Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study.

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomes after emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conducted in a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

Effect of Neck Rotation With Flexion on Ultrasonographic Optic Nerve Sheath Diameter in Patients Undergoing Elective Craniotomy.

Background Extreme neck positioning to facilitate craniotomy can result in impaired venous drainage from the brain and a subsequent rise in increased intracranial pressure (ICP). The effects of varied neck positioning intraoperatively on ultrasonographic optic nerve sheath diameter (USG-ONSD) are still unexplored. This study aims to quantify the angle of neck rotation and flexion that can cause a significant increase in USG-ONSD in patients undergoing elective craniotomy. Methods A total of 100 patients were recruited in this non-randomized study and equally divided into two groups. In one group, patients with neck rotation ≤30 degrees and in another group, patients with neck rotation >30 degrees with varying degrees of neck flexion were included. The average of three USG-ONSD measurements in both eyes was obtained and compared in both groups at baseline, after positioning, and at the end of the surgery after making the neck neutral. Results The results of 100 recruited patients were analyzed. All the patients had neck flexion in the range of 40° to 45°, whereas the neck rotation ranged from 10° to 45°. The USG-ONSD of both eyes changed significantly from baseline to post-positioning time point in patients with neck rotation >30° (right eye p=0.038, left eye p=0.04) when compared to neck rotation ≤30°. There was no significant change in USG-ONSD from baseline to the postoperative time point after making the neck neutral (right eye p=0.245, left eye p=0.850) in both groups. Conclusions This study demonstrates that USG-ONSD, a surrogate measure of ICP, increased significantly after neck flexion with rotation >30° in neurosurgical patients. However, USG-ONSD becomes comparable to baseline after putting the patient's neck in a neutral position after surgery.

Comparison of Opioid-Based Versus Opioid-Sparing Anesthesia in Patients Undergoing Glioma Surgery.

Background In the neurosurgical population, opioids may cause respiratory depression, leading to hypercapnia, increased cerebral blood flow (CBF), and ultimately increased intracranial pressure (ICP), which can mask early signs of intracranial complications and delayed emergence. This study was designed to compare perioperative hemodynamic stability, analgesia, and recovery parameters in opioid-based (fentanyl) general anesthesia versus opioid-sparing (dexmedetomidine) general anesthesia in patients undergoing glioma surgeries. Methodology This prospective observational comparative study compared 52 patients in two groups. Twenty-six (50%) patients in group F received Inj. fentanyl IV (intravenous; bolus 2 mcg/kg 10 minutes before induction and then infusion 1 mcg/kg/hour till 30 minutes before skin closure), whereas 26 (50%) patients in group D received Inj. dexmedetomidine IV (0.5 mcg/kg infusion 10 minutes before induction and then maintenance with a 0.5 mcg/kg/hour infusion till 30 minutes before skin closure). Perioperative heart rate (HR), mean arterial pressure (MAP), Numerical Rating Scale for Pain (NRS) assessment and postoperative emergence time, modified Aldrete score, patient satisfaction, and surgeon satisfaction score were estimated and compared in both groups. Results The mean HR was less in group D compared to group F at following time points - 10 minutes after infusion (P = 0.006), laryngoscopy and intubation (P = 0.003), pinning of the skull (P < 0.001), one hour after dura opening (P = 0.007), two hours after dura opening (P = 0.006), five minutes after extubation (P < 0.001), and 30 minutes after extubation (P = 0.011). MAP was lower in group D compared to group F at the following time intervals: 10 minutes after infusion (P = 0.008), five minutes after extubation (P = 0.007), 30 minutes after extubation (P < 0.001), and one hour after extubation (P = 0.023). A significant decrease in emergence time in group D compared to group F (P < 0.001) was noted. NRS was lower in group D at eight hours (P = 0.005) and 12 hours (P < 0.001) post-extubation. Conclusions Dexmedetomidine can be used as an alternative to fentanyl in terms of perioperative hemodynamic stability, perioperative analgesia, smooth early recovery from anesthesia, patient satisfaction, and surgeon satisfaction.

The analgesic efficacy of ultrasound-guided erector spinae plane block versus ultrasound-guided caudal epidural block for abdominal surgery in pediatric patients - A patient and assessor-blind, randomized controlled study.

Background: Literature on the efficacy and safety of erector spinae plane block (ESPB) in pediatric patients is limited. Hence, we aimed to compare ESPB versus caudal epidural block (CEB) in children undergoing abdominal surgery. Methods: In this patient and assessor-blind study, fifty-two ASA I-II patients, between 1 to 9 years of age, were randomized into groups of 26 each. ESPB group received unilateral or bilateral ultrasound (USG)-guided ESPB with 0.5 ml/kg of 0.25% bupivacaine per side. CEB group received USG-guided CEB with 1 ml/kg of 0.25% bupivacaine. The primary objective was to estimate the proportion of patients requiring postoperative rescue analgesia. The secondary objectives were to assess postoperative Face, Legs, Activity, Cry and Consolability (FLACC) scale scores, duration of analgesia, and consumption of rescue analgesic drugs. Results: More patients in the ESPB group (88.4%), compared to the CEB group (42.3%), required rescue analgesics (P value <0.001). FLACC scores in the ESPB group, though satisfactory, were inferior, to the CEB group. The duration of postoperative analgesia was shorter in the ESPB group by 9.54 h (95% CI: 4.51 to 14.57 h, P value <0.001). The median (IQR) consumption of rescue paracetamol was significantly higher in the ESPB group (20 mg/kg (10,20) compared to the CEB group (0.0 mg/kg (0.0,10) P value <0.001)). No adverse effects were reported. Conclusion: In children undergoing abdominal surgery, both ESPB and CEB were safe and efficacious. CEB provided a longer duration and better quality of analgesia. ESPB may be considered when CEB is contraindicated or difficult.

Accuracy of Sonographic Airway Parameters in Difficult Laryngoscopy Prediction: A Prospective Observational Cohort Study from Central India.

Objective: Though airway ultrasonography (USG) is used to assess difficult laryngoscopy (DL), there is still ambiguity about approach followed and parameters assessed. There is need of a simple, stepwise sonographic assessment with clearly defined parameters for DL prediction. The primary objective of this study was to find diagnostic accuracy of sonographic parameters measured by a stepwise Airway-USG in DL prediction (DLP). Methods: This prospective, observational cohort study was done in 217 elective surgical adult patients administered general anaesthesia with tracheal intubation using conventional laryngoscopy from 1st May 2019 to 31st July 2020, after ethical approval. A sagittal Airway-USG was done using 2-6 Hz transducer in three steps specifying probe placement and head position. Demographic, clinical and Airway-USG measurements were noted. Correlation of the clinical/sonographic parameters was made with Cormack-Lehane score on DL. After receiver operating characteristic curve plotting, the sensitivity, specificity, positive predictive value, negative predictive value (NPV) of DL was calculated for each parameter using open-epi software. Results: DL was observed in 19/217 patients. Airway-USG parameters of skin to epiglottis distance >2.45 cm, hyomental distance with head extension <5.13 cm, head neutral <4.5 cm, their ratio <1.18, maximum tongue thickness >3.93 cm and maximum skin to tongue distance >5.45 cm were statistically significant in predicting DL. DLP score with presence of >3 positive parameters showed 98% specificity, 98% NPV and 96% diagnostic accuracy to predict DL. Conclusion: DLP score derived from Airway-USG may be used as a screening and diagnostic tool for DL.

Prediction of the difficult airway by pre-operative ultrasound-based measurement of airway parameters: A prospective observational study.

Background and Aims: Ultrasonography has emerged as a new airway assessment tool. However, its role in predicting difficult airways needs to be explored. This study aimed to evaluate the accuracy of pre-operative ultrasound assessment of the neck in predicting difficult airways in patients undergoing elective surgery under general anaesthesia. Methods: One hundred and fourteen adult patients undergoing elective surgeries under general anaesthesia were enrolled in this study. In the pre-operative room, upper airway ultrasound measurements of the neck were obtained, namely, distance from skin to the hyoid bone, distance from skin to the thyroid isthmus and thickness of the base of the tongue. Clinical airway assessment details were noted from the pre-anaesthetic evaluation form. The airway management technique was noted. Receiver operating characteristic curves were used to assess the diagnostic value of these upper airway ultrasound measurements in predicting difficult airways. Results: The distance from the skin to the thyroid isthmus in the difficult airway group (0.37 ± 0.133 cm) was significantly higher than in the non-difficult group (P = 0.007). It appeared to be a better predictor of difficult airways and correlated better with clinical tests among the measured ultrasound parameters. The body mass index was significantly higher in the difficult airway group (P = 0.009). Conclusion: Considering the difference in means between the two groups, distance from the skin to the thyroid isthmus should be explored as a potential predictor of a difficult airway in studies with a larger sample size.

Comparison of lung ultrasound technique versus clinical method to evaluate the accuracy of size and placement of left endobronchial double lumen tube in patients undergoing elective thoracic surgery: a prospective observational study.

Anthropometric measurements like height and gender have been frequently found to be inaccurate in prediction of size of double lumen tube (DLT). A tracheal ultrasonography (TUS) is a technique that can be used to predict the size of DLT and its correct placement for lung isolation. We aim to check the accuracy of ultrasound over clinical methods. This prospective study included 68 patients undergoing elective thoracic surgery requiring one-lung ventilation (OLV) with DLT. The groups were assessed for the size of DLT by either anthropometric measurement using height and gender (Group C) or ultrasound method (Group U). Further, the accuracy of placement of DLT was assessed through, either lung auscultation in group C or various ultrasonographic and ventilatory parameters such as lung isolation in the first attempt (lung sliding and lung pulse sign), oxygenation status and peak airway pressure, in group U. Surgeon satisfaction score was also compared in both the groups. The accuracy of predicted DLT size between Group C and Group U was statistically significant (p=0.044). In Group C, 56% of patients showed a mismatch between the predicted DLT size and the actual size required, while in Group U, the mismatch was only 32.4%. The accuracy of DLT placement through group C was 41% as compared to 79% in Group U. Surgeon satisfaction score was also significantly higher in Group U as compared to Group C (p=0.0028). Thus, our study suggests that tracheal and chest ultrasonography for DLT size selection and placement for lung isolation is superior to clinical methods.

A Randomized Trial to Compare Ultrasound-Guided Dorsalis Pedis Versus Posterior Tibial Artery Cannulation in Neurosurgical Patients.

Introduction Dorsalis pedis or posterior tibial artery is selected as an alternative to radial artery cannulation when there is no access or unsuccessful cannulation of a radial artery. This study aimed to compare the two major arteries of the foot (dorsalis pedis and posterior tibial) in terms of their ultrasound (USG)-guided cannulation characteristics in patients posted for elective neurosurgical procedures. Methods All consenting patients, 18-65 years of age, scheduled for elective neurosurgical procedures under general anesthesia requiring arterial cannulations were enrolled. The first-pass success rate, assessment time, cannulation time, total procedural time, and the number of cannulation attempts for both procedures were estimated. Results A total of 90 patients were included in the study. The assessment time, cannulation time, and total time for arterial cannulation were significantly greater in the dorsalis pedis artery group than in the posterior tibial artery group (p < 0.001). Successful arterial cannulation in the first attempt was 73.3% in the dorsalis pedis, whereas it was 80% in the posterior tibial group but comparable (p = 0.455). The successful cannulation outcome was slightly more in the posterior tibial artery group but comparable (p = 1.00). Conclusion First-pass successful cannulation rates in the posterior tibial and the dorsalis pedis artery are comparable. However, the assessment time, cannulation time, and total procedural time are higher and statistically significant for dorsalis pedis artery cannulation compared to the posterior tibial artery group.

Role of Thromboelastography and Thromboelastometry in Predicting Risk of Hypercoagulability and Thrombosis in Critically Ill COVID-19 Patients: A Qualitative Systematic Review.

Thromboelastography and rotational thromboelastometry are the viscoelastic point of care devices that use whole blood samples to assess coagulation and fibrinolysis. These devices give information from initiation of the coagulation cascade, activation of clotting factors to fibrin cross-linking, and contribution of fibrinogen and platelet to clot strength and clot lysis. Viscoelastic point of care tests are well established in hypocoaguable states like trauma, cardiac surgery, liver transplantation, and their use in critical care settings with coronavirus disease 2019 (COVID-19) is not so well-known. We performed a systematic review of studies on thromboelastography and rotational thromboelastometry and their modifications to assess their role in critically ill patients with COVID-19. Inclusion criteria were any kind of studies using thromboelastography or rotational thromboelastometry during coronavirus disease critical illness published in English. Ninety-three articles, from December 1, 2019, to August 31, 2020, were identified in the initial search, out of which 12 articles (a total of 380 patients) satisfied the inclusion and exclusion criteria. Thromboelastography and rotational thromboelastometry were observed to detect the hypercoagulable changes and fibrinolysis shutdown associated with COVID-19. Hypercoagulability is associated with an increased risk of venous thrombosis and micro-thrombosis. This review identifies the role of thromboelastography and rotational thromboelastometry in studying the mechanisms contributing to coagulopathy and incidence of thrombosis in COVID-19.

Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study.

BACKGROUND: Tracheostomy is integral in long-term intensive care of coronavirus disease-2019 (COVID-19) patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. MATERIALS AND METHODS: We conducted a retrospective, single-center, observational study of severe COVID-19 patients who underwent elective tracheostomy (n = 65) during critical care in a tertiary care institute in Central India from May 1, 2020, to April 30, 2021. Data were collected from Medical records, ICU charts, and follow-up visits by patient. A primary objective was to study the clinical characteristics, tracheostomy complications, weaning outcomes, and mortality at 28 and 60 days of ICU admission. We categorized the cohort into two groups (deceased and survivor) and studied association of clinical parameters with 28-day mortality. Cox Proportional regression analysis was applied to calculate the hazard ratio among the predictors of mortality with p value <0.05 as significant. RESULTS: Elective tracheostomy was done in 69 of 436 (15.8%) patients on invasive mechanical ventilation, of which 65 were included. Tracheostomy was percutaneous in 45/65 (69%) and surgical in 20/65 (31%) with timing from intubation as early in 41/65 and late in 24/65 with most common indication as weaning failure followed by anticipated prolonged ventilation. Tracheostomy complications were present in 29/65 (45%) patients with no difference in complication rates between timing and type of tracheostomy. Downsizing, decannulation, and weaning were successful in 22%, 32 (49%), and 35/65 (54%) patients after tracheostomy. The 28-day mortality was 30/65 (46%). The fractional inspired oxygen concentration (FiO2) requirement in survivors was lower (0.4-0.6, p = 0.015) with a higher PaO2/FiO2 ratio (118-200, p = 0.033). Early tracheostomy within 7 days of intubation was not associated with weaning or survival benefit. CONCLUSIONS: We suggest that tracheostomy should be delayed to after 7 days of intubation, especially till FiO2 reduces to 0.5 with improvement in PaO2/FiO2 for better outcomes and avoiding a wasted procedure (CTRI/2021/07/034768). STUDY HIGHLIGHTS: Tracheostomy is integral in care of COVID-19 patients needing prolonged ventilation. There is no difference in complications in early/late or percutaneous dilatational/surgical technique. We observed successful weaning post-tracheostomy in 54% patients. Mortality at 28 days was 46%. Early tracheostomy within 7 days of intubation did not improve weaning or survival. HOW TO CITE THIS ARTICLE: Karna ST, Trivedi S, Singh P, Khurana A, Gouroumourty R, Dodda B, et al. Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study. Indian J Crit Care Med 2022;26(1):85-93.

Tracheostomy Tube as Foreign Body in Right Main Bronchus: A Case Report.

Tracheostomy is a commonly performed procedure to secure airway in patients who need prolonged airway support (Marchese et al. in Respir Med 104(5):749-753, 2010). It is relatively safe procedure but associated with few early and late complications (Fernandez-Bussy et al. in J Bronchol Interv Pulmonol 22(4):357-364, 2015). Metallic tracheostomy tubes were used in patients in the past. Those tubes were associated with fracture and dislodgement due to corrosive injury. Few case reports have been published in the past (Lynrah et al. in Int J Pediatr Otorhinolaryngol 76(11):1691-1695, 2012; Agarwal and Agarwal in Indian J Chest Dis Allied Sci 53(2):111, 2011). PVC tubes are less prone for fracture, but wear and tear associated with prolonged use can lead to break in the tube and dislodgement. We successfully diagnosed and managed such a case of broken PVC Tracheostomy tube in right main bronchus and share our experiences.

Analysis of dynamic changes in optic nerve sheath diameter (ONSD) with ultrasound in post-craniotomy patients: Trends and correlation with computed tomography ONSD and Glasgow coma scale in post-operative period.

Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoing craniotomy is usually done in perioperative period in intensive care unit. Invasive measurement of ICP, though considered as the gold standard, has its own limitations such as availability of expertise, equipment, and associated complications. Period of raised ICP in post-operative period may impact patient outcomes. Post-craniotomy computed tomography (CT) assessment is done routinely and may need to be repeated if indicated during post-operative stay. Utility of sonographic serial optic nerve sheath diameter (ONSD) assessment in post-operative monitoring of patients who have undergone elective craniotomy was explored in this study. The primary objective of the study was to measure the dynamic change in ONSD as compared to baseline pre-operative measurement in the first 3 postoperative days after elective craniotomy. The secondary objective of the study was to evaluate correlation between ONSD value with Glasgow Coma Scale (GCS) and post-operative CT findings. Materials and Methods: In this prospective, observational, and cohort study, we studied adult patients undergoing craniotomy for intracranial tumors. GCS assessment and sonographic measurement of ONSD were done preoperatively, immediate post-operative period, and 12, 24, and 48 h after surgery. CT scan to detect raised ICP was done at 24 h post-operative. Correlation of ONSD with GCS at respective period and correlation of CT scan finding with respective ONSD assessment were evaluated. Results: A total of 57 patients underwent elective craniotomy for intracranial tumors. Significant difference was observed in ONSD value depending on time of measurement perioperatively (χ2 = 78.9, P = 0.00). There was initial increase in the first 12 h followed by decrease in ONSD in the next 48 h. Negative correlation was observed between baseline ONSD and 12 h GCS (ρ = -0.345, P = 0.013). There was significant change in GCS scores based on the status of ONSD (raised or normal) at 12 h after surgery (P = 0.014). Significant correlation between USG ONSD and CT ONSD was observed (ρ = 0.928, P = 0.000). Optimal cutoff value of ONSD to detect raised ICP with reference to CT signs was 4.8 mm with 80% sensitivity and 95% specificity. Conclusion: ONSD undergoes dynamic changes, correlates with CT scan, and has good diagnostic accuracy to detect raised ICP post-craniotomy for intracranial tumors. It may serve as a useful tool in monitoring in resource-limited setup.

Frequency and Impact of Preadmission Digestive Symptoms on Outcome in Severe COVID-19: A Prospective Observational Cohort Study.

BACKGROUND: Coronavirus disease-2019 (COVID-19) commonly presents with respiratory symptoms. However, symptoms involving the digestive system may be present, significance of which is not well studied in the Indian scenario. METHODS: This prospective observational cohort study included consecutive patients with severe COVID-19 admitted to intensive care unit of our tertiary care hospital from September 9, 2020, to March 14, 2021. We evaluated the frequency of preadmission digestive symptoms and compared the demographic, clinical, laboratory parameters, and organ failure at admission and during intensive care along with mortality between those with and without digestive symptoms. In the digestive group, we sought to find predictors of mortality. RESULTS: Digestive symptoms were present in 76/234 (32.4%) with severe COVID-19 infection. In comparison to nondigestive group, digestive patients had higher need for noninvasive ventilation (p 0.028), invasive lines (68%, p 0.003), vasopressors (64%, p 0.01), blood product transfusion (21.1%, p <0.001), and heart failure (55.4%, p 0.041). Confounding factors of alcohol abuse, smoking, sedentary lifestyle as a causative agent for heart failure could not be ruled out. Proportional mortality rate is higher in the digestive group (65.8%, p = 0.015). Mortality is multifactorial with preadmission abdominal pathologies (HR 4.3) or central nervous system (CNS)-related comorbidities (HR 2.829), presentation with multiple digestive symptoms (HR 6.9), higher sequential organ failure assessment score (SOFA) score at admission (HR 1.258) and discharge (HR 1.162), and presence of acute kidney injury (AKI) Grade 3 (HR 2.95) as predictors of mortality. After adjusting for all confounders, need for vasopressor was observed to be associated with 11.58 times higher risk of mortality. CONCLUSION: Preadmission digestive symptoms may be associated with a turbulent illness with invasive interventions, heart failure, and greater proportional mortality in severe COVID-19. AKI Grade 3 is identified as a preventable risk factor predicting mortality. CTRI/2021/03/032325. HOW TO CITE THIS ARTICLE: Karna ST, Singh P, Revadi G, Khurana A, Shivhare A, Saigal S, et al. Frequency and Impact of Preadmission Digestive Symptoms on Outcome in Severe COVID-19: A Prospective Observational Cohort Study. Indian J Crit Care Med 2021;25(11):1247-1257.

Fiber-optic-assisted endotracheal intubation complicated by iatrogenic right main bronchus obstruction.

Several aids have been designed for helping anesthetist in managing the difficult airway. Oral carcinomas often distort the airway anatomy and present as difficult airway usually with restricted mouth opening. In these scenarios, elective nasotracheal intubation with fiberoptic is done to secure the airway as well as to provide the full surgical field to the surgeon. Vertically split nasopharyngeal airway is one of the popular aids used as a conduit to pass fiber-optic bronchoscope. Timely removal of the split nasopharyngeal airway is must and if missed, and pushed inside bronchus leading to iatrogenic complication.

Résumé Plusieurs aides ont été conçues pour aider l'anesthésiste dans la gestion des voies respiratoires difficiles.Les carcinomes oraux déforment souvent l'anatomie des voies respiratoires et présentent comme voie aérienne difficile habituellement avec l'ouverture restreinte de bouche.Dans ces scénarios, l'intubation nasotrachale élective avec la fibreoptique est faite pour fixer les voies respiratoires aussi bien que pour fournir le champ chirurgical complet au chirurgien.Les voies aériennes nasopharyngées à fente verticale est l'une des aides populaires utilisées comme conduit pour passer le bronchoscope à fibre optique.L'enlèvement en temps opportun des voies respiratoires nasopharyngées fendues est doit et si manqué, et poussé à l'intérieur des bronches menant à la complication iatrogène.

Correlation of correct needle placement in caudal epidural space and anatomical structures of sacral canal in paediatric patients: An observational study.

BACKGROUND AND AIMS: Caudal epidural block (CEB) is commonly performed using surface landmark-based technique in the paediatric patients, with a good success rate. Failure to perform CEB is usually attributable to anatomic variations. The aim of this study was to perform measurements of the anatomical landmarks that are generally used to perform CEB and find a relation between these measurements and successful needle placement. METHODS: This was an observational study that included 114 patients, aged up to 15 years. Ultrasonography (USG) scan of the sacrococcygeal region with measurement of cornu height, skin to cornu distance, inter-cornu distance (ICD), vertical and oblique size of hiatus were done. Needle placement for CEB was done using the usual palpatory hiatal approach. Needle position was checked by using ultrasound. Spearman correlation coefficient and multi-variate logistic regression were used for measuring the correlation and predictors of correct needle placement, respectively. RESULTS: Correct placement of needle was found in 84% patients. Statistically significant correlation was found between all the anatomical parameters. Regression analysis revealed that only ICD had a statistically significant contribution (OR1.67, 95% CI 1.024-2.7; P = 0.04) in predicting an incorrect needle placement. If ICD was less than 12.5 mm, it predicted a difficult needle placement; all the children were less than 1.5 years in age; AUC was 77%, P = 0.001, sensitivity 83% and specificity 76.5%. CONCLUSION: ICD can be used as predictor of difficult needle placement for CEB. USG guidance may be of help while performing CEB in children less than 1.5 years.

Comparison Between a Single Subpedicular Transforaminal Epidural Steroid Injection and Lateral Recess Steroid Injection in Reducing Paracentral Disc Herniation-Related Chronic Neuropathic Leg Pain: A Retrospective Study.

BACKGROUND: This retrospective study compares the results of 2 different techniques of transforaminal epidural steroid injection (TFESI)-subpedicular (SP-TFESI) and lateral recess epidural steroid injection (LRSI) in relieving chronic lumbar radicular pain. METHODS: Records of 97 patients who had undergone injection for unilateral lumbar radicular pain and had a paracentral disc were analyzed. Numerical rating scale (NRS) and Oswestry Disability Index (ODI) scores were measured at baseline and at 2, 4, 12, and 24 weeks thereafter. RESULTS: At 24 weeks, the NRS was significantly lower than the baseline in both groups; NRS in the LRSI group was significantly lower than NRS in the SP-TFESI group at 12 and 24 weeks (P = 0.02 each). ODI score was also significantly lower in the LRSI group through the 12-week time point (P = 0.003 at 2 weeks; P = 0.009 at 4 weeks; P = 0.02 at 12 weeks). At the end of 24 weeks, a significantly greater number of patients in the LRSI group achieved minimal clinically important difference for NRS and ODI (P = 0.008 and 0.016, respectively). CONCLUSIONS: At the end of 24 weeks, LRSI appears to be a superior technique in relieving unilateral lumbar radicular pain due to a paracentral disc.

Airway management of palatoglossal bands - A challenge to an anaesthesiologist.

Palatoglossal bands are one of the very rare congenital anomaly with very few documented cases worldwide. They can present with respiratory distress which requires immediate surgical intervention, or with feeding difficulties. The management of such a patient is a challenge to any anaesthesiologist because of inability to perform conventional laryngoscopy and associated cardiac or digital anomalies. We discuss here the management of such an infant who presented at 18 months with feeding difficulties.