Cost analysis of different medical oxygen sources for a healthcare facility in India.

Background and Aims: Multiple sources of medical oxygen, namely liquid medical oxygen (LMO) tanks, pressure swing adsorption (PSA) plants, concentrators, and gaseous cylinders, are available at different healthcare facilities. These sources of oxygen have varying installation and operational costs. In low-resource settings, it is imperative to utilise these assets optimally. This study investigated the operational costs of multiple oxygen sources available at a healthcare facility. Methods: A Microsoft (MS) Excel-based model was developed to analyse and compare the oxygen manufacturing costs (in ₹/m3) using PSA plants and procurement costs (in ₹/m3) of LMO and third-party vendor-refilled cylinders. Results: The oxygen manufacturing costs for PSA plants of different capacities and running times on electricity and diesel generators (DGs) as a power source were calculated. This study highlights the cost-benefit of using PSA plants over LMO and third-party vendor-refilled cylinders as a source of oxygen. PSA plants are most economical when they are of higher capacity and used to their maximum capacity on electricity as the power source. On the contrary, they are most expensive when used on a DG set as a power source. Furthermore, this study provides evidence of PSA plants being more cost-effective for refilling cylinders using a booster compressor unit when compared to third-party vendor-cylinder refilling. Conclusion: Given their cost-effectiveness and low third-party dependence, they should be utilised to their maximum capacity as medical oxygen sources at healthcare facilities.

Recent advances in obstetric anaesthesia and critical care.

Newer modalities in labour analgesia and anaesthesia for caesarean section including regional anaesthesia techniques and airway management are emerging constantly. Techniques such as point of care ultrasound, especially of the lungs and stomach and point of care tests of coagulation based on viscoelastometry are about to revolutionise perioperative obstetric care. This has improved the quality of care thereby ensuring good perioperative outcomes in the parturient with comorbidities. Critical care for obstetrics is an emerging field that requires a multidisciplinary approach with obstetricians, maternal-foetal medicine experts, intensivists, neonatologists, and anaesthesiologists working together with enhanced preparedness and uniform protocols. Newer techniques and concepts of understanding have thus been established in the traditional speciality of obstetric anaesthesia over the last decade. These have improved maternal safety and neonatal outcomes. This article touches upon some recent advances that have made a significant impact in the field of obstetric anaesthesia and critical care.

The effect of different pressures of pneumoperitoneum on the dimensions of internal jugular vein - A prospective double-blind, randomised study.

Background and Aims: During laparoscopic surgeries, pneumoperitoneum increases intraabdominal pressure (IAP) which can increase the central venous pressure (CVP), and significant haemodynamic changes. In this study, we evaluated the effect of two different pressures of pneumoperitoneum, standard (13-15 mmHg), and low (6-8 mmHg) on the cross-sectional area (CSA) of the internal jugular vein (IJV) using ultrasonography, haemodynamic changes and duration of surgery. Surgeon's comfort and feasibility of performing laparoscopic surgeries with low pressure pneumoperitoneum was also studied. Methods: This prospective, double-blind, randomised study included 148 patients of American Society of Anesthesiologists physical status class I and II undergoing laparoscopic surgeries. They were allocated into two groups: group S (standard) (number (n) = 73) had the IAP maintained between 13-15 mmHg; group L (low) had an IAP of 6-8 mmHg (n = 75). CSA of right IJV was measured before induction of anaesthesia (T1), 5 min after intubation (T2), 5 min after pneumoperitoneum (T3), before desufflation (T4) and 5 min prior to extubation (T5). Chi-square test, and Student's paired and unpaired t test were used for statistical analysis. Results: The increase in IJV CSA at T3 when compared to T2 was statistically significant in both the groups (P < 0.001). On desufflation, the change in IJV CSA showed significant decrease in T5 value than T4 value in both the groups (P < 0.001). However, the percentage change in the IJV CSA was more in group S (35.4%) than group L (21.2%). Conclusion: CSA of IJV increased significantly even with lower IAP of 6-8 mmHg. Laparoscopic surgery can be performed conveniently even at low IAP.

An Observational Crossover Study of N95 Respirator with Surgical Mask and Visor in Various Combinations on Healthy Volunteers and Their Impact on Physiological Variables.

Background and Aim: The COVID pandemic necessitated the use of masks to reduce the propagation of coronavirus by airborne transmission. This research was conducted in healthy volunteers to assess the changes in noninvasive measurable physiological variables over 45 min at rest. Methods: This was a prospective randomized controlled crossover trial. Twenty-one healthy volunteers were monitored for pulse rate (PR), peripheral oxygen saturation (SpO2), systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate (RR), inspired carbon dioxide and expired carbon dioxide (ECO2), inspired (FiO2) and expired oxygen (FeO2), every 15 min for 45 minute (min) with N95 respirator, N95 respirator with surgical mask (SM), N95 with SM and visor (V), SM with N95, and N95 respirator with visor. Results: Repeated measures analysis of variance (ANOVA) of PR, RR, SpO2, SBP, and DBP over time within the group and intragroup was calculated and found statistically insignificant. P value for comparison of mean value within the group was calculated by paired t-test with Bonferroni correction. There was a significant rise in ECO2 in the N95 group over time, and repeated measures ANOVA showed P = 0.04 at 30 min between the N95 + V group and the N95 + SM + V group. Inspired CO2 was statistically significant over time in the N95 + SM + V with P = 0.02. Conclusion: N95 alone or in combination with a SM and visor does not cause any clinically significant measurable physiological derangements. The inspired CO2 may be implicated in the symptoms manifested by individuals.

Evaluation of the accuracy of vibration sense with VibraTip™ as a tool to determine the level of anesthesia following subarachnoid block and its correlation with the pinprick sensation.

BACKGROUND AND AIMS: Assessment of level of anesthesia after subarachnoid block (SAB) is essential. We aimed to evaluate the efficacy of vibration sense as a criteria to determine the level of surgical anesthesia. METHOD AND MATERIALS: The study included patients, scheduled for various surgeries under SAB. The baseline values of vibration sense perception using VibraTip™, motor power using the modified Bromage scale, and sensory block by pinprick method were recorded preoperatively and at 5 and 7 min after administration of SAB. The correlation between vibration sense, loss of pinprick sensation, and level of anesthesia were assessed. RESULTS: The concordance correlation coefficient between the pinprick and vibration sense at 5 min and 7 min showed poor strength of agreement with Pearson ρ (precision) being 0.4192 at 5 min and 0.4701 at 7 min. CONCLUSION: Vibration sense serves as a reliable indicator to assess the level of surgical anesthesia following SAB. Vibration sense testing with VibraTip™along with motor power assessment can be used as a tool for assessment of level of block. There is a poor correlation between level of vibration sense and pinprick.

Comparative Evaluation of Efficacy of Preventive Analgesia with Diclofenac and Buprenorphine Patch versus Single Diclofenac Patch for Postoperative Pain following General Anesthesia for Laparoscopic Cholecystectomy.

BACKGROUND: Acute postoperative pain is managed with parenteral and oral medications requiring skilled personnel for administration and vigilance. Previous studies have been done either with transdermal buprenorphine or diclofenac patch separately in mitigating postoperative pain. AIMS: The primary aim was to compare pain scores and rescue analgesia requirement. The secondary aims were comparison of side effects, time to mobilization and oral intake start, sedation scores, and satisfaction scores of surgeons and patients receiving transdermal patches of buprenorphine and diclofenac versus placebo and diclofenac patches following laparoscopic cholecystectomy. SETTINGS AND DESIGN: This is a randomized double-blinded (1:1), case-control study. MATERIALS AND METHODS: One hundred patients undergoing laparoscopic cholecystectomies were enrolled for the study. Patients were allocated into two groups by computer-generated randomization: those receiving dual patch of buprenorphine and diclofenac (DP) and those receiving patches of diclofenac and placebo (SP). Outcomes were measured after extubation and at 4, 8, 12, 24, 36, and 48 h after surgery. STATISTICS: Analysis was done using the Statistical Package for the Social Sciences version 22.0, R environment 3.2.2 for data analysis, and Microsoft Excel to generate graphs and tables. RESULTS: The pain scores and rescue analgesia requirements were significantly higher in group SP compared to group DP. Patient satisfaction scores were better with group DP. No significant difference was found in both the groups concerning sedation scores, side effects, and time to patient mobilization and start of oral intake. CONCLUSIONS: Concomitant use of transdermal patches of buprenorphine and diclofenac for postoperative pain in laparoscopic cholecystectomy provides adequate analgesia and patient satisfaction without compromising postoperative recovery.

The Effect of Forced-Air Warmer, Ondansetron or their Combination on Shivering in Pregnant Women Coming for Elective Cesarean Section under Spinal Anesthesia: A Prospective, Randomized Controlled Comparative Study.

CONTEXT: Perioperative shivering can occur in up to 85% of patients undergoing cesarean section under spinal anesthesia. It has many detrimental effects and disrupts early mother-child bonding. Therefore, it should ideally be prevented by either pharmacologic or nonpharmacological means. AIMS: The primary aim of this study was to evaluate the efficacy of intraoperative forced-air warming, ondansetron or their combination in preventing perioperative shivering in patients undergoing elective cesarean section under spinal anesthesia. SETTINGS AND DESIGN: A prospective randomized controlled comparative study done at the tertiary care center. SUBJECTS AND METHODS: A total of 120 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to three groups. Group O received ondansetron 4 mg intravenously (i.v.) after giving block with no forced air warming. Group W received forced-air warming intraoperatively. Group C received ondansetron 4 mg i.v. after giving block plus intraoperative forced-air warming. Core temperature (tympanic membrane) and the arm skin temperature were measured and shivering was graded simultaneously. STATISTICAL ANALYSIS USED: Parametric data were analyzed using one-way ANOVA and Student's paired t-test where ever appropriate. Nonparametric data were analyzed using the Kruskal-Wallis and the Chi-square test. Values of P < 0.05 were considered statistically significant. RESULTS: Shivering incidence was higher in Group O and Group W being 17.5% and 20%, respectively, and least in Group C being 5%. The incidence of Grade ≥3 shivering requiring rescue drug was lower in Group C (2.5%) compared to that of the Groups W (5%) and O (10%) but was not statistically significant (P = 0.21). CONCLUSIONS: Combined use of ondansetron and forced- air warmer was more effective in reducing the incidence of shivering in pregnant women during elective cesarean section than when used individually.