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.

The effect of anesthetic techniques on neutrophil to lymphocyte ratio in patients undergoing infraumbilical surgeries.

BACKGROUND: Neutrophil to lymphocyte ratio (NLR) is a simple marker in peripheral blood and is used to assess inflammatory response and physiological stress during the peri-operative period. Anesthetic technique may influence NLR, thereby modulating the inflammatory response and surgical outcomes. The study aimed to evaluate the relationship between blood NLR and anesthetic techniques in patients undergoing infraumbilical surgeries. METHODS: Institutional ethical committee approval and patient consent were obtained. A prospective randomized double- blinded study was conducted between July 2017 and November 2017, involving 80 patients classified as the American Society of Anesthesiologists grade 1 and 2, aged 18-60 years, and scheduled for elective infraumbilical surgeries. Unwilling and those with infections were excluded. The patients were randomly divided into two groups: Group G (general anesthesia) and Group S (spinal anesthesia) as per the standardized protocol. Differential counts of leukocytes and NLR in the peripheral blood were obtained pre-operatively on the morning of surgery and at 2 h and 24 h after surgery in both the groups. The data were analyzed using appropriate statistical tests. RESULTS: The demographic parameters, basal total leukocyte count (TLC), and NLR were comparable between the groups. TLC and NLR were significantly higher in Group G as compared to that in Group S post-operatively. The post-operative rise in TLC and NLR from the basal values was significantly higher in Group G as compared to that in Group S. CONCLUSIONS: General anesthesia was associated with a greater increase in TLC and NLR when compared with spinal anesthesia.

Comparison of Upper Lip Bite Test and Ratio of Height to Thyromental Distance with Other Airway Assessment Tests for Predicting Difficult Endotracheal Intubation.

BACKGROUND AND AIMS: Unanticipated difficult intubation or the failed intubation in operating room and in emergency department is an imperative source of anesthesia-related patient's mortality. The aim of this study is to compare the predictive value of upper lip bite test (ULBT) and ratio of height to thyromental distance (RHTMD) with other commonly used preoperative airway assessment tests for predicting difficult intubation in Indian population. MATERIALS AND METHODS: In this prospective, single-blinded observational study, 260 adult patients of either sex, belonging to American Society of Anesthesiologists physical Status I and II undergoing elective surgical procedure under general anesthesia were included in the study. ULBT, RHTMD, inter-incisor gap, modified Mallampati grade, horizontal length of the mandible, head and neck movements, sternomental distance, and TMD were assessed preoperatively and correlated with Cormack and Lehane's grading during laryngoscopy under anesthesia. Statistical analysis was done by Chi-square and Fisher's exact test. RESULTS: ULBT and RHTMD had highest sensitivity (66.7% and 63.3%), specificity (99.1% and 89.6%), positive predictive value (90.9% and 44.2%), and negative predictive value (96.9% and 95.0%), respectively, when compared to other parameters in predicting difficult airway. CONCLUSION: ULBT and RHTMD may be used as a simple bedside airway assessment tools for prediction of difficult intubation.

Effects of bilateral superficial cervical plexus block on sevoflurane consumption during thyroid surgery under entropy-guided general anesthesia: a prospective randomized study.

BACKGROUND: Bilateral superficial cervical plexus block (BSCPB) provides good postoperative analgesia, but its effect on anesthetic consumption is unknown. This study evaluated the effects of BSCPB on sevoflurane consumption during thyroid surgery. METHODS: Fifty patients were randomly allocated into groups A and B of 25 each in this prospective double-blind study. Group A received BSCPB with 20 ml 0.25% bupivacaine, whereas group B received 20 ml saline immediately before entropy-guided general anesthesia. Intraoperative hemodynamic parameters, end-tidal sevoflurane concentration, minimum alveolar concentration, and sevoflurane consumption were recorded. Postoperative pain was assessed using a visual analog scale, and the time of the first request for analgesia was noted. All side effects were recorded. RESULTS: Demographics were comparable. Mean sevoflurane consumption [for 30 min: group A = 7.2 (1.1) ml, group B = 8.8 (2.0) ml, P = 0.001; for 60 min: group A = 13.5 (1.7) ml, group B = 16.5 (3.9) ml, P = 0.002] and mean end-tidal sevoflurane concentration [for 30 min: group A = 1.2% (0.2%), group B = 1.4% (0.2%), P = 0.008; for 60 min: group A = 1.2% (0.1%), group B = 1.4% (0.2%), P = 0.010] were significantly lower in group A. Patients in group A had a longer duration of analgesia [361.6 (79.5) min vs. 151.0 (60.2) min, P < 0.001] compared to those in group B. CONCLUSIONS: Preinduction BSCPB during thyroid surgery significantly reduced sevoflurane consumption and increased the duration of postoperative analgesia.

Effect of co-administration of different doses of phenylephrine with oxytocin on the prevention of oxytocin-induced hypotension in caesarean section under spinal anaesthesia: A randomised comparative study.

INTRODUCTION: Co-administration of phenylephrine prevents oxytocin-induced hypotension during caesarean section under spinal anaesthesia (SA), but higher doses cause reflex bradycardia. This study compares the effects of co-administration of two different doses of phenylephrine on oxytocin-induced hypotension during caesarean section under SA. METHODS: In this prospective, double-blind study, 90 parturients belonging to the American Society of Anesthesiologists' physical status 1 or 2, undergoing caesarean section under SA were randomised into Group A: oxytocin 3U and phenylephrine 50 µg, Group B: oxytocin 3U and phenylephrine 75 µg, Group C: oxytocin 3U and normal saline, administered intravenously over 5 min after baby extraction. The incidence of hypotension (the primary outcome), rescue vasopressor requirement and side effects were recorded. Statistical analyses were with analysis of variance, Kruskal-Wallis, chi-square and Fisher's exact tests. RESULTS: Demographic parameters such as age, height, weight, level of sensory block at 20 min and duration of surgery were comparable in all the groups. The incidence of hypotension (Group A - 90%, Group B - 10%, Group C - 98%, P = 0.001), magnitude of fall in mean arterial pressure (Group A-15.03 ± 6.12 mm of Hg, Group B - 6.63 ± 4.49 mm of Hg and Group C-13.03 ± 3.39 mm of Hg, P < 0.001) and rescue vasopressor requirement (Group A-45 ± 15.25 mg, Group B-5 ± 15.25, Group C-91.66 ± 26.53, P < 0.001) were significantly lower in Group B compared to A and C. CONCLUSION: Co-administration of phenylephrine 75 µg with oxytocin 3U reduces the incidence of oxytocin-induced hypotension compared to phenylephrine 50 µg with oxytocin 3U during caesarean section under spinal anaesthesia.

Study of Effect of Magnesium Sulphate in Management of Acute Organophosphorous Pesticide Poisoning.

BACKGROUND: Organophosphorus compound poisoning (OPCP) is a major public health problem in developing countries like India. Atropine and oximes remain the main-stay of management. Magnesium sulfate (MgSO4) has shown benefit in the management of OPCP. AIMS: This study was designed to assess the effect of MgSO4 on outcome in OPCP patients admitted to Intensive Care Unit (ICU). SETTINGS AND DESIGN: Double-blind prospective randomized clinical trial in an ICU of tertiary care institution. METHODS: One hundred patients (50 in each group) of OPCP, confirmed by history and syndrome of OPCP with low plasma pseudocholinesterase, aged between 18 and 60 years were studied. Magnesium group (Group M) received 4 g of 20% MgSO4 infusion over 30 min at admission to ICU, control group (Group C) received normal saline placebo in the same manner. Patients were assessed for the need for intubation, requirement of atropine, duration of mechanical ventilation, duration of ICU stay, and its effect on mortality. STATISTICAL ANALYSIS: Chi-square test and Fisher's exact test for categorical data, independent sample t-test, and paired t-test for nominal data. RESULTS: Demographics and basal serum magnesium levels were comparable. Atropine requirement was higher in Group C (74.82 ± 22.39 mg) compared to Group M (53.11 ± 45.83 mg) (P < 0.001). A total of 33 patients in Group C and 23 patients in Group M required intubation, respectively (P = 0.043). The mean duration of mechanical ventilation was 4.51 ± 2 days in Group C compared to 4.13 ± 1.6 days in Group M (P = 0.45). ICU stay was 5.36 ± 2.018 days in Group C compared to 4.54 ± 1.581 days in Group M (P = 0.026). There was no significant difference in mortality between the groups. CONCLUSION: Four grams of MgSO4 given to OPCP patients within 24 h of admission to ICU, decreases atropine requirement, need for intubation, and ICU stay.

Effect of breastfeeding on haemodynamics and consumption of propofol and sevoflurane: A state entropy guided comparative study.

BACKGROUND AND AIMS: Unique post-partum endocrine hormone oxytocin secreted during breastfeeding (BF) has amnestic, sedative properties and down-regulates stress responses. This study was done to assess the effect of BF on consumption of propofol, sevoflurane and haemodynamic stability in women. METHODS: Study was conducted on 120 women aged 20-30 years of American Society of Anesthesiologists I and II physical status scheduled for tubectomy under general anaesthesia who were randomly allocated to three groups 40 of each; BF, withhold feeding (WF), and non-feeding (NF) groups. All received standard premedication. Heart rate (HR), mean arterial pressure (MAP) and state entropy (SE) values were recorded at regular intervals. All patients were induced with intravenous propofol until the SE levels dropped to 45, and dose of propofol recorded. Airway was secured with laryngeal mask airway and anaesthesia was maintained with sevoflurane in 60% N2O and O2. Sevoflurane concentration was adjusted to maintain SE between 40 and 60. End tidal concentration of sevoflurane and consumption of sevoflurane (ml) was recorded by GE Datex-Ohmeda S/5™ System. Results were analysed by analysis of variance and Chi-square test. RESULTS: Demographic parameters were comparable. Dose of propofol and sevoflurane consumption in group BF was significantly reduced by 20% and 35%, respectively (P < 0.05) compared to group NF. Intra-operative HR and MAP were persistently low in group BF and elevated in group WF (P < 0.05). CONCLUSION: BF before induction of anaesthesia decreases the consumption of propofol, sevoflurane and maintains the intra-operative haemodynamic stability, whereas withholding BF increases propofol and sevoflurane consumption with intra-operative higher HR and MAP, compared to control group.

Comparison of ventilatory efficacy and airway dynamics between ProSeal laryngeal mask airway and endotracheal tube in adult patients during general anesthesia.

BACKGROUND AND AIMS: Studies have demonstrated minimal hemodynamic variation and postoperative complications with ProSeal laryngeal mask airway (PLMA) compared to endotracheal tube (ETT). Hence, a study was conducted to compare the ventilatory parameters and airway dynamics required to maintain normocarbia and stable hemodynamics with PLMA and ETT. MATERIAL AND METHODS: A prospective, randomized, single blinded study was conducted on 60 patients aged 20-40 years of American society of anesthesiologists class I and II, divided into Group PLMA and Group ETT. Standard anesthesia protocol was instituted. Group PLMA received PLMA sizes as per manufacturer's recommendations and group ETT received appropriate sized cuffed ETT. Patients were initially ventilated at 14 bpm, I:E ratio 1:2, tidal volume (Vt) 6 ml/kg and later adjusted to maintain end tidal carbon dioxide (EtCO2) between 35 and 40 mmHg. Peak airway pressure (Ppeak), compliance (Compl.), Vt, airway resistance (Raw), hemodynamic parameters, oxygen saturation (SpO2) and EtCO2 were recorded throughout surgery. Postoperative complications if any, were noted. RESULTS: Demographic parameters, Raw, EtCO2, SpO2 were comparable between groups. Ppeak was lower and Vt needed to maintain EtCO2 of 35-40 mmHg was lesser in Group PLMA. Compl was low for 5 min after insertion of PLMA. Heart rate was significantly reduced at 1 min post insertion; blood pressures were significantly lower upto 2 min after insertion and post removal in group PLMA. Incidence of cough was significantly lower in group PLMA. CONCLUSION: ProSeal laryngeal mask airway maintains adequate ventilation at lower Vts and minimal peak pressures, has lesser hemodynamic variations and lower incidence of postoperative cough compared to ETT.

Anaesthesia for patient with chronic obstructive pulmonary disease.

The chronic obstructive pulmonary disease has become a disease of public health importance. Among the various risk factors, smoking remains the main culprit. In addition to airway obstruction, the presence of intrinsic positive end expiratory pressure, respiratory muscle dysfunction contributes to the symptoms of the patient. Perioperative management of these patients includes identification of modifiable risk factors and their optimisation. Use of regional anaesthesia alone or in combination with general anaesthesia improves pulmonary functions and reduces the incidence of post-operative pulmonary complications.