A randomized comparative evaluation of C-MAC video-laryngoscope with Miller laryngoscope for neonatal endotracheal intubation.

Background and Aims: An efficient neonatal airway management is peculiarly challenging even in the most experienced hands. Considering the recent interest in assessing the performance of various video-laryngoscopes (VL) in pediatric cohort, the prospective randomized study was contemplated to stage a comparative evaluation of C-MAC with Miller laryngoscope for neonatal endotracheal intubation. Material and Methods: 150 neonates were randomized to undergo intubation with either the C-MAC VL (n = 75) or the Miller laryngoscope (n = 75) performed by an experienced anesthesiologist in a tertiary care perioperative setting. The percentage of glottic opening (POGO), time to best glottic view (TTBGV), time to intubation (TTI), number of attempts, optimal external laryngeal manipulation (OELM) employed, and the complications were assessed and compared between the two groups. Results: C-MAC group demonstrated a significantly higher POGO, compared to the Miller group (88 ± 26.7%;76.8 ± 32.1%, respectively, P = 0.022). TTBGV was significantly lower in the C-MAC (7.7 ± 0.1s) group as opposed to the Miller group (11.3 ± 1.1s). The C-MAC group displayed higher TTI values compared to the Miller group (25.4 ± 1.6s; 19.7 ± 1.2s, respectively, P < 0.01). The first-attempt intubation success rate and the number of attempts were comparable in both the groups. OELM was required in 24% of the patients in the Miller group as opposed to 10.7% in the C-MAC group (P = 0.031). Higher patient percentage in the C-MAC group required the need of stylet for assisting a successful intubation, although the difference between the two groups was not statistically significant. Conclusion: Despite an improved view of the glottis, the TTI was higher for C-MAC compared to direct laryngoscopy with a comparable first-attempt success rate in the two techniques.

Plasmalyte-A Based del Nido Cardioplegia Versus Plain Ringer Based del Nido Cardioplegia: Double-Blind Randomized Trial.

Background: In this prospective randomized controlled trial, we compared the standard del Nido cardioplegia solution (SDN) with the modified del Nido cardioplegia solution (MDN) in which the base solution was the plain Ringer solution. Methods: A total of 80 patients aged < 12 years undergoing intracardiac repair of Tetralogy of Fallot were randomized into SDN (n = 39) or MDN (n = 41) groups. The primary outcome was a change in cardiac index (CI). Secondary outcomes were ventricular arrhythmias after the release of aortic-cross clamp, postoperative inotropic score (IS), time to peripheral rewarming, duration of mechanical ventilation, intensive care unit (ICU) length of stay, and hospital length of stay, and electron microscopic differences between the 2 groups. Cardiac Troponin-I, inflammatory markers tumor necrosis factor-α (TNF-α), and interleukin-L (IL-6) were measured. Results: Applying the noninferiority confidence interval approach, the difference between the changes in CI between the 2 groups was -0.093 L/min/m2 (95% CI: -0.46-0.27 L/min/m2) which was within the noninferiority threshold of -0.5 indicating that CI was similar in both SDN and MDN. Ventricular arrhythmias postclamp release (P = .91), IS (P = .09), duration of mechanical ventilation (P = .27), ICU length of stay (P = .50), hospital length of stay (P = .57), IL-6 (P = .19), TNF-α (P = .17), Troponin-I (P = .15), electron microscopy changes (P > .05) were not different between groups. Conclusion: MDN was shown to be noninferior to the SDN cardioplegia in terms of preservation of cardiac index. In addition, other metrics indicative of myocardial protection were similar between groups. In developing nations where SDN is not available or is expensive, MDN cardioplegia is an acceptable alternative.

Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group.

In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.

Renal Replacement Therapy Practices in India: A Nationwide Survey.

INTRODUCTION: Renal replacement therapy (RRT) is utilized for patients admitted with acute kidney injury and is becoming indispensable for the treatment of critically ill patients. In low middle income and developing country like India, the epidemiological date about the practices of RRT in various hospitals setups in India are lacking. Renal replacement therapy although is being widely practiced in India, however, is not uniform or standardized. Moreover, the use of RRT beyond traditional indications has not only increased but has shifted from the ambit of the nephrologist and has come under the charge of intensivists. AIMS AND OBJECTIVES: The goal of the study was to record perceptions and current practices in RRT management among intensivists across Indian intensive care units (ICUs). MATERIALS AND METHODS: A questionnaire including questions about hospital and ICU settings, availability of RRT, manpower availability, and RRT management in critically ill patients was formed by an expert panel of ICU physicians. The questionnaire was circulated online to Indian Society of Critical Care Medicine (ISCCM) members in October 2019. RESULTS: The facilities in government setups are scarce and undersupplied as compared to private or corporate setups in terms of ICU bed strength and availability of RRT. High cost of continuous renal replacement therapy (CRRT) makes their use restricted. CONCLUSION: Resources of RRT in our country are limited, more in government setup. Improvement of the existing resources, training of personnel, and making RRT affordable are the challenges that need to be overcome to judiciously utilize these services to benefit critically ill patients. HOW TO CITE THIS ARTICLE: Sodhi K, Philips A, Mishra RC, Tyagi N, Dixit SB, Chaudhary D, et al. Renal Replacement Therapy Practices in India: A Nationwide Survey. Indian J Crit Care Med 2020;24(9):823-831.

Sonoclot analysis in children with congenital heart disease.

BACKGROUND: This study aimed to compare preoperative baseline Sonoclot variables between acyanotic and cyanotic congenital heart disease patients. METHODS: 100 patients aged from infancy to 9-years were studied. Fifty patients each from the cyanotic and acyanotic groups were studied for Sonoclot parameters preoperatively. After inhalational anesthetic induction, blood was collected from the arterial line and analyzed in a Sonoclot analyzer to measure Sonoclot activated coagulation time, clot rate, and platelet function. RESULTS: Sonoclot activated coagulation time was normal in both groups, but lower in the cyanotic group (127.95 ± 51.4 s) than the acyanotic group (147.85 ± 45.48 s; p = 0.54). Both groups had abnormal clot rates and platelet function. The clot rate was significantly lower in the cyanotic group (19.31 ± 10.68 U·min(-1)) than acyanotic group (24.88 ± 9.23 U·min(-1); p = 0.009). Platelet function was deranged in 31% of patients (cyanotic, 59%; acyanotic, 8%; p <0.001). Platelet function was the most severely affected baseline parameter. CONCLUSIONS: Pediatric acyanotic and cyanotic congenital heart disease patients have deranged coagulation parameters as assessed by the Sonoclot analyzer. The abnormality is more marked in cyanotic patients. Platelet function is the most severely affected parameter. These baseline parameters in conjunction with post-bypass parameters for an individual patient will help in the formulation of specific blood component transfusion guidelines.