondents in Group 2 found it easier to manoeuvre the hands to handle instruments than Group 1(p = 0.024). Conclusion: We recommend that usage of intubation box during intubation or extubation is a non-harmful and necessary compromise that we must make to protect the /safeguard the well-being of Health Care Worker without affecting patient care in our fight with COVID-19. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03692-7.