Lactate Monitoring in Intensive Care: A Comprehensive Review of Its Utility and Interpretation.

Lactate monitoring is critical in managing critically ill patients in intensive care settings. Elevated lactate levels often signify underlying metabolic disturbances such as tissue hypoxia, anaerobic metabolism, or impaired lactate clearance, which are prevalent in conditions like sepsis, shock, and trauma. Understanding the physiological basis of lactate production and its significance in clinical practice is essential for interpreting its diagnostic and prognostic value. This comprehensive review aims to explore the utility of lactate monitoring across various critical care scenarios. It provides an overview of lactate's metabolic pathways, methods of measurement, and the clinical implications of interpreting lactate levels in different contexts. Additionally, the review discusses current evidence on lactate-guided therapeutic interventions and highlights challenges and limitations to their application. By synthesizing the existing literature and clinical insights, this review aims to enhance the understanding of the role of lactate monitoring in assessing disease severity, guiding treatment strategies, and predicting outcomes in critically ill patients. Ultimately, this review underscores the importance of integrating lactate monitoring into routine clinical practice to optimize patient care and improve clinical outcomes in intensive care settings.

Morel-Lavallee Lesion Associated With Rhabdomyolysis in Polytrauma.

We describe the case of a 30-year-old man who allegedly had a history of road traffic accidents. While walking on the road, he was hit by a truck. He presented with complaints of facial injuries and being unable to move his right lower limb. On examination, there is a 15x4 cm lacerated wound in the perineal area, with left testes exposed; anal tone could not be assessed; the right lower limb is externally rotated; and deformity is present with palpable peripheral pulses. He was diagnosed with a right sacral ala fracture, a distal one-third shaft of the right tibia fracture, and a right suprapubic rami fracture. Ultrasound of the right thigh showed hematoma and subcutaneous edema all around the gluteal and inguinal regions and fluid collection in the right inguinal region, which is suggestive of Morel-Lavallee lesion (MLL) type 6. On day two of admission, urine was dark in color, and creatinine kinase was elevated, which is suggestive of rhabdomyolysis. He was managed with hydration, electrolyte correction for rhabdomyolysis, and wound debridement for MLL apart from perineal injury, right sacral ala fracture, right suprapubic rami fracture, and distal one-third shaft of the right tibia fracture, with perineal repair and loop colostomy, pelvic binder, and external fixator, respectively. Early identification of the MLL associated with rhabdomyolysis in this polytrauma patient led to recovery and a successful outcome.

A Cross-Sectional Study on Bedside Abdominal Ultrasound Findings as a Diagnostic and Prognostic Tool in Dengue Fever in Manipal Hospital, Bengaluru, India.

Background Dengue fever poses a significant health burden globally, particularly in tropical and subtropical regions. Early diagnosis and effective management are crucial in reducing morbidity and mortality associated with the disease. Bedside abdominal ultrasound has emerged as a promising tool for assessing dengue patients, providing real-time imaging of abdominal organs, and aiding clinical decision-making. Materials and methods This cross-sectional study was conducted in 55 adult emergency departments of Manipal Hospital, Bengaluru, from March 2017 to March 2018. Adult patients presenting with signs and symptoms suggestive of dengue fever were included. Clinical data, laboratory investigations, and bedside abdominal ultrasound findings were systematically recorded and analyzed using appropriate statistical methods. Results Descriptive statistics revealed characteristic clinical measurements and symptom ratings observed in dengue fever patients. Frequency distributions highlighted common symptoms encountered, while statistical analyses demonstrated significant associations between ultrasonic parameters, disease severity, and outcomes. The study found notable correlations between ultrasonic findings and dengue severity levels, emphasizing the potential of bedside ultrasound as a diagnostic and prognostic tool. Conclusion Bedside abdominal ultrasound shows promise as a valuable adjunctive tool in assessing dengue fever patients. The significant associations between ultrasonic parameters and disease severity suggest its utility in risk stratification and guiding clinical management decisions. Incorporating bedside ultrasound into routine practice may improve patient care and outcomes in dengue fever management. Further research is warranted to validate these findings and explore additional bedside ultrasound applications in dengue fever diagnosis and prognosis.

A Comparative Study Between Intravenous Esmolol and Oral Clonidine in Attenuating Hyperdynamic Cardiovascular Response to Laryngoscopy and Endotracheal Intubation.

Background In today's era of anesthesia, balanced anesthesia is the main basis of patient care and pain management. Of all the medications given during general anesthesia, premedication, induction agents, and muscle relaxants play a major role in keeping the hemodynamics properly under control. When laryngoscopy is performed to intubate, a pain stimulus will be generated, leading to a rise in blood pressure and heart rate. This stimulus can be avoided without any complications if appropriate premedication is given to the patient at the appropriate dosage. In this research, we compare the influence of injection esmolol and oral clonidine during the time of induction as premedications to suppress the hemodynamic response. Material and methods In a prospective randomized controlled trial, 90 patients were divided into three groups: Group E (esmolol) received 2 mg/kg IV esmolol diluted in 0.9% NS two minutes pre-anesthesia; Group C (clonidine) received oral clonidine 4 mcg/kg 90 minutes pre-anesthesia; and Group P (placebo) received IV normal saline and oral water. Blood pressure, heart rate, and mean arterial pressure were measured at baseline and seven subsequent time points. Results The study compared systolic blood pressure (SBP), mean arterial pressure (MAP), and diastolic blood pressure (DBP) changes over seven minutes in three groups, clonidine (Group C), placebo (Group P), and esmolol (Group E). At one minute, Group E showed a consistent MAP decrease from 95.21 mmHg to 85.92 mmHg, while Group C and Group P exhibited fluctuating trends. DBP decreased across all groups, with Group P ending highest (77.7 mmHg) and Group C lowest (66.8 mmHg). Group E's SBP decreased steadily from 126.2 mmHg to 118.0 mmHg, Group C decreased from 128 mmHg to 116.1 mmHg, and Group P showed more erratic fluctuations in SBP, DBP, and MAP. Conclusion These findings suggest that intravenous esmolol shows a good hemodynamic response having superior control over heart rate and getting the pressure under control quickly without major drop compared with the clonidine and placebo groups.

A Comprehensive Review of the Role of Biomarkers in the Early Detection of Endocrine Disorders in Critical Illnesses.

Endocrine disorders pose significant challenges in the management of critically ill patients, contributing to morbidity and mortality in intensive care settings. Timely detection of these disorders is essential to optimizing patient outcomes. Biomarkers, as measurable indicators of biological processes or disease states, play a crucial role in the early identification and monitoring of endocrine dysfunction. This comprehensive review examines the role of biomarkers in the early detection of endocrine disorders in critical illnesses. We provide an overview of common endocrine disorders encountered in the intensive care unit (ICU) and discuss the impact of endocrine dysregulation on patient outcomes. Additionally, we classify biomarkers and explore their significance in diagnosing and monitoring endocrine disorders, including thyroid dysfunction, adrenal insufficiency, and hypopituitarism. Furthermore, we discuss the clinical applications of biomarkers, including their utility in guiding therapeutic interventions, monitoring disease progression, and predicting outcomes in critical illnesses. Emerging trends and future directions in biomarker research are also highlighted, emphasizing the need for continued investigation into novel biomarkers and technological advancements. Finally, we underscore the potential of biomarkers to revolutionize the early detection and management of endocrine disorders in critical illnesses, ultimately improving patient care and outcomes in the ICU.

Cervical Epidural Anesthesia in the Management of a Patient With Breast Cancer With Cardiac Dysfunction: A Case Report.

As one of the most common cancers in the world, breast cancer management is fraught with difficulties. Modified radical mastectomy (MRM) is one of the surgical procedures that is essential to the treatment of breast cancer. Cardiovascular issues, especially a reduced ejection fraction (EF), make these procedures more complex. Due to their increased vulnerability to adverse cardiac events during surgery, it is imperative to preserve hemodynamic stability and reduce physiological stress responses in these patients. A promising option in this changing field of anesthetic techniques is cervical epidural anesthesia (CEA). It effectively reduces hemodynamic fluctuations frequently linked to general anesthesia while providing analgesia. We report the case of an elderly patient with decreased EF and breast cancer scheduled for an MRM. To ensure the best possible outcomes in complex cases, the case report covers preoperative assessment, anesthesia technique, intraoperative management, and postoperative outcomes. This highlights the critical significance of customizing anesthesia and surgical procedures, informed consent, and meticulous postoperative pain management, and ultimately advocates for the broader implementation of CEA in such settings.

Mobilizing Progress: A Comprehensive Review of the Efficacy of Early Mobilization Therapy in the Intensive Care Unit.

Early mobilization therapy has emerged as a crucial aspect of intensive care unit (ICU) management, aiming to counteract the detrimental effects of prolonged immobility in critically ill patients. This comprehensive review examines the efficacy of early mobilization therapy in the ICU setting, synthesizing evidence from clinical trials, meta-analyses, and guidelines. Key findings indicate that early mobilization is associated with numerous benefits, including reduced muscle weakness, a shorter duration of mechanical ventilation, decreased ICU and hospital length of stay, and improved functional outcomes. However, safety concerns, staffing limitations, and patient-specific considerations pose significant barriers to widespread adoption. Despite these challenges, early mobilization is important for improving ICU patient outcomes. This review underscores the critical need for continued research and implementation efforts to optimize early mobilization protocols, address remaining challenges, and expand access to this beneficial therapy. By working collaboratively to overcome barriers and prioritize early mobilization, healthcare providers can enhance the quality of care and improve outcomes for critically ill patients in the ICU.

Recent Advances in Immunomodulatory Therapy in Sepsis: A Comprehensive Review.

Sepsis remains a critical healthcare challenge, characterized by dysregulated immune responses to infection, leading to organ dysfunction and high mortality rates. Traditional treatment strategies often fail to address the underlying immune dysregulation, necessitating exploring novel therapeutic approaches. Immunomodulatory therapy holds promise in sepsis management by restoring immune balance and mitigating excessive inflammation. This comprehensive review examines the pathophysiology of sepsis, current challenges in treatment, and recent advancements in immunomodulatory agents, including biologics, immunotherapy, and cellular therapies. Clinical trial outcomes, safety profiles, and future research and clinical practice implications are discussed. While immunomodulatory therapies show considerable potential in improving sepsis outcomes, their successful implementation requires further research, collaboration, and integration into standard clinical protocols.

Echocardiography as a Vital Tool in Assessing Shock: A Comprehensive Review.

Shock is a critical condition characterized by inadequate tissue perfusion, leading to cellular hypoxia and organ dysfunction. Early and accurate assessment is crucial for timely intervention and improved patient outcomes. Echocardiography has emerged as a vital tool in the assessment of shock, offering real-time visualization of cardiac anatomy, function, and hemodynamics. This comprehensive review aims to elucidate the role of echocardiography in shock assessment by providing an overview of its principles, techniques, and clinical applications. We discuss the importance of early diagnosis, identification of underlying pathology, monitoring response to therapy, and prognostic value offered by echocardiography in managing shock. Furthermore, we explore its utility in different types of shock, including hypovolemic, cardiogenic, distributive, and obstructive shock. Challenges and limitations of echocardiography, as well as future directions and innovations, are also discussed. Through a synthesis of current evidence and clinical insights, this review underscores the significance of echocardiography in optimizing shock management and highlights areas for further research and development.

Myocardial Injury as a Harbinger of Multi-organ Failure in Septic Shock: A Comprehensive Review.

Myocardial injury in the context of septic shock presents a multifaceted challenge in critical care medicine with implications for patient prognosis and therapeutic strategies. This comprehensive review explores the mechanisms, diagnostic approaches, and clinical implications of myocardial injury as a harbinger of multi-organ failure in septic shock. We delineate the pathophysiological processes underlying myocardial injury, including inflammation, oxidative stress, and microcirculatory dysfunction, and discuss the diagnostic utility of cardiac biomarkers and imaging modalities in identifying myocardial injury. Furthermore, we elucidate the prognostic significance of myocardial injury and its implications for patient management, highlighting the need for tailored therapeutic interventions to mitigate its adverse effects. Future research and clinical practice directions are also discussed, emphasizing the importance of personalized medicine approaches and multidisciplinary collaboration in optimizing outcomes for patients with septic shock-associated myocardial injury. This review aims to provide a comprehensive understanding of myocardial injury in septic shock and inform strategies for improving patient care in this challenging clinical scenario.

Efficacy and Safety of Cryoablation Compared with Cooled Radiofrequency Ablation of Genicular Nerves in Advanced Osteoarthritis of the Knee: A Study Protocol of Single-Centric, Assessor-Blinded, Randomized, Parallel-Group, Non-inferiority Study.

PURPOSE: In patients with symptomatic osteoarthritis knee (OAK), cryoneurolysis (CRYO) and cooled radiofrequency ablation (C-RFA) are reported to be effective and safe; however, they have not been compared directly. The objective of this study is to compare CRYO and C-RFA of the genicular nerve (GN) in terms of efficacy and safety profile in patients with Kellgren and Lawrence (KL) grade ≥ 3 OAK. METHODS: This single-centric, assessor-blinded, randomized, parallel-group, non-inferiority study will include 80 patients with KL grade ≥ 3 OAK. The patients with ≥ 50% pain relief on diagnostic block of three GNs will be randomized to one of the two groups, i.e., CRYO (n = 40) or C-RFA (n = 40). The three target GNs for the interventions will include: superior medial, superior lateral, and inferior medial. The primary outcome will be efficacy of CRYO or C-RFA at 2, 12, and 24 weeks post-procedure based on the 11-point Numerical Pain Rating Scale. The secondary outcomes will be functional improvement based on 12-item Oxford Knee Score and safety of both the procedures. The study is registered in the Clinical Trials Registry-India. CONCLUSION: CRYO and C-RFA provide pain relief and improve functional outcome by preventing transmission of pain signals, though by distinct mechanisms. While C-RFA is an established treatment modality, recent evidence supports CRYO in patients with OAK. This study intends to demonstrate non-inferiority of CRYO against C-RFA, thereby supporting the use of CRYO as an additional treatment modality in patients with KL grade ≥ 3 OAK.

Intubation in a Case of Ectodermal Dysplasia During Surgery: A Case Report.

Ectodermal dysplasia, a heterogeneous group of rare genetic disorders, is characterized by the aberrant development of ectodermal structures, leading to various clinical anomalies. This case report presents a unique and challenging case of a 33-year-old male with ectodermal dysplasia who underwent Le Fort III advancement and implant rehabilitation surgery to address severe craniofacial and dental deficiencies. This case, characterized by facial dysmorphism, craniofacial anomalies, and the absence of a nasal bone, highlights the complexity of surgical planning required to address these diverse clinical features. The crucial element of this report is the innovative approach to airway management through trans mylohyoid/submental intubation, which successfully navigated the patient's aberrant anatomy. Multidisciplinary collaboration played a pivotal role in achieving a holistic and patient-centered approach. By sharing this case, we aim to provide insights into the nuances of managing complex patients with ectodermal dysplasia, emphasizing the importance of individualized care, innovative techniques, and interdisciplinary teamwork to optimize patient outcomes and contribute to advancing medical knowledge.

Anesthetic and Airway Management in a Case of Surgical Excision of Recurrent Buccal Hemangioma.

Difficult airway is one of the challenges trained anesthesiologists face in their life. Induction of general anesthesia in a patient with a compromised airway has always caused a dilemma for anesthesiologists. Challenges were more in this case of buccal hemangioma as its bleeding tendency makes it a challenging job. Hemangioma is a benign vascular anomaly characterized by rapid endothelial cell proliferation. It appears within the first eight weeks of life, rapidly proliferates between the ages of six and 12 months, and progressively involutes between the ages of nine and 12 years. Hemangiomas are more common in women, with a male-to-female ratio of 1:3 to 1:5. By the age of nine years, over 80%-90% of hemangiomas have completely involuted. The remaining 10%-20% involute incompletely, necessitating post-adolescent ablative treatment or alternative management options. Hemangiomas in the head and neck region account for 50%-60% of all hemangiomas. Intra-orally, the lips, buccal mucosa, and tongue are the most prevalent sites of involvement. Here, we report a case of recurrent left-sided buccal hemangioma in a 20-year-old female patient. Treatment options available to manage hemangioma include cryotherapy, laser ablation therapy, radiotherapy, sclerotherapy, and selective embolization. After prophylactic embolization of feeder vessels, surgically excising the lesion is the modality of choice. So from a general anesthesia management point of view, buccal hemangioma poses multiple challenges including difficulty in mask ventilation, difficulty in intubation, bleeding, and pulmonary aspiration.

Revolutionizing Patient Care: A Comprehensive Review of Artificial Intelligence Applications in Anesthesia.

This review explores the intersection of artificial intelligence (AI) and anesthesia, examining its transformative impact on patient care across various phases. Beginning with a historical overview of anesthesia, we highlight the critical role of technological advancements in ensuring optimal patient outcomes. The emergence of AI in healthcare sets the stage for a comprehensive analysis of its applications in anesthesia. In the preoperative phase, AI facilitates personalized risk assessments and decision support, optimizing anesthesia planning and drug dosage predictions. Moving to the intraoperative phase, we delve into AI's role in monitoring and control through sophisticated anesthesia monitoring and closed-loop systems. Additionally, we discuss the integration of robotics and AI-guided procedures, revolutionizing surgical assistance. Transitioning to the postoperative phase, we explore AI-driven postoperative monitoring, predictive analysis for complications, and the integration of AI into rehabilitation programs and long-term follow-up. These new applications redefine patient recovery, emphasizing personalized care and proactive interventions. However, the integration of AI in anesthesia poses challenges and ethical considerations. Data security, interpretability, and bias in AI algorithms demand scrutiny. Moreover, the evolving patient-doctor relationship in an AI-driven care landscape requires a delicate balance between efficiency and human touch. Looking forward, we discuss the future directions of AI in anesthesia, anticipating advances in technology and AI algorithms. The integration of AI into routine clinical practice and its potential impact on anesthesia education and training are explored, emphasizing the need for collaboration, education, and ethical guidelines. This review provides a comprehensive overview of AI applications in anesthesia, offering insights into the present landscape, challenges, and future directions. The synthesis of historical perspectives, current applications, and future possibilities underscores the transformative potential of AI in revolutionizing patient care within the dynamic field of anesthesia.

Continuous Spinal Anesthesia Technique After Accidental Dural Puncture.

Continuous spinal anesthesia (CSA) is a mode of anesthesia and analgesia that has various therapeutic advantages. CSA allows the anesthesiologist to titrate tiny doses of a local anesthetic to achieve the desired degree of spinal anesthesia. The duration can be extended to accommodate the demands of the protracted operation. Due to a lack of equipment and financial restraints, particularly in resource-constrained areas, and worries of neurologic consequences such as cauda equina syndrome, CSA is yet to acquire general acceptability among anesthesiologists. In terms of postoperative pain management, CSA can be comparable to epidural analgesia and is considered far superior to abdominal wall blocks when correctly applied. Here we discuss a case wherein a standard epidural catheter in subarachnoid space was used to successfully perform an emergency exploratory laparotomy.

Anesthetic Management in a Post-COVID Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Patient in Rural Central India: A Close Shave.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a dangerous complication of pregnancy amounting to significant mortality and morbidity. While conducting a cesarean delivery for such cases special care and consideration have to be taken in order to prevent maternal mortality. Thrombocytopenia is a significant abnormality that has to be weighed before induction in cases of HELLP syndrome with no clear cut-off value for the administration of neuraxial anesthesia. This case report aimed to explain the anesthetic management of a case with an indication for an emergency cesarean delivery.

Evaluation of Nasopharyngeal Airway to Facilitate Nasotracheal Intubation.

BACKGROUND AND AIMS: Nasotracheal intubation is the most common method of airway management in oral and maxillofacial surgery patients. However, many times, it is associated with bleeding resulting from trauma to nasopharyngeal mucosa. We conducted this study to determine the effectiveness of nasopharyngeal airway (NPA) to easily facilitate the nasopharyngeal insertion and to reduce the trauma during nasotracheal intubation. METHODS: A total of 120 patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly divided into two groups of 60 each, after preparation with xylometazoline drops intranasally, lubrication with lignocaine jelly, and thermosoftening of the tip of the endotracheal tube (ETT). In group NPA, dilatation of the nasal cavity was done with NPA before nasotracheal intubation and in Group C, nasotracheal intubation was done without dilatation of the nasal cavity. The smoothness of insertion of ETT was graded on a 4­point rating scale. Assessment of bleeding into nasopharynx was confirmed during laryngoscopy and was also graded with 4­point scale. RESULTS: In the NPA group, all the 60 (100%) patients had smooth or relatively smooth (Grade 0 or 1) insertion compared to 51 (85%) patients in the control group (P < 0.0001). Eighteen (30%) patients had mild (Grade 1) bleeding and one (1.67%) patient had moderate bleeding (Grade 2) in the control group, whereas only four (6.67%) patients in the NPA group had mild (Grade 1) bleeding (P = 0.0005). CONCLUSION: Dilatation of nasal cavity with NPA significantly eases the insertion of ETT into the nasopharynx and also significantly decreases the incidence and severity of trauma and bleeding during nasotracheal intubation.

Comparison of Inhalational Vital Capacity Induction with Sevoflurane to Intravenous Induction with Propofol for Insertion of Laryngeal Mask Airway in Adults: A Randomized Study.

BACKGROUND: Since the development of laryngeal mask airway (LMA) by Dr. Brain, it is extensively used for airway management; satisfactory insertion of LMA requires administration of an induction agent and suppression of airway reflexes. Among intravenous agents, propofol has been the drug of choice in view of better safety profile, relaxation and depression of upper airway reflexes. Sevoflurane on the other hand, with pleasant odor, nonirritating to the airways and with bronchodilator property are best among the volatile induction agents. While it is true both propofol and sevoflurane have their merits, still both have certain limitations. We aimed to compare the quality and ease of LMA insertion, hemodynamic changes, and complications with inhalation of 8% sevoflurane vital capacity breath and propofol. MATERIALS AND METHODS: A prospective randomized study of 100 American Society of Anaesthesiologists' Class I and II patients was conducted equal distribution among two groups with 50 each undergoing gynecological procedures under general anesthesia. Group P received injection propofol and Group S received sevoflurane. At the end point of induction, the LMA insertion was attempted. Scoring systems were used to grade the conditions for insertion of the LMA. Induction characteristics, hemodynamic changes, and complications were assessed. RESULTS: Sevoflurane took a longer time for induction and jaw relaxation than propofol. There was no statistically significant difference between the two groups, with respect to LMA insertion time, and conditions. Apnea time was more in propofol group. Fall in heart rate and mean blood pressure was more in propofol. CONCLUSION: Propofol is associated with faster induction while sevoflurane is associated with good hemodynamic stability.