Managing acute pancreatitis pain with bilateral erector spinae plane catheters in a patient allergic to opioids and NSAIDS: A case report.

Acute pancreatitis is one of the major causes of abdominal pain and is mainly related to either gallstone or heavy alcohol intake. We have managed a patient with acute pancreatitis with a bilateral erector spinae catheter because he was not suitable for other analgesics. A 72-year-old male with a known alcoholic patient was admitted with severe acute pancreatitis. He also had the chronic obstructive pulmonary disease (COPD) and oesophageal reflux disease. He was allergic to nonsteroidal anti-inflammatory medications and opioids. Therefore, his pain was managed successfully with bilateral erector spinae block with a continuous infusion with 0.125% levobupivacaine 1 ml/hr background infusion and 30 ml every 4 hours using a CADD Solis regional analgesia pump. Although erector spinae block is relatively new and to date, the optimal dose is not determined. We inserted the catheters at the T8 level; however, further study is needed to determine the ideal insertion site and drug volumes. We have mentioned key features, techniques, and management plans and reviewed the latest literature in this case report.

Burkitt's Lymphoma with an Unusual Cardiac Involvement: A Case Report.

Burkitt's lymphoma (BL), a variety of non-Hodgkin's lymphoma, is uncommon in India. Cardiac involvement in sporadic BL is rare. Cardiac involvement may be primary or a part of a systemic disease process. It affects the endocardium, myocardium, or pericardium. Cardiac symptoms may or may not be present in the early clinical stages. We are presenting a case of sporadic BL in a 13-year-old child with cardiac and systemic involvement.

A Retrospective Study of Ultrasound-Guided Pericapsular Nerve Group Block With Dexamethasone: An Excellent Option for Early Mobility Following Total Hip Replacement Surgery.

Background Severe postoperative pain and immobility increase the length of hospital stay and immobility-related life-threatening complications after total hip replacement (THR). Pericapsular nerve group (PENG) block is a recent addition to pain management of neck of femur (NoF) fracture, the use of which has been incorporated into THR as alternative analgesia or as an adjunct with other regional analgesia techniques. The present study primarily aims to assess postoperative mobility. Secondary outcomes measured were the length of hospital stay, pain score, opioid consumption, and side effects. Methods This is a retrospective study of 50 patients who underwent primary THR. Twenty-eight patients received PENG block after spinal anesthesia (PENG Group), seven patients had general anesthesia (GA) with patient-controlled analgesia (PCA) postoperatively (PCA Group), and the remaining 15 received spinal anesthesia with fascia iliaca block (FIB Group). Mobilization was attempted in all patients (ability to stand and walk a few steps with a walker) 10 hours after the end of surgery. Data was collected for average postoperative pain score, time of mobilization, total opioid consumption (till discharge from the hospital), opioid-related side effects, and time of discharge. Results Mobilization was attempted in all patients 10 hours after the end of the surgery, irrespective of their anesthetic technique. In the PENG Group, 26 patients (n=28) could be mobilized after the first 10 hours without opioids. The total morphine requirement until discharge was significantly less in the PENG Group of patients compared to the FIB and GA+PCA patients. The average time of discharge (hours) from the hospital (22.1+/-4.9) was also significantly lower in the PENG Group compared to all other groups (31.7 +/- 3.4, p=<0.01). The average postoperative pain score was significantly low in the PENG Group within the first 48 hours. Conclusion The PENG block helps in early mobilization and enhanced recovery after THR.

Elevated jugular venous oxygen saturation after cardiac arrest.

BACKGROUND: We performed a retrospective analysis of our earlier study on cerebral oxygenation monitoring by jugular venous oximetry (SjvO2) in patients of out-of-hospital cardiac arrest (OHCA). The study was focused on high SjvO2 values (≥75%) and their association with neurological outcomes and serum neuron-specific enolase (NSE) concentration. METHOD: Forty OHCA patients were divided into (i) high (Group I), (ii) normal (Group II), and (iii) low (Group III) SjvO2, with the mean SjvO2 ≥ 75%, 55-74% and <55% respectively. The neurological outcome was evaluated using the Cerebral Performance Category scale (CPC) on the 90th day after cardiac arrest (post-CA). NSE concentration was determined after ICU admission and then at 24, 48, and 72 hours (h) post-CA. RESULTS: High mean SjvO2 occurred in 67% of patients, while no patients had low mean SjvO2. The unfavourable outcome was significantly more common in Group I than Group II (74% versus 23%, p < 0.01). Group I patients had significantly higher median NSE than Group II at 48 and 72 h post-CA. A positive correlation was found between SjvO2 and PaCO2. Each 1 kPa increase in CO2 led to an increase of SjvO2 by 2.2 %+/-0.66 (p < 0.01) in group I and by 5.7%+/-1.36 (p < 0.0001) in group II. There was no correlation between SjvO2 and MAP or SjvO2 and PaO2. CONCLUSION: High mean SjvO2 are often associated with unfavourable outcomes and high NSE at 48 and 72 hours post-CA. Not only low but also high SjvO2 values may require therapeutic intervention.

Anaesthetic Challenges and Transesophageal Echocardiography-Guided Perioperative Management in a Patient with Uncorrected Adult Congenital Heart Disease Presenting for Emergency Laparoscopic Hysterectomy.

Anaesthetic management of a patient with adult congenital heart disease with a single ventricle physiology presenting for an emergency laparoscopic surgery is challenging. The importance of a multidisciplinary approach, astute understanding of the pathophysiology and optimisation of intraoperative hemodynamic goals cannot be overemphasised. The present report describes the anaesthetic challenges and the role of transoesophageal echocardiography in perioperative management of a patient with uncorrected tetralogy of Fallot with pulmonary atresia, who successfully underwent an emergency laparoscopic hysterectomy under general anaesthesia.

Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients?

Cerebral protection against secondary hypoxic-ischemic brain injury is a key priority area in post-resuscitation intensive care management in survivors of cardiac arrest. Nevertheless, the current understanding of the incidence, diagnosis and its' impact on neurological outcome remains undetermined. The aim of this study was to evaluate jugular bulb oximetry as a potential monitoring modality to detect the incidences of desaturation episodes during post-cardiac arrest intensive care management and to evaluate their subsequent impact on neurological outcome. We conducted a prospective, observational study in unconscious adult patients admitted to the intensive care unit who had successful resuscitation following out of hospital cardiac arrest of presumed cardiac causes. All the patients were treated as per European Resuscitation Council 2015 guidelines and they received jugular bulb catheter. Jugular bulb oximetry measurements were performed at six hourly intervals. The neurological outcomes were evaluated on 90th day after the cardiac arrest by cerebral performance categories scale. Forty patients met the eligibility criteria. Measurements of jugular venous oxygen saturation were performed for 438 times. Altogether, we found 2 incidences of jugular bulb oxygen saturation less than 50% (2/438; 0.46%), and 4 incidences when it was less than 55% (4/438; 0.91%). The study detected an association between SjVO2 and CO2 (r = 0.26), each 1 kPa increase in CO2 led to an increase in SjvO2 by 3.4% + / - 0.67 (p < 0.0001). There was no association between SjvO2 and PaO2 or SjvO2 and MAP. We observed a statistically significant higher mean SjvO2 (8.82% + / - 2.05, p < 0.0001) in unfavorable outcome group. The episodes of brain hypoxia detected by jugular bulb oxygen saturation were rare during post-resuscitation intensive care management in out of hospital cardiac arrest patients. Therefore, this modality of monitoring may not yield any additional information towards prevention of secondary hypoxic ischemic brain injury in post cardiac arrest survivors. Other factors contributing towards high jugular venous saturation needs to be considered.

The Transport Medicine Society Consensus Guidelines for the Transport of Suspected or Confirmed COVID-19 Patients.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) and has been declared as a pandemic. COVID-19 patients may require transport for diagnostic or therapeutic purposes intra- or interhospital or transport from an outside hospital to a healthcare facility. Transport of critically ill or infectious patients is always challenging and involves the integration of various tasks and manpower. The adverse events have been attributed to various factors such as a multidisciplinary team and lack of appropriate communication among team members, absence of equipment, or failure during transport, apart from physiological alteration inherent to the disease of the patient. The transport of COVID-19 patients carries an additional risk of not only the disease itself but also due to the risk of its transmission to the transport team. The human-to-human transmission of the virus can occur via respiratory droplets. So, the person involved in the transport of such patients shall be at risk and warrants appropriate steps for their safety. Appropriate planning by a well-trained transport team is an essence for the safe transport of the suspected or confirmed COVID-19 patients. The Transport Medicine Society guidelines present consensus guidelines for the safe transport of COVID-19 patients. DISCLAIMER: These consensus guidelines are applicable for the safe transport of suspected or confirmed COVID-19 adult patients. These recommendations should be used in conjunction with medical management guidelines and advisories related to COVID-19. These recommendations should be adapted to the local policies prevalent at the workplace and also per agreement among the hospitals for transport (agreement between referring and receiving facilities). With the emergence of new scientific evidence, these guidelines may require modification. HOW TO CITE THIS ARTICLE: Munjal M, Ahmed SM, Garg R, Das S, Chatterjee N, Mittal K, et al. The Transport Medicine Society Consensus Guidelines for the Transport of Suspected or Confirmed COVID-19 Patients. Indian J Crit Care Med 2020;24(9):763-770.

Systemic Involvement of Novel Coronavirus (COVID-19): A Review of Literature.

COVID-19 outbreak has caused a pandemonium in modern world. As the virus has spread its tentacles across nations, territories, and continents, the civilized society has been compelled to face an unprecedented situation, never experienced before during peacetime. We are being introduced to an ever-growing new terminologies: "social distancing," "lockdown," "stay safe," "key workers," "self-quarantine," "work-from-home," and so on. Many countries across the globe have closed their borders, airlines have been grounded, movement of public transports has come to a grinding halt, and personal vehicular movements have been restricted or barred. In the past couple of months, we have witnessed mayhem in an unprecedented scale: social, economic, food security, education, business, travel, and freedom of movements are all casualties of this pandemic. Our experience about this virus and its epidemiology is limited, and mostly the treatment for symptomatic patients is supportive. However, it has been observed that COVID-19 not only attacks the respiratory system; rather it may involve other systems also from the beginning of infection or subsequent to respiratory infection. In this article, we attempt to describe the systemic involvement of COVID-19 based on the currently available experiences. This description is up to date as of now, but as more experiences are pouring from different corners of the world, almost every day, newer knowledge and information will crop up by the time this article is published. HOW TO CITE THIS ARTICLE: Munjal M, Das S, Chatterjee N, Setra AE, Govil D. Systemic Involvement of Novel Coronavirus (COVID-19): A Review of Literature. Indian J Crit Care Med 2020;24(7):565-569.

Comparative Efficacy of Methylprednisolone Acetate and Dexamethasone Disodium Phosphate in Lumbosacral Transforaminal Epidural Steroid Injections.

OBJECTIVE: Transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. But in view of accidental intravascular injections and consequent neurological injuries, the safety profile of particulate steroids has been questioned. Dexamethasone (DEXA), being non-particulate, is presumed to be a safe replacement for earlier particulate agents. However, the efficacy of DEXA is still doubtful as compared to particulate steroids. The present study aims to determine the comparative efficacy of DEXA and methylprednisolone (MP) in terms of pain relief and improvement of disability. METHODS: Seventy-six patients were sorted into two groups (MP and DEXA) to receive lumbar TFESI. A protocol of one-time single- or two-level TFESI with equipotent doses of MP or DEXA was followed. Numeric Rating Scale (NRS) and Roland-Morris Disability Questionnaire (RMDQ) scores were collected pre-treatment and at different times for a duration of 6 months at follow-up appointments. RESULTS: Overall, the extent of pain relief (determined from NRS) and quality of life (determined from RMDQ) were significantly better (p<0.01) in patients belonging to MP group following TFESI. NRS was 2.8±1.2, 3.3±1, 5.1±1.6 and 3.9±1.4, 4.5±1.3, 6.2±1.1 respectively in MP and DEXA group at 1 month, 3 months and 6months of follow-up, whereas RMDQ was 7.9±2.8, 7.4±2.3, 8.5±2.4 and 10±2.2, 11.4±2.6, 12.4±2.7 respectively in MP and DEXA group at similar time points. CONCLUSION: The immediate and short term pain relief following TFESI in lumbar radicular pain remained satisfactory and is comparable between MP and DEXA groups, but the long term benefit is significantly more with the use of MP, as evidenced by the NRS and RMDQ scores.

Use of a Minimally Invasive Cardiac Output Monitor to Optimise Haemodynamics in a Patient with Mitral Valve Disease Undergoing Cerebrovascular Surgery.

Patients with mitral valve disease undergoing cerebrovascular surgery face increased inherent risks due to their associated cardiac comorbidities. As such, the anaesthetic management of such patients is distinctly challenging. Simultaneous consideration of both the cerebrovascular and underlying cardiac conditions determines key anaesthetic issues, as fluids and vasopressors or inotropes need to be titrated according to haemodynamic variables in order to optimise cerebral blood flow without compromising cardiac function. We report a 45-year-old female patient with mild mitral stenosis and moderate-to-severe mitral regurgitation who presented to the Khoula Hospital, Muscat, Oman, in 2016 following a ruptured anterior communicating artery aneurysm requiring urgent surgical intervention. As highlighted in this case, the VolumeView EV1000™ (Edwards Lifesciences, Irvine, California, USA) system is a minimially invasive haemodynamic monitor that can help immensely in the perioperative management of such patients.

Ultrasound Guided Out-of-Plane Versus In-Plane Transpectoral Left Axillary Vein Cannulation.

OBJECTIVE: The primary objective was to compare the frequency of first-attempt successful axillary vein cannulation by the Seldinger technique using out-of-plane ultrasound guidance versus in-plane imaging. Between the two ultrasound imaging planes, this study also compared the number of attempts that were necessary for the cannulation of the left axillary vein along with the number of needle redirections that had to be done for final cannulation of the vein. Incidence of complications and the number of times the procedure was abandoned also were compared between the two imaging planes. DESIGN: Prospective, randomized, interventional study. SETTING: Tertiary care cardiac center. PARTICIPANTS: Cardiac surgical patients. INTERVENTIONS: Left axillary vein cannulation under ultrasound guidance by Seldinger technique. MEASUREMENTS AND MAIN RESULTS: The left axillary vein was accessed under ultrasound guidance in 86 consecutive adult cardiac surgical patients. They were randomized to out-of-plane (Group I, n = 43) and in-plane (Group II, n = 43) groups. In group I, the number of first-attempt cannulations was very high (p < 0.01). The number of attempts to access the vein was significantly lower in this group (p < 0.05). The duration for completion of the procedure was also less in group I with out-of-plane ultrasound guidance (p < 0.01). The number of needle redirections and the incidence of complications (arterial puncture, pneumothorax hematoma formation) were similar between the groups. There was no difference in the number of times the procedure was abandoned between the two groups. With an assumption that the first 10 patients in each group would suffice for overcoming the learning curve, the above aspects were analyzed further in each group. The first-attempt cannulation success continued to be significantly higher in the out-of-plane group. CONCLUSIONS: Out-of-plane ultrasound imaging during axillary vein cannulation increased the chance of first-attempt successful cannulation. Axillary vein cannulation under out-of-plane ultrasound imaging also appeared to be quicker and was preferable in terms of the fewer number of attempts that were necessary for a successful vein cannulation.

Early Versus Late Tracheostomy for Patients with High and Low Cervical Spinal Cord Injuries.

OBJECTIVES: This study aimed to evaluate the effects of early versus late tracheostomies among patients with cervical spinal cord injuries (CSCIs). METHODS: This retrospective study included 69 adult CSCI patients who underwent bedside percutaneous tracheostomies at the Intensive Care Unit of Khoula Hospital, Muscat, Oman, between January 2011 and October 2015. The tracheostomy was considered early if the procedure took place within one week of the CSCI. The impact of an early tracheostomy on patient outcomes was analysed in terms of duration of mechanical ventilation and intensive care unit (ICU) stay among patients with high (C1-C2 vertebrae) and low (C3-C7 vertebrae) CSCIs. Ventilator dependence, bradycardia episodes and surgical intervention outcomes were also examined. RESULTS: Patients with a high CSCI who underwent an early tracheostomy spent significantly fewer days on mechanical ventilation compared to those who underwent a late tracheostomy (9.3 ± 7.2 days versus 13.7 ± 3.2 days; P = 0.041). Low CSCI patients who received an early tracheostomy also experienced significantly fewer days on mechanical ventilation compared to those undergoing a late tracheostomy (12.1 ± 10.4 days versus 25.2 ± 17.7 days; P = 0.035). Moreover, ICU mortality was significantly lower for high CSCI patients who underwent an early tracheostomy (P = 0.015). However, there was no association between length of ICU stay and either type of CSCI or timing of the tracheostomy procedure. CONCLUSION: An early tracheostomy is beneficial in reducing the duration of mechanical ventilation among patients with CSCIs, irrespective of the level of injury.