Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure and cerebral blood flow assessed using transcranial doppler: A prospective observational study.

Background and Aims: Laparoscopic lower abdominal surgeries involve carbon dioxide (CO2) insufflation and Trendelenburg position. The raised intra-abdominal pressure can increase intracranial pressure (ICP) and alter cerebral blood flow. This study was conducted to determine the effect of pneumoperitoneum and Trendelenburg position on ICP and cerebral perfusion pressure (CPP) measured using transcranial Doppler (TCD). Material and Methods: A prospective observational study was conducted in 43 patients of either sex, aged between 18 and 60 years with American Society of Anesthesiologists physical status I and II, undergoing elective laparoscopic surgery in Trendelenburg position. After standard anesthesia induction, pneumoperitoneum was created to facilitate surgery, maintaining an intra-abdominal pressure of 10-15 mmHg and Trendelenburg position of 25°-30°. End-tidal carbon dioxide (EtCO2) was maintained between 30 and 35 mmHg. The ICP was assessed non-invasively using TCD-based diastolic flow velocities (FVd) and pulsatility index (PI) of middle cerebral artery. Data was represented as mean ± standard deviation and compared using paired t test. A P value of < 0.05 was considered significant. Results: Mean ICPPI at baseline was 14.02 ± 0.89 mmHg which increased to 14.54 ± 1.21 mmHg at pneumoperitoneum and Trendelenburg position (P = 0.005). Mean ICPFVd at baseline was 6.25 ± 2.47 mmHg which increased to 8.64 ± 3.79 mmHg at pneumoperitoneum and Trendelenburg position (P < 0.001). There was no statistically significant change in the CPP or mean arterial pressure values intraoperatively. Conclusions: Laparoscopic procedures with CO2 pneumoperitoneum in Trendelenburg position increase ICP as measured using TCD ultrasonography. The CPP was not significantly altered when EtCO2 was maintained in the range of 30-35 mmHg.

National board governed post-graduate curriculum: Strengths and scope.

The National Board of Examinations was established to boost the quality of medical education by laying down exclusive norms, uniform standards and a national level evaluation for the postgraduate medical courses. The content and context of the training curriculum is well updated as per advances in the field and current requirements. Diplomate of National Board (DNB) courses are considered to be at par with the postgraduate and post doctorate degrees for all intents and purposes. The introduction of a formative assessment with objective evaluation pattern has improved the scope of the board. Moving on to a competency-based training with emphasis on novel research can maximise the quality of training to international standards. Training DNB teachers and assessors in the newer teaching and assessment methods can improve the calibre of residents. Stringent monitoring and review of the training can increase the credibility of the courses and the board can be expected to cater for students abroad.

Point-of-Care Ultrasound (POCUS) for the assessment of volume status and fluid management in patients with severe pre-eclampsia: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Appropriate volume assessment and fluid management can prevent maternal deaths in the severely pre-eclamptic (SPE) parturients. We planned a systematic review and meta-analysis (MA) to evaluate the role and ability of point-of-care ultrasound (POCUS) in the assessment of volume status and early detection of lung oedema in an SPE parturient. METHODS: An e-literature search was done from several databases. Data were extracted under five domains including POCUS-derived parameters like echo comet score (ECS), lung ultrasound (LUS) scores, B-patterns, optic nerve sheath diameter (ONSD), E/e' ratio, presence of pleural effusion, pulmonary interstitial syndrome and pulmonary congestion. The risk of bias was assessed. Extracted data were analysed using MetaXL and Revman 5.3. Heterogeneity in the studies was evaluated using the Cochrane Q test and I2 statistics. Funnel plots were used for the assessment of publication bias. RESULTS: Seven prospective studies including 574 parturients (including 396 pre-eclamptics) were selected. POCUS included lung, optic nerve, cardiac and thoracic US. In two studies, the ECS and LUS scores pre-delivery were higher in pre-eclamptics. Two studies found a mean ONSD of 5-5.84 mm before delivery. MA revealed a significantly lower mean ECS score at post-delivery than pre-delivery, and the summary prevalence of B-pattern and pleural effusion among SPE parturients was found to be 0.28 (0.03-0.84) and 0.1 (0-0.2), respectively. A good correlation was observed between B-line patterns and diastolic dysfunction (increased E/e' ratio), LUS score and thoracic fluid content, ONSD and ECS in individual studies. CONCLUSION: POCUS parameters can be useful as early markers of fluid status and serve as useful tools in the precise clinical management of pre-eclampsia.

Analgesia nociception index and hemodynamic changes during skull pin application for supratentorial craniotomies in patients receiving scalp block versus pin-site infiltration: A randomized controlled trial.

BACKGROUND: Noxious stimulation such as skull pin insertion for craniotomy elicits a significant hemodynamic response. Both regional analgesic techniques (pin-site infiltration [PSI] and scalp block [SB]), and systemic strategies (opioids, alpha-2 agonists, anesthetics, and beta-blockers) have shown to attenuate this response. Analgesia Nociception Index (ANI) provides objective information about the magnitude of nociception and adequacy of analgesia. This study compared ANI and hemodynamic changes in patients receiving local anesthetic SB versus PSI during skull pin application for craniotomy. MATERIALS AND METHODS: Sixty adult patients scheduled for elective supratentorial tumor surgery were randomly allocated to receive local anesthetic SB or PSI for skull pin insertion after the induction of anesthesia. Data regarding heart rate (HR), blood pressure (BP), and ANI were collected every minute for 5 min after the skull pin insertion beginning from the baseline. RESULTS: A significant difference was observed in ANI values between the SB (higher ANI) and the PSI groups during skull pin insertion, P < 0.001 and P = 0.003 for ANIi and ANIm, respectively. Similarly, a significant difference was seen in HR and BP both within and between the two groups during skull pin insertion (P < 0.001 for both). The magnitude and duration of change were smaller in the SB group compared with the PSI group for the parameters studied. A strong negative linear correlation was noted between ANI and hemodynamic parameters. CONCLUSIONS: The changes in HR, BP, and ANI were significantly less with local anesthetic SB compared with PSI during skull pin insertion in patients undergoing supratentorial craniotomy.

Analgesia nociception index and systemic haemodynamics during anaesthetic induction and tracheal intubation: A secondary analysis of a randomised controlled trial.

BACKGROUND AND AIMS: Direct laryngoscopy and tracheal intubation is a noxious stimulation that induces significant stress response. Currently, this nociceptive response is assessed mainly by haemodynamic changes. Recently, analgesia nociception index (ANI) is introduced into anaesthesia practice and provides objective information about parasympathetic (low nociceptive stress) and sympathetic (high nociceptive stress) balance, which reflects the degree of intraoperative nociception/analgesia. This study evaluated the changes in ANI and haemodynamics during anaesthetic induction and intubation, and their correlation during tracheal intubation. METHODS: Sixty adult patients scheduled for elective brain tumour surgery under general anaesthesia were studied for changes in ANI, heart rate (HR) and mean blood pressure (MBP) during anaesthetic induction and intubation. This was a secondary analysis of a previously published trial. Linear mixed effects model was used to evaluate changes in ANI, HR and MBP and to test correlation between ANI and haemodynamics. RESULTS: Anaesthetic induction reduced ANI (but not below the critical threshold of nociception of 50) and MBP, and increased the HR (P < 0.001). Direct laryngoscopy and tracheal intubation resulted in increase in HR and MBP with decrease in ANI below the threshold of 50 (P < 0.001). A linear negative correlation was observed between ANI and HR; r = -0.405, P < 0.001, and ANI and MBP; r = -0.415, P = 0.001. CONCLUSION: Significant changes are observed in ANI during anaesthetic induction and intubation. There is a negative linear correlation between ANI and systemic haemodynamics during intubation.

Analgesia Nociception Index-guided intraoperative fentanyl consumption and postoperative analgesia in patients receiving scalp block versus incision-site infiltration for craniotomy.

BACKGROUND: Scalp block or local anesthetic infiltration for craniotomy blunts hemodynamic response to noxious stimuli, reduces opioid requirement and decreases postoperative pain. Analgesia Nociception Index (ANI) provides objective information about the magnitude of pain (rated from 0 to 100 with 0 indicating extreme nociception and 100 indicating absence of nociception) and adequacy of intra-operative analgesia. This study compared intra-operative fentanyl consumption guided by ANI and postoperative pain in patients who receive scalp block with those who receive incision-site local anesthetic infiltration for craniotomy. METHODS: Sixty adult patients undergoing elective supra-tentorial tumor surgery were randomly allocated to receive scalp block or incision-site infiltration after induction of anesthesia. Throughout the intra-operative period, patients received fentanyl 0.5 µg/kg/h and ANI was continuously monitored. Fentanyl 1 µg/kg bolus was administered when ANI decreased to <50. Intraoperative fentanyl consumption was compared using unpaired t-test. Correlation between ANI and postoperative numerical rating scale (NRS) pain score was done using Spearman's rho. RESULTS: The fentanyl consumption (µg/kg/h) was less with scalp block when compared to incision-site infiltration (median [interquartile range]; 1.04 [0.92-1.34] vs. 1.34 [1.18-1.59], P=0.001). Postoperative pain scores were similar [median (interquartile range); 1.5 (0-4) vs. 3 (0-4), P=0.840]. No correlation was observed between postoperative NRS Score and ANI (correlation coefficient = 0.072; P=0.617). CONCLUSIONS: ANI-guided analgesic administration during craniotomy demonstrated lower intra-operative fentanyl consumption in patients receiving scalp block as compared to incision-site local anesthetic infiltration. No correlation was seen between postoperative NRS and ANI.

Epidural anesthesia for cesarean section in a primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia.

Ebstein's anomaly is an uncommon congenital heart defect with an extremely variable natural history due to a wide spectrum of pathological features. We report on the anesthetic management of a 24-year-old primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia for emergency cesarean section.

Ketamine: Current applications in anesthesia, pain, and critical care.

Ketamine was introduced commercially in 1970 with the manufacturer's description as a "rapidly acting, nonbarbiturate general anesthetic" and a suggestion that it would be useful for short procedures. With the help of its old unique pharmacological properties and newly found beneficial clinical properties, ketamine has survived the strong winds of time, and it currently has a wide variety of clinical applications. It's newly found neuroprotective, antiinflammatory and antitumor effects, and the finding of the usefulness of low dose ketamine regimens have helped to widen the clinical application profile of ketamine. The present article attempts to review the current useful applications of ketamine in anesthesia, pain and critical care. It is based on scientific evidence gathered from textbooks, journals, and electronic databases.

An interesting perioperative rendezvous with a case of Henoch-Schonlein purpura.

Henoch-Schonlein purpura (HSP) is an autoimmune, multisystem, acute vasculitis of childhood commonly involving the skin, gut, joints and the kidneys. Fatal complications involving various systems can occur in this disease and careful perioperative management is advocated. We report here the occurrence of postoperative bradycardia and the successful perioperative management of a 12-year-old boy with HSP for diagnostic laparoscopy.