Continuous Bilateral Transversus Thoracicmuscle Plane Block: An Analgesia Boon for Scoliotic Patients Undergoing Cardiac Surgery.

ABSTRACT: A person with thoracolumbar scoliosis for cardiac surgery presents with problems of restrictive lung disease with the additional risk of reduced lung compliance and respiratory complications compared to the other patients. Post-operative analgesia in the form of continuous bilateral transversus thoracic muscle plane block (TTMPB) may help such patients in early respiratory rehabilitation by decreasing the time to extubation, reducing the opioid requirement, and early initiation of physiotherapy decreasing the risk of complications.

Fournier's gangrene and diabetic ketoacidosis with lower-than-anticipated glucose levels associated with SGLT-2 inhibitor: A double trouble.

Empagliflozin has a demonstrated cardiovascular benefit. It is co-prescribed as a glucose-lowering medication in patients with type II diabetes mellitus. Herein, we discuss dual-emergency side-effects, Fournier's gangrene (FG) and diabetic ketoacidosis with lower-than-anticipated glucose levels in a patient on Empagliflozin, a sodium-glucose transport protein 2 inhibitor (SGLT-2i). The pathophysiologic mechanism of FG in correlation with SGLT-2i is not yet elucidated. SGLT-2i increase predisposition to genital mycotic and urinary infections, a mechanism favouring FG. A patient with type II diabetes mellitus on SGLT-2i presented with acute necrotic infection of the scrotum and simultaneous diabetic ketoacidosis with lower-than-anticipated glucose levels. This dual emergency was managed with debridement and medical treatment on lines of diabetes ketoacidosis, respectively. A re-look at this group of glucose-lowering medications from bedside towards benchtop research may help to prod into any other mechanistic basis of these life-threatening clinical occurrences.

Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid.

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20-30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ≤30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

Quality of Life and its Determinants in Patients with Diabetes Mellitus from Two Health Institutions of Sub-himalayan Region of India.

BACKGROUND: Diabetes mellitus (DM) causes serious deterioration in general quality of life (QoL) mainly affecting the health-related quality of life (HRQOL). Routine assessment of QoL improves communication with the patient, helps to predict treatment response, and supports clinical decision-making. QoL can predict an individual's capacity to manage the disease and maintain long-term health and wellbeing. AIMS: To find out the QoL and its socio-demographic, anthropometric, and clinical determinants among DM patients attending health institutions from sub-Himalayan region, catering rural population. SETTINGS AND DESIGN: This cross-sectional study was conducted in two hospitals mostly catering rural population from 2014 to 2018. Purposive sampling technique was used. MATERIALS AND METHODS: Socio-demographic, anthropometric, and clinical data of DM patients (N = 300) were collected. They were administeredHindi translation of QoL Instrument for Indian Diabetes Patients (QOLID) and Patient Health Questionnaire-9 (PHQ-9). All statistical analyses were carried out using Statistical Package for Social Sciences (SSPS) (Version 17.0, USA). RESULTS: About 10% had very poor, 13% poor, 11% average, 16% good, and 50% very good QoL on QOLID. General health (GH) and treatment satisfaction (TS) were the most affected domains. Fatigue was the most common symptom (79%) reported in QOLID. Age more than 55 years, rural background, and PHQ-9 score of more than 7 were predictors of poorer QoL. CONCLUSION: There is a need for a holistic and collaborative care of DM patients, to maintain a good HRQoL. Screening of depression, fatigue, and regular assessment of QoL should be emphasized.

Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the second line of therapy in diabetes mellitus type 2. They are frequently coprescribed with other noninsulin glucose-lowering medications. Diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels is an important SGLT2i-related adverse effect in postoperative patients. This case highlights the need for increased postoperative surveillance of patients on this group of medications. Ketonuria was managed with short-acting insulin infusion with dextrose-containing intravenous fluid, as a part of the ongoing intensive care treatment to which the patient responded well. Awareness of DKA with lower-than-anticipated glucose levels is an important clinical challenge, an entity that can be confused in the setting of major and complex surgeries. The frequency of this arcane and underreported diagnosis in the perioperative setting is unknown. How to cite this article: Vadi S, Lad V, Kapoor D. Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery. Indian J Crit Care Med 2021;25(8):958-959.

Comparative evaluation of Air-Q blocker and Proseal laryngeal mask airway in patients undergoing elective surgery under general anaesthesia: A randomised controlled trial.

BACKGROUND AND AIMS: The Air-Q blocker (Cook gas LLC, Mercury Medical, Clearwater, FL, USA) is a relatively new supraglottic airway device (SAD) with capability to serve as a conduit for intubation. As there is limited data on Air-Q blocker, the present study was performed to compare the efficacy of Air-Q blocker and Proseal laryngeal mask airway (PLMA) in patients undergoing elective surgery. METHODS: A total of 90 American Society of Anesthesiologists (ASA) physical status I and II patients were randomly allocated to Air-Q blocker or PLMA group. Oropharyngeal leak pressure (OLP), insertion success, insertion time, ease of orogastric tube (OGT) insertion, fibreoptic visualisation of the glottis, haemodynamic and ventilation parameters, and complications at emergence and postoperatively were investigated. RESULTS: OLPs were higher in PLMA group as compared to Air-Q blocker group (P = 0.002). Still, the OLP (27.5 ± 5.8 cm H2O) was clinically effective in Air-Q blocker group. The mean time for successful insertion was significantly shorter for Air-Q blocker than PLMA (P = 0.019). The number of attempts to insert both the devices was comparable (P ≥ 0.05). Air-Q blocker provided a significantly better fibreoptic score than PLMA (P = 0.038). The two groups were comparable in terms of ease of OGT insertion, haemodynamics and ventilation parameters, and complications at emergence and postoperatively. CONCLUSIONS: Air-Q blocker provides a clinically effective OLP though PLMA provides a slightly better sealing function in patients undergoing laparoscopic and non-laparoscopic surgeries under general anaesthesia requiring neuromuscular blockade. Air-Q blocker has shorter insertion time and a better fibreoptic view of glottis as compared to PLMA.

Gnana Laryngeal Airway in Clinical Practice: A Prospective Observational Study.

OBJECTIVE: The Gnana Laryngeal Airway (GLA) device, a novel supraglottic airway device, is similar to the LMA-Classic in basic design, but with an additional suction port on the convex portion of the laryngeal mask to remove the saliva. We evaluated the GLA device in terms of ease and time to insertion, the number of attempts, oropharyngeal leak pressure (OLP), correct placement, and complications in adult patients undergoing elective surgical procedures. METHODS: After general anaesthesia, the GLA device was inserted in ASA Class I-II consecutive patients aged 18-60 years, who were scheduled for elective surgeries lasting <2h. An independent observer noted (1) 10 consecutive successful GLA device insertions, all on the first attempt; (2) 10 consecutive device insertions, each <20 second in duration; and (3) 10 consecutive patients with the mean leak <10%. The criteria were fulfilled in 50 consecutive patients. RESULTS: In 72% of patients, the GLA device was successfully placed on the first attempt and was effortless in 64%. Between the first 10 and last 10 consecutive patients of the total 50, the ease-of-insertion grade progressively decreased (mean±standard deviation [SD]: 2.80±0.25 to 1.30±0.15, p<0.0001) and so did insertion time in seconds (28.70±1.87 to 14.20±0.79, p<0.0001). The post-insertion, OLP and airway compliance progressively increased, while the cuff inflation volume, peak airway pressure and airway resistance progressively decreased, along with minimal side effects and malposition. CONCLUSION: The GLA device insertion became progressively easier and faster; thus, such a device is promising and warrants further clinical evaluation.

Depression prevalence, its psychosocial and clinical predictors, in diabetes mellitus patients attending two health institutions of north India catering rural population.

BACKGROUND: Diabetes mellitus (DM) poses a greater risk of depression and a poor quality of life (QoL). There is a limited data regarding relationship of depression to QoL in patients from rural health care settings of North India. AIM: To know the prevalence and predictors of depression in patients of DM among various sociodemographic, clinical and QoL variables. SETTINGS AND DESIGN: This cross-sectional study was conducted in two hospitals of North India mostly catering rural population from 2014 to 2018. MATERIALS AND METHODS: Sociodemographic and clinical data of DM patients was collected. They were applied Hindi translation of QoL Instrument for Indian Diabetes Patients and Patient Health Questionnaire-9. Analyses were done by Statistical Package for Social Sciences (Version 17.0, USA). RESULTS: Among 300 patients, 25.6% had clinical depression. Illiteracy, the affect on general, emotional/mental health and role limitation by diabetes predicted risk of depression. CONCLUSION: Education of patients regarding self-management in DM to assure good health should be emphasised.

Linezolid-induced rare triad of hypoglycaemia, bone marrow suppression and hyponatraemia in elderly.

WHAT IS KNOWN AND OBJECTIVE: Linezolid, a member of the oxazolidinone class of antibacterial drugs, is approved by the US Food and Drug Administration (FDA) for the treatment of vancomycin-resistant Enterococcus faecium infections, nosocomial and community-acquired pneumonia, as a part of anti tubercular regimen and complicated and uncomplicated skin and soft tissue infections, including diabetic foot infections. Linezolid has potential adverse effects like bone marrow suppression, peripheral neuropathy and hyponatremia. One of the extremely rare reported adverse effects of the drug is hypoglycaemia. We present a case of Linezolid toxicity presenting as resistant hypoglycemia, bone marrow suppression and severe hyponatremia all together in a single patient. CASE DESCRIPTION: We present a case of an 82 years old gentleman with no known chronic co-morbidities. He was started on Linezolid 600 mg twice a day for 10 days by a local doctor possibly for some minor infection post hip surgery. He was in respiratory distress on arrival. Blood sugars showed severe hypoglycemia of 36 mg/dL (2.0 mmol/L). He was admitted in intensive care unit and started on injectable antibiotics and 5% dextrose infusion and sugars were strictly monitored. His blood tests revealed severe hyponatremia with sodium level of 119 mEq/L and haemoglobin (Hb) of 8.8 gm/dL, leucocytes of 6500/µL, platelets of 82 000/µL. The infection markers were normal throughout. The platelet count went progressively down from 82 000/µL on admission to 20 000/µL 2 days later; before it started rising back. Similarly there was drop in Hemoglobin and white cell counts. He required vasopressors to maintain mean arterial pressures. The blood sugar levels stabilized after the same. However patient had suffered acute lung injury secondary to aspiration and became NIV dependent and eventually passed away. WHAT IS NEW AND CONCLUSION: Our case was unique in a way that our patient had adverse effects of linezolid like myelosuppression as well as the rare side effects of hypoglycemia at the same time. This combination of adverse events has never been described in the past to our knowledge. All the adverse effects responded to antibiotic de-challenge in our case. We had ruled out the possibility of other causes of Hypoglycemia such as sepsis, insulinoma, alcohol excess, malnutrition or hypoadrenalism. We searched the PubMed database and found four case reports out of which two were diabetics and other two were non diabetics. Out of 15 cases described by Vishwanathan et al only three cases were non diabetics. Our patient was non diabetic as well. Therefore our case is only the sixth reported case of hypoglycemia in non diabetic receiving Linezolid to our knowledge.