Comparative evaluation of pre-emptive analgesic efficacy of Posterior Transversus Abdominis Plane block with Fascia Transversalis Plane Block in adult patients undergoing unilateral inguinal hernia repair: A prospective, randomized, single-blind, two-arm parallel study.

Introduction: Abdominal wall blocks, in conjunction with multimodal analgesia, have demonstrated efficacy in providing post-operative analgesia, reducing opioid requirements in patients undergoing inguinal hernia repair. The inguinal region is primarily innervated by the ilioinguinal nerve (IIN) and iliohypogastric nerve (IIH). Posterior transverse abdominis plane block (pTAP) and fascia transversalis plane block (TFP) have been observed to reliably block IIN and IIH. We hypothesized that posterior TAP block (pTAP) owing to its potential paravertebral spread will provide better post-operative analgesia than TFP block in patients undergoing unilateral open inguinal hernia repair. Methods: This prospective, randomized, single-blind, two-arm parallel study was conducted over a duration of one year for which sixty patients undergoing unilateral open inguinal hernia repair under spinal anesthesia were enrolled. They were equally and randomly assigned to receive either preoperative pTAP block or TFP block. The primary aim of the study was to compare median static and dynamic NRS scores during a 24-hour period, with the secondary aim to compare the number of patients who required rescue analgesics in each group. Results: All enrolled patients completed the study. Results showed no statistically significant difference in median static NRS scores between Group pTAP and Group TFP at the designated time of observation during the 24-hour period [1.2 (0.4-1.60 vs. 1 (0.6-1)]. Group pTAP reported a higher median dynamic NRS scores during the 24-hour period [2.6 (1.2-3) v/s 2 (1.6-2.4); P < 0.035], although this difference was clinically insignificant. The mean time to request for the first rescue analgesia was comparable (11.7 h v/s 12 h; P = 0.99). In all the patients of both groups, loss of pinprick and cold touch sensation was observed at T10, T12, and L1 dermatomal levels. However, sensory assessment at T6 and T8 levels showed variability between the two groups (P > 0.05). Conclusion: In conjunction with background analgesia and the use of dexamethasone as an adjuvant, both blocks (pTAP and TFP) were observed to be equally effective for post-operative pain relief with similar patient satisfaction scores.

Peri-operative management of diabetes mellitus - A survey of current practices among Indian anesthesiologists.

Background and Aims: Increased burden of diabetes in India has resulted in a spurt in the number of patients with diabetes posted for surgeries. The paucity of national guidelines can lead to marked practice variations in the peri-operative management of diabetes. This survey intends to discern current peri-operative practices among anesthesiologists working in medical colleges, tertiary care government, and private health care institutes of the country. Material and Methods: An anonymous online survey comprising of 25 closed-ended questions was conducted using Google Forms® and disseminated through social media, emails, and messaging platforms. The questionnaire dealt primarily with the peri-operative management of diabetes in patients scheduled for elective surgery. The survey was conducted over a period of 1 month and targeted anesthesia resident trainees with more than 1-year experience, senior residents, and consultants working in India. Results: Statistically significant difference was observed between the three types of health facilities with respect to prior evaluation for diabetes (P = 0.007), prioritizing operative list (P = 0.006), hospital encouragement of day care surgery (P < 0.001), glycated hemoglobin level (HbA1c) level >8.5 for postponement of surgery (P < 0.05), insulin infusion preference (P < 0.001), hourly intra-operatively capillary blood glucose (CBG) assessment (P = 0.021), and avoiding peri-operative use of Ringer's lactate (RL) (P = 0.025). Conclusion: This survey primarily highlights the lack of prioritizing the operative list, early discontinuation of metformin, and reduced tendency to consider diabetics for day care surgeries.

Routine hematology parameters in COVID-19: A predictor of disease severity and mortality.

Background: Our understanding of the pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still evolving and is limited for prognostication. The study was performed to predict severity and mortality based on hematology parameters in coronavirus disease (COVID-19). Material and Methods: The study was a single-center retrospective analysis of 240 patients with COVID-19. The hematological parameters were compared between different grades of severity. The receiver operating characteristics (ROC) curve along with the Classification and Regression Trees (CART) methods were used for the analysis. Result: The total leukocyte count, absolute neutrophil count, neutrophil-lymphocyte ratio (NLR), and neutrophil-monocyte ratio (NMR) were increasing along with an increase in severity; while the absolute lymphocyte count and lymphocyte-monocyte ratio (LMR) were decreasing (P < 0.001). For prediction of severity and mortality on admission, the NLR, NMR, and LMR were significant (P < 0.001). The NLR, NMR, and LMR had an area under the receiver operating characteristics curve (AUROC) of 0.86 (95% CI of 0.80-0.91), 0.822 (95% CI of 0.76-0.88), and 0.69 (95% CI of 0.60-0.79), respectively, for severity. While the NLR, NMR, and LMR had an AUROC value of 0.85 (95% CI of 0.79-0.92), 0.83 (95% CI of 0.77-0.89), and 0.67 (95% CI of 0.57-0.78), respectively, for mortality. Conclusion: With the increase in severity there was an increase in the total leukocyte count and absolute neutrophil count while the absolute lymphocyte count decreased. On admission, the cut-off value of NLR >5.2, NMR >12.1, while LMR <2.4 may predict severity and mortality in COVID-19.

A comparison of endotracheal intubation characteristics between Macintosh, CMAC, and Smart Trach Video laryngoscope: a randomized prospective clinical trial.

BACKGROUND: In this study, we compared the performance characteristics of Macintosh laryngoscope, CMAC videolaryngoscope with a recently developed videolaryngoscope called Smart Trach. RESEARCH DESIGN AND METHODS: Three hundred seventy-five patients belonging to mixed population without having anticipated difficult airways undergoing elective surgeries were randomly allocated to be intubated using either of the three laryngoscopes (Macintosh, CMAC, or Smart Trach). Time needed for successful intubation, number of attempts, Cormack Lehane's (CL) grading, optimization maneuverers, intubation difficulty score (IDS), subjective ease of intubation (VAS), subjective lifting force, and complications were recorded. RESULTS: Demographic and anthropometric measurements (sex, height, weight, and body mass index) among the groups were comparable. CL grades, lifting force, IDS, VAS, and intubation times (seconds) were significantly different whereas need for maneuver, attempts, and complications was similar (p > 0.05 each). Intubation times (seconds) were significantly different between Macintosh [36(29-43) seconds], CMAC [30(24-37)], and Smart Trach [35(30-42] groups. (p < 0.001). Subjective ease of intubation based on VAS score was lowest in Smart trach group [1(1-2)] (p < 0.001). CONCLUSION: Shortest intubation times were achieved with CMAC with least use of lifting force. First attempt success rates of were similar. Intubation was easiest subjectively using Smart Trach as manifested by lowest VAS and IDS. TRIAL REGISTRATION: Clinical Trial registry of India (CTRI/2019/09/021279 dated 17/09/2019).

A survey on knowledge, attitude, and practices of workplace radiation safety amongst anaesthesiology personnel in northern Indian tertiary care institutes.

Background and Aims: Exposure to ionising radiation to Anaesthesiology consultants, residents, technicians and nurses (Anaesthesiology personnel) is steadily increasing as a consequence of growing usage of imaging technology for diagnostic and therapeutic purposes. We conducted a questionnaire-based survey of Anaesthesiology professionals (consultants, residents, technicians and nursing staff) working in three major tertiary care medical institutes in northern India regarding the existing knowledge, attitudes and practices of radiation safety at their workplaces. Methods: A printed and validated 30-point questionnaire was distributed. Questions were graded into the domains of demographics (6 questions), knowledge (9 questions), attitude (4 questions) and practice (11 questions). Data obtained from the responses was collated and analysed statistically. Results: Out of the 403 questionnaires distributed, 222 were returned completed (55%). Majority of the respondents were residents (53.60%) and males (57.20%). Many were unaware of the principle of As Low As Reasonably Achievable (ALARA), (70.7%) regarding collimators (65.85%) and their usage (41.9%). Maximum respondents stressed on the necessity of knowing the exposure dosage of radiations (89.2%) and were concerned regarding the same (87.8%). Lead apron was the commonest protection equipment and 97.3% of them were not using dosimeters. Highest levels of knowledge, attitude, and practices were demonstrated by the consultants. In terms of practices, the technicians fared better than the residents. Conclusion: Knowledge, attitude and practices regarding radiation protection issues and doses of radiological procedures is limited. Although all the cadres scored high on their attitude scores, the practice sector requires improvement.

Comparative evaluation of intubation performances using two different barrier devices used in the COVID-19 era: A manikin based pilot study.

BACKGROUND AND AIMS: Protection of anaesthesiologists from contaminated aerosols of COVID 19 patients during endotracheal intubation has spurred the development of barrier devices like aerosol boxes and clear transparent plastic sheets and usage of videolaryngoscopes in COVID 19 patients. However, the efficiency, feasibility and difficulties faced by anaesthesiologist while performing endotracheal intubations under barrier devices require scientific validation. This manikin-based pilot study aims to assess the laryngoscopic performances of experienced anaesthesiologists under two different barrier enclosures. METHODS AND MATERIALS: 53 anaesthesiologists (14 Consultants and 39 Senior Residents) who were undergoing an airway training module as a part of preparedness for handling the COVID 19 pandemic were recruited. Using an aerosol box over a manikin, the participants attempted intubation using a Glidescope Videolaryngoscope and Macintosh laryngoscopes (GA and MA Groups). Subsequently, intubation was attempted under a transparent plastic sheet using both laryngoscopes (GP and MP groups). Time required for intubation, first pass success rates, subjective ease of intubation and the feedback obtained from the participants were recorded and analysed. RESULTS: Time required for accomplishing successful intubation was 38.55 ± 12.16 seconds, 26.58 ± 5.73 seconds, 46.89 ± 15.23 seconds and 37.26 ± 8.71 seconds for GA, MA, GP and MP groups respectively. Time for intubation and difficulty (VAS) was least for Macintosh group with aerosol box (MA) and maximum time was taken in Glidescope group with transparent polythene drape (GP). First attempt success rate for Glidescope groups (GP and GA) were 100% and in MA and MP group was 98% and 96% respectively. Restriction in hand movement and stylet removal were the major difficulties reported. CONCLUSION: Longer intubation times were observed while using Glidescope Videolaryngoscopes with either of the two barrier devices in place compared to Macintosh laryngoscopes.

Lessons learned from blunt trauma abdomen: Surgical experience in level I trauma centre.

OBJECTIVES: The number of accident cases is increasing day by day, so as the challenges. With an emphasis on trauma care, the government started a 120 bedded level I trauma centre in northern India catering to a population of 2.8 million in June 2018. Through this article, we aimed to share our experience of blunt abdominal trauma management from a new level I trauma centre. MATERIAL AND METHODS: In this retrospective observational study, historical analysis of all available records from July 2018 to March 2020 was done. Inclusion criteria included blunt trauma abdomen with or without associated injuries. Data regarding age, sex, mechanism of injury, time taken to reach the hospital, the pattern of solid organs and hollow viscus injuries, associated extra abdominal injuries, mode of treatment, complications, length of ICU and hospital stay, and mortality were reviewed. RESULTS: Overall, 154 cases sustained abdominal injuries during the study period. Seventy-five percent were male. The most common cause of blunt trauma abdomen was road traffic crashes. Operative management was required in 57 (37.01%) cases while 97(62.98%) were managed non-operatively (NOM). Mean ICU stay was 05.73 days, while the average hospital stay was 12 days (range 10-60 days). Procedures performed included splenectomy, liver repair, primary closure of bowel injury, and stoma formation. Complications occured in 16.88% cases and the overall mortality rate was 11.68%. CONCLUSION: The study revealed that among 154 cases of fatal blunt abdominal trauma, road traffic crash was the most common cause of blunt abdominal trauma, predominantly affecting males. The visceral and peritoneal injury frequently perceived was liver in 40 cases (25.9%), spleen 66 (43%), intestine 21(13.6%) and kidney 13 cases (09%). Abdominal injury was associated with other injuries like head, chest and extremity injuries in 52.5% cases. Duration of injury, presence of associated injury and preoperative ventilation requirement were independent predictors of mortality apart from contributary factors such as clinical presentation, organ involved and presence of complications.

A national survey evaluating the effect of COVID-19 pandemic on the teaching and training of anaesthesiology postgraduate students in India.

BACKGROUND AND AIMS: Anaesthesiologists have been in the forefront of managing patients of the novel coronavirus disease 19 (COVID-19) globally. The rearrangement of duties of anaesthesiology professionals and trainees along with the enforced containment measures like cessation of gatherings (for classroom teaching), cancellation of large number of elective cases and restricted number of procedures that are being performed have adversely affected the training of anaesthesiology postgraduate students across the country. METHODS: An electronic survey to assess the effect of the measures taken by hospitals due to COVID-19 on postgraduate teaching was undertaken using a validated questionnaire. We used snowball sampling, and the survey invitation with the web link was shared through freeware WhatsApp. The participation in the survey was voluntary and anonymity was maintained. Data obtained from the responses was collated and analysed. RESULTS: A total of 595 anaesthesiology postgraduate students (males = 298, females = 297) responded to the survey. Majority of the participants reported a steep depreciation (>50%) in the quality and quantity of academic activities (57.47%), major changes or cessation of clinical rotations (73.61%) and inability to conduct thesis-related cases (55.29%). In total, 56.97% of the students reported the rise in usage of online platforms like "Zoom" for conduct of routine academic activities. CONCLUSION: Teaching and training schedules of anaesthesiology postgraduate students have undergone major modifications following the COVID 19 pandemic. Resourcefulness and ingenuity in teaching methods is the need of the hour to sustain the desired standards of training courses and to maintain the quality of the budding anaesthesiologists.

Ultrasound-Guided Suprainguinal Fascia Iliaca Compartment Block for Postoperative Analgesia in Patients Undergoing Hip and Femur Surgeries: A Retrospective Analysis.

CONTEXT: Fractures of femur and hip surgeries pose a challenge because of excruciating pain. Fascia iliaca compartment block is an effective and easily learned procedure to decrease postoperative pain score and dosage of opioid. Many adjuvants are combined with local anesthetics to prolong the postoperative analgesia. AIMS: The aim was to study duration of postoperative analgesia in terms of Numeric Rating Scale (NRS), number of times rescue analgesic used, any adverse effect, and patient satisfaction score. SETTINGS AND DESIGN: Operation theatre of Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. MATERIALS AND METHODS: The present study was retrospective study with 203 patients evaluated. Based on the combination of the anesthesia and drugs, study patients were divided into six groups. Pain scores were assessed at 6 hourly intervals for 24 h. STATISTICAL ANALYSIS USED: Kruskal-Wallis H-test used to compare NRS as well as age and duration of anesthesia. Chi-square test/Fisher's exact test used to compare the proportions. RESULTS: Postoperative analgesia was comparable and insignificant (P > 0.05) at 0, 6, 12 h in all six groups. Better postoperative analgesia was observed with dexmedetomidine and dexamethasone as adjuvant at 18 h, dexmedetomidine as adjuvant in comparison to dexamethasone as adjuvant at 24 h. Rescue analgesia in postoperative period was required maximum in plain bupivacaine. Satisfaction levels were good and excellent in dexmedetomidine and dexamethasone as adjuvant. CONCLUSIONS: Addition of dexmedetomidine to bupivacaine provides longer duration, good quality postoperative analgesia, reduced requirement for rescue analgesic, lesser postoperative nausea and vomiting, and better satisfaction levels.

Effect of Two Different Doses of Dexmedetomidine on Stress Response in Laparoscopic Pyeloplasty: A Randomized Prospective Controlled Study.

BACKGROUND: Clonidine, opioids, ß-blockers, and dexmedetomidine have been tried to attenuate stress responses during laparoscopic surgery. We evaluated the efficacy of dexmedetomidine in two different doses in attenuating stress responses on patients undergoing laparoscopic pyeloplasty. SUBJECTS AND METHODS: Ninety patients were assigned to one of the three groups: Group A, Group B, and Group C. Group B received dexmedetomidine 1 mcg/kg as loading dose, followed by 0.7 mcg/kg/h for maintenance; Group C received dexmedetomidine 0.7 mcg/kg as a loading dose, followed by 0.5 mcg/kg/h for maintenance. Group A received normal saline. Stress responses were assessed by the variations in heart rate (HR), mean arterial pressure (MAP), blood glucose levels, and serum cortisol levels. One-way analysis of variance test was applied. Multiple comparisons between groups were done with post hoc Bonferroni test. RESULTS: The HR and MAP were found to be higher in Group A. The difference was statistically significant (P < 0.05) during intubation, carbon dioxide insufflation, and extubation when compared with Groups B and C. Blood glucose levels at postintubation and at extubation were higher in Group A and statistically significant (P < 0.05) when compared with Groups B and C. Serum cortisol levels at postintubation, during midsurgery, and 2 h after extubation were higher in Group A and statistically significant (P < 0.05) when compared with Groups B and C. However, HR, MAP, blood glucose levels, and serum cortisol levels were similar in dexmedetomidine groups. CONCLUSIONS: Dexmedetomidine decreases stress response and provides good condition for maintenance of anesthesia. Dexmedetomidine when used in lower dose in Group C decreases stress response comparable to higher dose in Group B.

Ultrasound-guided probe-generated artifacts stimulating ventricular tachycardia: A rare phenomenon.

Electrocardiographic (ECG) artifacts may arise due to interference, faulty earthing, and current leakages in biomedical equipment which might create clinical dilemmas in the perioperative settings. Piezoelectric signals generated by ultrasonography probe are another uncommon source which might be sensed by the ECG electrodes and produce tracings similar to pathological arrhythmias triggering false alarms and avoidable therapies. Anesthesiologists should be familiar with these uncommon sources which might produce these artifacts and they should be identified swiftly.

Evaluation of efficacy of amikacin for attenuation of catheter-related bladder discomfort in patients undergoing percutaneous nephrolithotomy: A prospective, randomized, placebo-controlled, double-blind study.

CONTEXT: Catheter-related bladder discomfort (CRBD) is the most distressing symptom in patients due to intraoperative urinary catheterization. Amikacin significantly inhibits detrusor contraction evoked by prejunctional stimulation. AIMS: The aim of this study is to evaluate the efficacy of amikacin in prevention of CRBD in patients undergoing percutaneous nephrolithotomy. SETTINGS AND DESIGN: Study areas were operation theater and postanesthesia care unit of the Department of Anesthesiology, SGPGIMS, Lucknow. SUBJECTS AND METHODS: One hundred adult patients of either sex were randomly assigned into two groups of fifty each. Patients in control group received normal saline whereas patients in amikacin group received amikacin 10 mg/kg just before induction. Grading of CRBD was done as none, mild, moderate, and severe by a blinded observer at 0, 1, 6, 12, and 24 h after surgery. STATISTICAL ANALYSIS USED: Data were analyzed using Student's t-test and Chi-square test among groups. Incidence of CRBD was compared with Chi-square test whereas severity was analyzed by the test of proportions (Z-test). Visual analog score was compared using Mann-Whitney U-test for surgical site pain. RESULTS: Incidence of CRBD in control group was 66% as compared to 44% observed in amikacin group (P < 0.05). During intergroup comparison at different time points, incidence of CRBD was reduced at 1 and 6 h in the amikacin group (P < 0.05). Significant reduction in the severity of CRBD (moderate) was also observed at 1 h in the amikacin group (P < 0.05). At rest of the time points, there was no significant difference. CONCLUSIONS: Amikacin can significantly reduce the incidence and severity of CRBD in the first few hours after surgery.