Practices During Intubation in COVID-19 Intensive Care Units in India: A Cross-Sectional Questionnaire-Based Survey.

Background Healthcare workers are committed to learning from each other's experience to safely optimize patient management of COVID-19. Acute hypoxemic failure is common in COVID-19 patients, and nearly 3.2% may require intubation. Intubation is an aerosol-generating procedure (AGP) that might predispose the performer to COVID-19 infection. This survey was intended to evaluate the practices during tracheal intubation in COVID-19 intensive care units (ICUs) and analyze them against the recommendations of the All India Difficult Airway Association (AIDAA) for safe practice. Methodology It was a web-based, multicentric cross-sectional survey. The choices in the questions were based on guidelines for airway management in COVID-19. Survey questions were divided into two parts - the first part consisted of demographics and general information, and the second part focused on safe intubation practices. Results A total of 230 responses were obtained from physicians all over India, presuming their active involvement in COVID-19 cases, of which 226 responses were taken into account. Two-thirds of responders did not receive any training before ICU posting. The Indian Council of Medical Research (ICMR) guideline was followed by 89% of responders for personal protective equipment use. Intubation in COVID-19 patients was predominantly conducted by a senior anesthesiologist/intensivist in the team and a senior resident (37.2%). Rapid sequence intubation (RSI) and modified RSI were preferable among the responder's hospitals (46.5% vs. 33.6%). In most centers, responders used direct laryngoscope for intubation (62.8%), whereas video laryngoscope was used by 34%. Most responders confirmed the endotracheal tube (ETT) position by visual inspection (66.3%) over end-tidal carbon dioxide (EtCO2) concentration tracing (53.9%). Conclusions Safe intubation practices were followed in most of the centers across India. However, teaching and training, preoxygenation methods, alternative ventilation strategies, and confirmation of intubation pertinent to COVID-19 airway management need more attention.

Applicability of the Broselow Pediatric Emergency Tape to Predict the Size of Endotracheal Tube and Laryngeal Mask Airway in Pediatric Patients Undergoing Surgery: A Retrospective Analysis.

Background This study aims to elucidate the applicability of the Broselow pediatric emergency tape in predicting the size of the endotracheal tube (ET) and laryngeal mask airway (LMA) in children of central India.  Methods A retrospective review was conducted in the Department of Pediatric Surgery during the period of four years (January 2018 to December 2021), and all children between 1 month and 12 years of age who were admitted for routine surgery and were operated on were included. The goal was to assess the accuracy of Broselow pediatric emergency tape in predicting the size of ET and LMA in children and assess the applicability of this tape in an Indian setting based on observation and comparison with the predicted ET tube and LMA size based on the tape. The correlation was done between the predicted ET tube and LMA size and used ET tube and LMA size (the difference and mean). The Chi-square test was applied to test the difference between those matching and those not matching with their respective color zones with respect to weight, tracheal tube (LMA/ET) tube, and for both weight and tracheal tube, and then the p-value was calculated. A p-value of less than 0.05 was considered to be significant.  Results  A total of 296 patients were included in the study. There were 230 males and 66 females. A maximum number of patients were in the white zone (56 patients). A total of 112 patients (37.8%) matched the zone with their weight; 192 patients (64.8%) matched their LMA/ET tube with their respective zones; 81 patients (27.36%) matched both their weights and tracheal tube (LMA/ET) size with the predicted values as per their respective zones. Pearson's Chi-square test was applied to assess the significance of the difference between the number of patients matching and not matching their weight, LMA/ET tube, and both weight and LMA/ET tube with their corresponding color zones as per the Broselow tape. For all the above parameters, the differences were found to be not significant for p-value <0.05.  Conclusions Broselow tape (BT) is applicable in acute trauma settings where it can be used for estimating weight and ET/LMA sizes in an emergency situation where weight measurement is not feasible.

A Rare Case of Giant Occipital Encephalocele With Thoracic Myelomeningocele: An Anesthetic Conundrum.

Encephalocele and myelomeningocele are congenital defects in the cranium and spine with herniation of contents into an extracranial and extraspinal sac, respectively. The occurrence of encephalocele and myelomeningocele in the same patient has rarely been described in the literature. The anesthetic management of such cases is associated with multiple challenges, which include difficulty in securing the airway, prone positioning, blood loss, electrolyte imbalance, hypothermia, cardiorespiratory disturbances, and perioperative care. The main aims are, to prevent hemodynamic fluctuations and excessive pressure on the sac to avoid premature rupture and manage a possible difficult airway due to the head and neck mass. We report such a rare case to highlight and share our experiences faced during perioperative management of a giant vascular occipital encephalocele with impending rupture and thoracic myelomeningocele requiring surgical excision and repair. Previous similar case reports were also reviewed, and potential perioperative complications were discussed.

A Systematic Review and Meta-Analysis of Harmonic Scalpel Versus Conventional Techniques of Appendiceal Stump Closure in Laparoscopic Appendicectomy.

Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy. This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I2 heterogeneity. Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.

Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations.

Aim: This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background: NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods: Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results: Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion: Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article: Karim HMR, Sarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938-948.

Transesophageal echocardiography and intraoperative phlebotomy during surgical repair of coarctation of aorta in a patient with atrial septal defect, moderately severe mitral regurgitation and severe pulmonary hypertension.

Acute left ventricular (LV) or right ventricular (RV) dysfunction during repair of coarctation of aorta (CoA) is rare. Well-developed collateral circulation between branches of both the subclavian arteries (SCAs) and upper descending thoracic aorta decompress LV and prevents acute rise in afterload. An adult patient presented for CoA repair. On chest X-ray, rib notching was not seen. Magnetic Resonance Imaging showed about 7 mm long CoA distal to the origin of left common carotid artery. Reconstruction images of distal arch and descending thoracic aorta showed origin of both the SCAs from CoA segment. Transthoracic echocardiography showed 1.3 cm atrial septal defect (ASD), left to right shunt, moderately severe mitral regurgitation (MR), dilated RV, and severe pulmonary artery hypertension (PH). During cardiac catheterization, the peak gradient across CoA was 60 mmHg. On aortic-root angiography, both the common carotids and the distal arch opacified simultaneously, the CoA segment and the distal aorta opacified a little later. Both the SCAs were filling retrograde. A unique anatomy in which aortic-clamping proximal to CoA and both the SCAs would increase flow to spinal-cord as clamping of the SCAs will stop stealing of blood into the CoA but potentially increase LV afterload, MR, left to right shunt across ASD and RV volume and pressure load depending on the magnitude of flow across the CoA. The increases in LV afterload, MR, and RV afterload and volume overload were managed by controlled phlebotomy and fine-tuned by manipulating inhaled isoflurane concentration whereas the Transesophageal echocardiography (TEE) monitored and guided the management.

Ketamine has no effect on oxygenation indices following elective coronary artery bypass grafting under cardiopulmonary bypass.

Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfunction. This can result in pulmonary dysfunction and deterioration of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies have reported varying results on anti-inflammatory strategies and oxygenation after cardiopulmonary bypass. Ketamine administered as a single dose at induction has been shown to reduce the pro-inflammatory serum markers in patients undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can result in better oxygenation in these patients. This was a prospective randomized blinded study. Eighty consecutive adult patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass were included in the study. Patients were divided into two groups. Patients in ketamine group received 1mg/kg of ketamine intravenously at induction of anesthesia. Control group patients received an equal volume of saline. All patients received standard anesthesia, operative and postoperative care.Paired t test and independent sample t test were used to compare the inter-group and between group oxygenation indices respectively. Oxygenation index and duration of ventilation were analyzed. Deterioration of oxygenation index was noted in both the groups after cardiopulmonary bypass. However, there was no significant difference in the oxygenation index at various time points after cardiopulmonary bypass or the duration of ventilation between the two groups. This study shows that the administered as a single dose at induction does not result in better oxygenation after cardiopulmonary bypass.