Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study.

Background: With the provision of a small positive end-expiratory pressure (PEEP) effect, high-flow nasal oxygen (HFNO) therapy carries a risk of stomach distension. The present study was conducted to find out the air leak in the gastric antrum leading to gastric distension in adult patients with acute respiratory failure receiving HFNO therapy. Materials and methods: Adult patients with early hypoxemic respiratory failure requiring HFNO therapy were enrolled in this trial. Before initiation of HFNO therapy, baseline gastric volume (GV) and the average number of peristaltic contractions over one minute were measured using ultrasound. Once the patient was stabilized on HFNO therapy, a 2nd, 3rd, and 4th ultrasound scans were acquired at 10, 20, and 30 minutes respectively. Vitals and blood gas values were recorded at the baseline and after 30 min of initiation of HFNO therapy. Patient comfort, duration of HFNO therapy, and outcome were also recorded. Results: The GV at 10, 20, and 30 minutes were significantly larger (p < 0.001) compared to baseline. This increase in GV was associated with a significantly increased number of peristaltic contractions and had a significant positive correlation with the HFNO flow (r = 0.541; p < 0.001). The HFNO therapy was well tolerated by most of the patients and led to a significant improvement in the vitals and blood gas parameters at 30 minutes after initiation of HFNO therapy. Conclusion: In adult patients with hypoxemic respiratory failure, the use of HFNO therapy produces gas leaks into the stomach leading to increased gastric volume. The gastric distension increases the peristaltic contraction and higher flows result in more distension. How to cite this article: Ramachandran A, Bhatia P, Mohammed S, Kamal M, Chhabra S, Paliwal B. Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2024;28(4):393-398.

Comparison of the effects of dexmedetomidine and nitroglycerin on cerebral oxygen saturation using near-infrared spectroscopy in patients undergoing controlled hypotensive anaesthesia: A randomised controlled non-inferiority trial.

Background and Aims: There is limited literature wherein the hypotensive drugs have been compared to know the cerebral effects by monitoring regional cerebral oxygen saturation (rScO2). This study aimed to compare the effects of dexmedetomidine and nitroglycerin on rScO2 during controlled hypotensive anaesthesia using near-infrared spectroscopy (NIRS). The primary objective was to evaluate the non-inferiority of dexmedetomidine versus nitroglycerin in the occurrence of cerebral desaturation events (CDEs) during hypotensive anaesthesia. Methods: Adult patients scheduled to undergo head and neck surgery under general anaesthesia randomised to receive either dexmedetomidine or nitroglycerin infusion for controlled hypotensive anaesthesia. Cerebral oximetry was monitored with NIRS, and data regarding CDEs, bilateral rScO2, and peri-operative haemodynamics were collected. Continuous data were analysed using unpaired Student's t-tests except for intra-group analyses, which were analysed using paired t-tests. Categorical data were analysed using the Chi-square test. For comparison of time to CDEs, Kaplan-Meier survival analysis with log-rank test was performed. Results: Of the 82 patients in both groups, CDEs were observed in 15 patients each. A decrease from baseline by 20% was observed in three patients: one in Group N and two in Group D. Statistically, there was an equal risk of getting CDEs in the groups. The time to CDE was comparable (P > 0.05). The difference in heart rate was statistically significant (P < 0.001). Conclusion: Dexmedetomidine is non-inferior to nitroglycerin in terms of the occurrence of cerebral desaturation events when used for controlled hypotensive anaesthesia in head and neck surgeries.

Effect of Different Extubation Strategies on Atelectasis in Older Adults after Major Abdominal Surgeries: A Prospective Randomised Controlled Trial.

Introduction: Older patients are particularly vulnerable to age-related respiratory changes. This prospective randomized controlled trial studied the effects of high and low fractions of inspired oxygen (FiO2) with the recruitment maneuver (RM) during extubation on lung atelectasis post-operatively in older patients undergoing major abdominal surgery. Methods: We randomized a total of 132 patients aged >60 years who underwent both elective and emergency major abdominal surgeries and met the inclusion criteria into three groups (H, HR, and LR) using computer-generated block randomization. Group H received high FiO2 (1), Group HR received high FiO2 (1) with RM followed by a positive end-expiratory pressure of 5 cm H2O, and Group LR received low FiO2 (0.4) with RM followed by a positive end-expiratory pressure of 5 cm H2O 10 min before extubation. Oxygenation and atelectasis were measured using the arterial partial pressure of oxygen (PaO2)/FiO2 ratios and lung ultrasound score. Postoperative pulmonary complications were recorded up to 24 h postoperatively. Results: The mean PaO2/FiO2 at 30 min post-extubation was significantly higher in Groups LR and HR compared to that in Group H (390.71 ± 29.55, 381.97 ± 24.97, and 355.37 ± 31.7, p <0.001). In the immediate postoperative period, the median lung ultrasound score was higher in Group H than that in Groups LR and HR (6 [5-7]), 3 [3-5], and 3.5 [2.25-4.75], p <0.001). The incidence of oxygen desaturation and oxygen requirements was higher in Group H during the postoperative period. Conclusion: The RM before extubation is beneficial in reducing atelectasis and postoperative pulmonary complications, irrespective of the FiO2 concentration used in older adults undergoing major abdominal surgeries.

Same-day discharge after craniotomy for tumor resection: a retrospective observational single-center study of 630 patients.

OBJECTIVE: Modern neurosurgical developments enable minimally invasive surgery with shorter operation times, faster recovery, and earlier hospital discharge. These in combination with Enhanced Recovery After Surgery (ERAS) protocols have the potential to safely shift craniotomy for tumor resection to the ambulatory setting in selected patients. The aim of this retrospective observational single-center study was to assess the success rate of planned same-day discharge from hospital in patients undergoing craniotomy for supratentorial brain tumor resection under general anesthesia or awake craniotomy as well as to explore potential associations with anesthesia techniques, complications, and readmission rates. METHODS: A retrospective analysis of all patients scheduled for same-day discharge after supratentorial craniotomy for tumor resection over 25 years (1996-2021) was performed. Patients were identified for same-day discharge based on specific inclusion and exclusion criteria. Data collected included patient demographics, comorbidities, anesthetic data, perioperative complications, and patient dispositions. Data are presented descriptively. RESULTS: A total of 630 patients (mean age 50.9 years; 311 females, 319 males) scheduled for same-day discharge were analyzed. Patients underwent either awake craniotomy (AC; n = 491) or craniotomy under general anesthesia (GA; n = 139). Successful preplanned same-day discharge occurred in 571 (90.6%). Failed same-day discharge happened in 59 patients (GA, n = 14; AC, n = 45). Reasons for failed discharge included the following: new neurological deficit (n = 28); presence of seizure (n = 8); postoperative nausea and vomiting (PONV; n = 12); excessive headache (n = 5); and/or social factors (n = 10). Nine patients (1.4%) (GA, n = 0; AC, n = 9) with same-day discharge required readmission to hospital within the first 24 hours after discharge. Reasons for readmission included headache (n = 2), seizure (n = 4), neurological deficit (n = 3), and/or PONV (n = 1); all patients were successfully discharged from hospital after 1 day with no need for reoperation. CONCLUSIONS: This retrospective, single-center analysis shows that same-day discharge after craniotomy can be safe in carefully selected patients after both GA and AC for tumor resection. Multidisciplinary involvement (surgeons, anesthesiologists, nurses, and other allied health professionals) optimizes success of same-day craniotomy programs. Future optimization of analgesia and prevention of PONV has the potential to increase the success rate.

Comparison of continuous erector spinae plane block and thoracic paravertebral block for postoperative analgaesia in patients undergoing modified radical mastectomy: A randomised controlled non-inferiority trial.

Background and Aims: Modified radical mastectomy (MRM) is associated with significant postoperative pain for which many blocks including thoracic paravertebral (TPV) block are being used. Erector spinae plane (ESP) block is a recently described technique. We planned to compare the efficacy and safety of ultrasound-guided continuous ESP and TPV blocks for postoperative analgaesia following MRM. Methods: Sixty-six patients belonging to American Society of Anaesthesiologists physical status I and II, aged 25-85 years, undergoing MRM were enrolled and randomly allocated into two groups. Ipsilateral block was given preoperatively at T3 or T4 level with 20 ml of 0.5% ropivacaine and 50 µg fentanyl. Infusion of 0.5% and 0.2% ropivacaine with fentanyl 2 µg/ml at a rate of 5 ml/hr was continued during intraoperative and postoperative period, respectively. Pain was assessed using visual analogue scale (VAS) till 24 hours. Block performance time, time to first rescue analgaesia, total amount of rescue analgaesic consumed, the incidence of procedure-related and postoperative complications, failure rate and patient satisfaction score were also recorded. Data collected were analysed using the Chi-square test or Student's t-test with the help of SPSS 22.0. Results: Demographics, baseline vitals, VAS scores both at rest and on movement, block performance time, time to first rescue analgaesia, the total amount of rescue analgaesia and patient satisfaction score were comparable in both groups (P value > 0.05). No complications were observed in either group. Conclusion: In patients undergoing MRM, continuous catheter technique ESP block is as efficacious and safe as TPV block for providing prolonged postoperative analgaesia.

Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report

Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report.

Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

The midpoint transverse process to pleura (MTP) block for postoperative analgesia in patients undergoing modified radical mastectomy: A case series.

Among the various regional anesthesia techniques used for postoperative analgesia in the modified radical mastectomy (MRM), thoracic paravertebral block (TPVB) is presently considered the technique of choice. Nevertheless, TPVB may lead to complications like inadvertent vascular puncture, hypotension, epidural or intrathecal spread, pleural puncture, or pneumothorax. Recently, a newer technique "midpoint transverse process to pleura" (MTP) block has been described in which the tip of the needle is placed at the midpoint between the transverse process and pleura. In this case series, we included ten patients of American Society of Anesthesiologist status I/II scheduled for MRM. Ultrasound-guided MTP block was performed and the catheter was inserted on the side of the surgery at the level of T4 level. The block was successful in the all patients as their median visual analogue score at rest and movement was 2 and 3, respectively, in first 24 h postoperatively. Only three patients required rescue analgesia in the first 24 h. No procedural-related complications were noticed in any patient. We concluded that MTP block provided effective perioperative analgesia with minimal rescue analgesia requirement and satisfactory safety profile.

Comparative Assessment of Enamel Microhardness Using Various Remineralising Agents on Artificially Demineralized Human Enamel.

INTRODUCTION: Various remineralizing agents can be used to remineralize initial carious lesions. AIM: The study aims to compare and evaluate the remineralizing efficiency of Remin Pro (VOCO GmbH, Cuxhaven, Germany), tricalcium phosphate, and HealOzone (CurOzone USA Inc., Ontario, Canada) by measuring the microhardness of enamel. MATERIALS AND METHOD: Forty-five mandibular premolars were collected and divided into three groups (A, B, and C). After sectioning mesiodistally, they were subdivided into the control and test groups. The test group was further subdivided into demineralized (A2a, B2a, and C2a) and remineralized (A2b, B2b, and C2b) groups. All test group samples were demineralized by immersing in demineralizing solutions for 24 hours. Afterwards, A2b, B2b, and C2b samples were remineralized by remineralizing agents (Remin Pro, tricalcium phosphate, and HealOzone) for three minutes (twice a day) for 14 days, and then Vickers microhardness testing (VHN) was performed. RESULT: The microhardness values of the demineralized group were lower compared to the samples of the control groups. In the remineralized group, the mean microhardness values were maximum for HealOzone (293.22 kgmm-2), followed by Remin Pro (287.5660 kgmm-2) and then tricalcium phosphate (282.4660 kgmm-2). CONCLUSION: The application of remineralizing paste proved potent in improving the remineralization in the demineralized enamel surface.

Psychosocial impact and coping strategies of frontline healthcare workers in Western Rajasthan during COVID-19 pandemic.

Background and Aims: Coronavirus disease-2019 (COVID-19) pandemic-related stress is an important but under-rated issue needing attention. Stress and causative factors vary between the regions and individuals depending on the availability of resources, socio-cultural differences, and individual perceptions. We aimed to study the psychosocial impact and coping strategies among the healthcare workers (HCWs) in Western Rajasthan during COVID-19 pandemic. Material and Methods: This questionnaire-based observational study, consisting of 59 questions in 6 sections, was conducted to identify stress, causative factors, coping strategies, and experiences of HCWs working in personal protective equipment (PPE). Chi-square test was used to compare the responses between different subgroups. Results: Majority of the HCWs felt responsible for treating COVID-19 patients (98.8%), but also felt that it was affecting their safety (81.4%). On subgroup analysis, doctors were found to be more stressed than nursing staff (P = 0.004). Major stressors included concerns about infecting family members and lack of specific treatment for COVID-19 (87.5%). Family support was found to be a major stress-relieving factor (97.3%). Most HCWs suggested that comfortable quarantine stay, adequate supply of PPE, and equipments would help in reducing stress. Conclusion: Frontline HCWs in Western Rajasthan were under significant stress during COVID-19 pandemic. We found that stress-causing factors and coping strategies varied between different subgroups based on profession, gender, and age. We recommend conducting such studies in different regions of the world to develop relevant and region-specific strategies to help HCWs cope with stress more efficiently, thereby, strengthening the healthcare system to deal with future pandemics.

Evaluation of Fracture Resistance of Reattached Fractured Tooth Fragment Stored in Different Storage Media: An In Vitro Study.

AIM: To evaluate the fracture resistance of coronal fractured tooth fragments stored in five different storage media when reattached with nanohybrid flowable composite. MATERIALS AND METHODS: The crown portion of 50 extracted human permanent maxillary central incisors were divided into three equal parts (incisal third, middle third and cervical third) and then marked incisal third were cut with the diamond disk. These were divided into five equal groups according to the type of storage media used i.e. dry storage, fresh tender coconut water, HBSS, milk, and propolis for 2 hours. Coronal fractured part with their respective apical parts were then reattached with flowable composite (G-aenial Universal Flo, GC India), then after thermocycling process samples were subjected to universal testing machine for testing fracture resistance. The collected data were subjected to statistical analysis using one way ANOVA and Post-hoc Tukey test. RESULTS: The obtained results revealed that large amount of force is required to fracture the reattached teeth which were stored in milk and fresh tender coconut water as compared to those which were stored in dry environment, HBSS and propolis. CONCLUSION: In this study, maximum fracture resistance was seen in teeth stored in milk and fresh tender coconut water. Therefore, these two were considered as better storage media. CLINICAL SIGNIFICANCE: Due to increased interest towards the use of tooth colored restoration, recently, fractured teeth reattachment treatment procedure gaining attention by preserving life like translucency of treated tooth.