Is High-Flow Nasal Oxygenation a Game Changer in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration?: A pilot study.

Objectives: This study aimed to compare the high-flow nasal oxygen (HFNO) and supraglottic airway device (SAD) techniques in oncological patients undergoing endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) to evaluate the efficacy of HFNO in them. Methods: This pilot study was conducted at Sultan Qaboos Comprehensive Cancer Care and Research Centre, Muscat, Oman, from May 2022 to March 2023. Patients undergoing EBUS TBNA under moderate sedation were quasi-randomised into the HFNO and SAD groups. The episodes and duration of hypoxia and the lowest level of oxygen saturation were the primary outcomes measured. Results: A total of 24 patients were included in the study (10 of them were in the HFNO group and 14 were in the SAD group), with an equal number of males and females. The duration of the procedure in both groups was similar (45 ± 20 and 44 ± 17 minutes in the HFNO and SAD groups, respectively). The mean lowest oxygen saturation in the HFNO group was 93.5 ± 4.5%, which was significantly higher than that of the SAD group (90 ± 3%; P <0.001). In both groups, maximum hypoxia occurred during the early phase of the procedure. However, the HFNO and SAD groups were similar in terms of the cumulative duration of hypotension (140 versus 95 seconds, respectively) and bradycardia (25 versus 40 seconds, respectively). Conclusion: HFNO is a good alternative to SAD and could be used safely and efficiently in patients undergoing EBUS TBNA.

Comparison of unilateral spinal anaesthesia with ultrasound-guided combined sciatic and femoral nerve block in elective arthroscopic knee surgeries.

Background: Arthroscopic knee surgeries are commonly performed orthopaedic procedures, which can be done under unilateral spinal anaesthesia (USA) or ultrasound-guided combined sciatic and femoral nerve block (USFB). However, not many studies have compared both these techniques. Hence this study was undertaken to compare USA and USFB in arthroscopic knee surgeries in terms of time to readiness for discharge (TRD). Methods: Eighty patients were randomised into the USA (n = 40) and USFB groups (n = 40). They were administered either USA or USFB on the affected side. The TRD values were compared. Patients were considered fit for discharge after voiding urine, ambulation and obtaining a visual analogue scale (VAS) score of <3. The maximum time required for any of the three parameters was taken as the TRD for that particular patient. Results: The mean TRD was 595.41 ± 195.69 min in the USA group and 351.86 ± 129.51 min in the USFB group (p < 0.001). The median VAS scores for postoperative pain assessment were lower in the USFB group at 2, 4, 12 and 24 h (p < 0.05). The number of patients requiring rescue analgesia was lower in the USFB group at 6 and 12 h after surgery (p < 0.05). Conclusion: Patients undergoing arthroscopic knee surgeries under USFB have an advantage when it comes to TRD as these patients have comparatively better postoperative analgesia, less requirement of rescue analgesia, early voiding of urine and early ambulation.

Real-time ultrasound-guided spinal anaesthesia vs pre- procedural ultrasound-guided spinal anaesthesia in obese patients.

BACKGROUND AND AIMS: Spinal anaesthesia is conventionally performed using a landmark-guided midline approach. These surface landmarks may be absent, indistinct or distorted in the presence of obesity, previous spinal surgeries, deformities, or degenerative changes associated with ageing. In the present study, we compared the efficacy of real-time ultrasound (RUS)-guided paramedian approach, and pre-procedure ultrasound (PUS) landmark-guided paramedian approach in obese patients. METHODS: Eighty patients with body mass index (BMI) >30 kg/m2 were included in the study. The participants were randomly assigned to two intervention groups, i.e., RUS and PUS approach. The primary end point was to attain a successful lumbar puncture. Variables like the number of attempts, the number of passes, the time taken for identifying landmark(s), and time for a successful lumbar puncture(s) were secondary end points and were recorded in both the groups. RESULTS: The median number of attempts were 4 (IQR 2-4) and 2 (IQR 1-2), respectively, in the PUS and RUS group (P-value < 0.001). The median number of passes, the median time for identifying space, and the time for successful lumbar puncture was statistically significantly less in the RUS group, than the PUS group. CONCLUSION: The time taken for the identification of the space, the number of attempts, number of passes, and the time taken for successful lumbar puncture was more in the PUS group as compared to the RUS group.

Does ATLS Training Work? 10-Year Follow-Up of ATLS India Program.

BACKGROUND: Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time. METHODS: The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively. RESULTS: ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving. CONCLUSIONS: Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings.

Embracing the change: Resuming advanced trauma training in the COVID-19 era.

BACKGROUND: Trauma is slowly regaining its pre-COVID-19 status in terms of prevalence. Advanced trauma training cannot be deferred indefinitely in the current pandemic owing to defense requirements and disaster preparedness in vulnerable regions. Advanced Trauma Life Support (ATLS) India resumed ATLS and Advanced Trauma Care For Nurses (ATCN) courses at one civilian and one military site. METHODS: Stakeholders of respective centers for advanced trauma training deliberated over safe means to resume ATLS and ATCN. Meticulous screening of all participants and pre- and post-course tracking were deemed the most important components for the safe resumption of courses. 'Paperless' course, 'open-air' skill stations, 'payment protection', 'buddy system', point of care sanitizer installation, packed food, and potable beverages were major organizational changes. Participants above 60 years and with uncontrolled comorbidities were not enrolled. RESULTS: Two ATCN, one ATLS (civilian), and one combined ATLS-ATCN (military) were conducted. 78 delegates trained by 32 faculties and 13 personnel. All underwent daily thermal scanning and smartphone application-based COVID-19 tracking. Manikins were utilized instead of moulages and instructors took up the role of nursing assistants in Initial Assessment. Exit exams were conducted with full PPE precautions at the military site and mask-distancing precautions at the civilian site. High fidelity simulator was used at one station at the civilian site. Expenses at the civilian site per course were USD 570 lower than conventional courses. There was no incidence of COVID-19 in any of the 123 participants at 14 days follow up. CONCLUSION: With stringent participant selection and moderate precautions, ATLS and ATCN can be resumed safely in the current COVID-19 pandemic. To the best of our knowledge and after a thorough search of published English literature, this is the first paper reporting on resuming Advanced trauma training in the COVID-19 era.

Realtime ultrasound guided percutaneous tracheostomy in emergency setting: the glass ceiling has been broken.

BACKGROUND: In recent years ultrasound guided percutaneous tracheostomy (USPCT) has become a routine practice in critical care units. Its safety and superiority over conventional percutaneous tracheostomy and bronchoscopic guided PCT is proven to be non-inferior in elective cases. However its role in emergency percutaneous tracheostomy has never been studied, since percutaneous tracheostomy itself remains an enigma in accessing emergency airway. There is no report of use of ultrasound guided percutaneous tracheostomy in emergency setting so far in the literature. We report our early experience with USPCT in emergency setting. METHODS: Sixteen adult patients who required access to an emergency surgical airway after failure to accomplish emergency oro-tracheal intubation were the study population. Their airway was accessed by USPCT. Recorded data included clinical and demographic data including time taken to perform the procedure and complications. Short term and long term follow ups for a period of 2 years were done for the survivors. RESULTS: Twelve male and four female patients underwent the procedure and the average time of the procedure was 3.6 min with no failures nor conversions to surgical tracheostomy and no complications. The average oxygen saturation was 86% and average Glasgow coma scale was 8.4. This time period included the oxygen insufflation time. 10 patients were decannulated while six patients died due to the pathology of the disease itself. There were no complications in either short term or long term follow up. CONCLUSION: USPCT has a definitive role in emergency both in trauma and non-trauma setting. It is safe, feasible and faster in experienced hands. Use of USPCT in emergency setting has further narrowed the list of contraindications of percutaneous tracheostomy.

Fluid resuscitation in haemorrhagic shock in combat casualties.

This brief update reviews the recent literature available on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the combat casualty care (CCC) environment. A number of changes need to be incorporated in the CCC guidelines: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hetastarch is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain tactical field care settings where this option might be feasible (FSC, GH) is discussed; (4) 1:1:1 damage control resuscitation (DCR) with plasma: packed red blood cells (PRBC): platelets is preferred to 1:1 DCR with plasma: PRBC when platelets are available; and (5) the 30-min wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure has been eliminated. Also included is an order of precedence for resuscitation fluid options. There should be an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of over resuscitation. Hetastarch is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- A preliminary study of 100 patients.

BACKGROUND AND AIMS: Oropharyngeal colonisation followed by aspiration of contaminated secretions is the major cause for ventilator-associated pneumonia (VAP). Pooled secretions present in the sub-glottic area above inflated endotracheal tube cuff may be aspirated into the lower airways. It was hypothesised that intermittent suctioning of sub-glottic secretions would prevent VAP. METHODS: Group I (n = 50) patients were intubated with HiLo Evac™ endotracheal (ET) tube with facility for sub-glottic suctioning, and Group II (n = 50) patients were intubated with HiLo Contour™ ET tube without such facility. In the Group I, sub-glottic suctioning was performed every 2 h. Incidence of VAP, mean ventilator days, Intensive Care Unit (ICU) stay and mortality were compared. Qualitative variables were reported as percentages and were compared by Chi-square test or unpaired two-tailed, Fisher's exact test, as appropriate, to analyse the significance of difference between the two groups. RESULTS: The two groups were similar with respect to demographic characteristics. VAP was seen in 6% of patients in Group I and 22% of patients in Group II (P = 0.021). Both early- and late-onset VAPs were significantly reduced in Group I. Both ventilator days (8.0 vs. 6.45; P = 0.001) and ICU stay (8.33 vs. 6.33; P = 0.001) on the day of onset of VAP were significantly more in the Group I. Total ventilator days were significantly less (6.52 vs. 8.32; P = 0.006) with lower incidence of mortality (36% vs. 48%; P = 0.224) in the Group I. CONCLUSION: Intermittent sub-glottic suctioning reduces the incidence of VAP including late-onset VAP.

Real time ultrasound-guided percutaneous tracheostomy: Is it a better option than bronchoscopic guided percutaneous tracheostomy?

BACKGROUND: The purpose of this study was to evaluate the efficacy of ultrasound guided percutaneous tracheostomy (USPCT) and bronchoscopic guided percutaneous tracheostomy (BPCT) and the incidence of complications in critically ill, obese patients. METHODS: Seventy four consecutive patients were included in a prospective study and randomly divided into USPCT and BPCT. Incidence of complications, ease and efficacy were compared in obese USPCT (n = 38)and BPCT (n = 36). Results are expressed as the median (25th-75th percentile) or number (percentage). RESULTS: The median times for tracheostomy were 12 min (9-14) in USPCT patients and 18 min (12-21.5) in BPCT (p = 0.05). The overall complication rate was higher in BPCT than USPCT patient group (75% vs. 321%, p < 0.05). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding) and of higher number in the BPCT. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths. CONCLUSIONS: This study demonstrated that real US-guided PCT is a favourable alternative to BPCT with a low complication rate and ease, thus proving more efficacious. A US examination provides information on cervical anatomy, vasculature etc. and hence modifies and guides choice of the PCT puncture site.