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.

Comparison of Oxygen Delivery Devices in Postoperative Patients with Hypoxemia: An Open-labeled Randomized Controlled Study.

Background: Acute hypoxemic respiratory failure is among the more commonly occurring complications in postoperative patients. Supplemental oxygen and addressing the primary etiology form the basis of its treatment. Materials and methods: We conducted an open-labeled randomized control trial with 90 adult patients and compared three oxygen delivery vehicles (ODV), i.e., noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and venturi mask (VM) in postoperative hypoxemic patients. The primary outcome variable was a change in the P/F ratio after 2 hours of use of ODV. Results: It was observed that the change in P/F ratio after 2 hours was similar in all three ODV groups (p = 0.274). The mean values of the post-ODV P/F ratio were comparable with the pre-ODV P/F ratio in all three modalities. The P/F ratio after HFNC was 358.08 ± 117.95; after NIV was 357.60 ± 220.67; and after VM was 355.47 ± 101.90 (p = 0.997). Conclusion: Among HFNC, NIV, and VM, none of the devices proved superior to the other for use in postoperative hypoxemia. How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod D, Meshram T, et al. Comparison of Oxygen Delivery Devices in Postoperative Patients with Hypoxemia: An Open-labeled Randomized Controlled Study. Indian J Crit Care Med 2024;28(3):294-298.

Comparison of procedural time with two different ultrasound-guided approaches for dorsalis pedis artery cannulation in adult patients: A randomized trial.

BACKGROUND: In adult patients, there has never been an evaluation of short-axis out-of-plane versus long-axis in-plane approaches of ultrasound-guided dorsalis pedis artery cannulation. This research was conducted to compare these two techniques to cannulate the dorsal pedis artery. METHODS: In this trial, 128 adult patients undergoing surgery and necessitating arterial cannulation were examined. Dorsalis pedis artery cannulation was performed utilizing an ultrasound by long-axis in-plane approach (group L) or short-axis out-of-plane (group S) techniques. RESULTS: Group S had a higher first attempt success rate than group L (46.9% vs 28.6%, p = 0.039). The S group had a lower assessment time than the L group (11.48 ± 3.07 vs 19.68 ± 2.79 s; p = 0.000). Cannulation time was higher in the S group (18.91 ± 1.92 s) compared to the L group (12.48 ± 1.61 s; p = 0.000). Nevertheless, the total procedure time was comparable between the L group and the S group (32.16 ± 2.95 vs 30.42 ± 4.07 s; p = 0.107). CONCLUSIONS: In adults, both views of ultrasonography can be used to guide DPA cannulation. The cannulation time for the DPA in L group was less than the S group, whereas the assessment time was less in S group. The total procedure time, however, was similar between both the groups.

Comparison of Caudal Dexmedetomidine and Midazolam as an Adjuvant to Ropivacaine for Postoperative Pain Relief in Children Undergoing Infra-Umbilical Surgeries: A Randomized Controlled Trial.

BACKGROUND: We explored the analgesic efficacy of two non-opioid adjuvants (midazolam and dexmedetomidine) with ropivacaine in children undergoing infraumbilical surgeries. METHODS: In this parallel group randomized controlled trial, 135 children aged between 2 and 8 years were recruited. Children were randomly allocated to one of three groups: RD received 1 mL/kg of ropivacaine (0.2%) with dexmedetomidine 1 µg/kg, RM received 1 mL/kg of ropivacaine (0.2%) with midazolam 30 µg/kg, and R received 1 mL/kg of ropivacaine (0.2%) with 1 mL normal saline. The primary outcome of the present study was to determine the duration of postoperative analgesia. Secondary outcomes were assessing postoperative face, leg, activity, cry, consolability (FLACC) pain score, rescue analgesics, hemodynamics, sedation scores, and adverse effects. RESULTS: The analgesia duration was significantly prolonged in the RD and RM group (600.0 [480.0-720.0] minutes and 600.0 [480.0-720.0] minutes, respectively) compared to the R group 360.0 (300.0-480.0) minutes (P < 0.001). The FLACC score was comparatively higher in the R group compared to the RD and RM groups postoperatively. Time for the first rescue analgesia was more prolonged in RD and RM groups when compared with the R group. Postoperative sedation was higher in the RM group up to 120 minutes postoperatively compared to the RD and R groups. CONCLUSION: The combination of dexmedetomidine or midazolam with local anesthetics significantly increases the analgesia duration while minimizing adverse effects.

Medication errors in the practice of paediatric anaesthesia - a narrative review.

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Count in Time So All is Fine.

Dislodgement of surgical sponge into airway during the intraoperative period is uncommon as the airway, in most cases secured by an endotracheal tube. We report such an unusual case during micro laryngeal surgery and direct laryngoscopy assessment under general anaesthesia. This shows early suspicion and quick action to avoid disaster.

Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study.

How to cite this article: Sahoo P, Kothari N, Sharma A, Goyal S. Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2023;27(8):603-604.

Comparison of intranasal dexmedetomidine-midazolam, dexmedetomidine-ketamine, and midazolam-ketamine for premedication in paediatric patients: a double-blinded randomized trial.

BACKGROUND: Paediatric patients are a population with a high level of anxiety. The prevention of perioperative stress in a frightened child is important to render the child calm and cooperative for smoother induction. Intranasal premedication is easy and safe, and the drug is rapidly absorbed into the systemic circulation, ensuring early onset of sedation in children and good effectiveness. METHODS: 150 patients in the age group 2-4 years, ASA class I, undergoing elective surgical procedures were enrolled. The patients were randomly divided into 3 groups: a DM group (receiving intranasal dexmedetomidine 1 µg kg -1 and midazolam 0.12 mg kg -1 ), a DK group (receiving intranasal dexmedetomidine 1 µg kg -1 and keta-mine 2 mg kg -1 ), and an MK group (receiving intranasal midazolam 0.12 mg kg -1 and ketamine 2 mg kg -1 ). After 30 minutes of administration of the drugs, the patients were assessed for parent separation anxiety, sedation, ease of IV cannulation, and mask acceptance. RESULTS: The comparison among the 3 groups showed a statistically significant difference for ease of IV cannulation and mask acceptance at 30 minutes, with a P -value of 0.010 with CI of 0.0-0.02, and P -value 0.007 with CI 0.0-0.02, respectively. The parent separation anxiety and sedation score at 30 minutes was statistically insignificant with a P -value of 0.82 with CI of 0.03-0.14 and P -value 0.631 with CI of 0.38-0.58, respectively. CONCLUSIONS: The combination of midazolam and ketamine had a better clinical profile for premedication as compared to other combination drugs used in our study in terms of IV cannulation and acceptance of masks with a comparable decrease in separation anxiety from parents and adequate sedation.

Comparison of ultrasound-guided dynamic needle tip positioning and acoustic shadowing technique with palpation technique for radial arterial cannulation by experienced clinicians: A randomized controlled trial.

BACKGROUND: Radial artery cannulation is usually done for monitoring invasive blood pressure during intraoperative period. The dynamic needle tip positioning approach allows continuous visualization of the needle tip during ultrasound-guided cannulation. The acoustic shadowing technique, using two lines on the ultrasound probe, might be used to facilitate radial artery puncture. We aimed to compare these two ultrasound-guided techniques of radial artery cannulation with the traditional palpation method in adult patients. METHODS: In this trial, 180 adult patients requiring arterial cannulation were randomized into three groups (Traditional palpation (TP), Dynamic needle tip positioning (DNTP), and acoustic shadow technique (AST)). All cannulations were carried out by experienced anesthetists. Data was analyzed for the success rate of arterial cannulation in the first attempt, total number of attempts in 5 min, time taken to cannulate, number of cannulas used, and complications related to the procedure. RESULTS: The first attempt success rates among TP, DNTP, and AST were 66.7%, 66.7%, and 71.7%, respectively (p = 0.794). The median time taken for cannulation was 60.5 (37.0, 129.5) s, 71.0 (50.0, 170.0) s, and 108.0 (58.0, 181.0) s, respectively (p = 0.066) and the median number of cannulation attempts was 1, in all the three groups (p = 0.684). There was also no difference in the total number of cannulas used, the overall success rate of cannulation, and complications related to the procedure in the three groups. CONCLUSION: The TP, DNTP, and AST technique for radial artery cannulation had comparable first attempt success rate, the time taken for cannulation, the number of cannulas used, and overall complications. We conclude that radial arterial cannulation by palpation, as well as ultrasound-guided DNTP and AST techniques performed by experienced clinicians in hemodynamically stable adult patients are equally advantageous.

Comparison of Diagnostic Accuracy of Presepsin and Procalcitonin for Sepsis in Critically Ill Patients: A Prospective Observational Study.

Objective: Early diagnosis of sepsis is crucial to institute appropriate therapy and then to avert a possible negative outcome. We planned this study to evaluate the diagnostic value of presepsin, its sensitivity and specificity for diagnosing sepsis in critically ill patients, and its ability to prognosticate the outcome of sepsis. Methods: In this prospective observational study, adult patients admitted to the intensive care unit (ICU) at our institute were screened, and those with features suggestive of sepsis were recruited into the study. Procalcitonin (PCT) and presepsin were assessed on the day of admission and day 7 of the ICU stay, apart from routine investigations. Patients were followed for outcome in terms of mortality till 28 days. Results: The study comprised 82 patients who satisfied the inclusion criteria. Presepsin sensitivity for sepsis diagnosis was determined to be 78%, while that of PCT was determined to be 69%. This gave a combined sensitivity of presepsin and PCT of 93% when used in parallel for the diagnosis of sepsis. Conclusion: A combination of PCT and presepsin provides higher sensitivity and can be used to screen for sepsis in the ICU. How to cite this article: Roy S, Kothari N, Sharma A, Goyal S, Sankanagoudar S, Bhatia PK, et al. Comparison of Diagnostic Accuracy of Presepsin and Procalcitonin for Sepsis in Critically Ill Patients: A Prospective Observational Study. Indian J Crit Care Med 2023;27(4):289-293.

Anesthetic challenges for pheochromocytoma surgery in pediatric patients: A case series.

Pheochromocytoma in children is an exceptionally uncommon cause of hypertension in this age group. These tumors pose a significant threat of adverse cardiovascular events during the perioperative phase. In this article, we describe three cases of pediatric pheochromocytoma to shed light on the difficulties associated with administering anesthesia to patients with this condition. The foundations for successful perioperative outcomes include preoperative blood pressure control, extensive intraoperative hemodynamic evaluation, and appropriate coordination with surgeons.

Assessment of the use and Safety of Protection Box for Intubation and Extubation Among Anaesthesiologists During COVID-19 Pandemic- A Cross-sectional Survey.

Introduction: Covid 19 epidemic has affected the people making them undergo emergency procedures requiring intubation. A protective box was innovated at our tertiary care centre to safeguard the HCW during intubation and/or extubation and the study was planned to assess its use and safety among the anaesthesiologists. Methods: A cross sectional, questionnaire base survey was done among anaesthesiologists in various strata of residency. The intubation box was used on the patient for intubation and extubation. The experience of participants was recorded via a Google Form and one response per participant was restricted. Participants were divided into two groups, Group 1(1stand 2nd year junior residents) and Group 2 (Senior resident and 3rd year junior resident). A valid response, was received from 25 anaesthesiologists who were either performing or assisting the intubation. The residents were evaluated based on the ease of use and safety features of the box. Results: There was a significant difference in the time taken to intubate between the two groups (p = 0.048) and it was found that Group 2 with more experience took less time to intubate than Group 1. Also, more respondents in Group 2 found it easier to manoeuvre the hands to handle instruments than Group 1(p = 0.024). Conclusion: We recommend that usage of intubation box during intubation or extubation is a non-harmful and necessary compromise that we must make to protect the /safeguard the well-being of Health Care Worker without affecting patient care in our fight with COVID-19. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03692-7.

Comparison of novel anteroposterior short-axis in-plane technique with conventional short-axis out-of-plane technique for ultrasound-guided internal jugular vein cannulation: A randomized-controlled trial.

OBJECTIVES: Various ultrasound (US)-guided probe positioning and needle procedures have been described in the literature for cannulation of the internal jugular vein (IJV). In the present study, we compared the conventional short-axis out-of-plane (SAX-OOP) method with a novel anteroposterior short-axis in-plane (APSAX-IP) technique for IJV cannulation under US guidance. The APSAX-IP method of IJV cannulation has not been compared to other IJV cannulation techniques. METHODS: A total of 104 patients above 18-year-old were randomly allocated to one of two groups - APSAX-IP or SAX-OOP and evaluated for US-guided IJV cannulation in either the operating room or critical care unit. The primary outcome of this research was the access time for IJV cannulation using both approaches. The secondary outcomes were the number of attempts of needle insertion, success rate, and complications of IJV cannulation. RESULTS: The access time for IJV cannulation was 13.0 (12.0-15.0) sec in the APSAX-IP group and 13.0 (12.0-14.0) sec in the SAX-OOP group; P = 0.947. The number of successful 1st attempts was 90.91%, and the 2nd attempts were 9.09% in the APSAX-IP group and 85.19% and 14.81% in the SAX-OOP group, respectively. Both techniques did not have any complications. CONCLUSIONS: We conclude that the US-guided APSAX-IP IJV cannulation method has comparable access time to the SAX-OOP technique.

A randomized controlled trial comparing ultrasound-guided versus traditional palpatory methods of posterior tibial artery cannulation in adult patients.

BACKGROUND: The palpation method of posterior tibial artery cannulation has not yet been compared to ultrasound-guided posterior tibial artery cannulation in adults. This research examined whether using ultrasound to cannulate the posterior tibial artery enhances first-pass cannulation success and lowers total procedure time. METHODS: In this randomized controlled experiment, 76 adult patients were included who were undergoing surgery under general anesthesia and required artery cannulation. Cannulation of the posterior tibial artery was performed utilizing either an ultrasound-assisted method (group U) or a palpation method (group P). Data were analyzed for cannulation success on the first attempt, number of cannulation attempts, assessment time, cannulation time, and total procedure time. RESULTS: The P group had a considerably shorter mean assessment time than the U group [14.29 ± 2.79 s vs 20.89 ± 2.70 s; p < .001]. Moreover, cannulation time was substantially longer in the P (29.20 ± 12.60 s) than in the U group (15.90 ± 6.50 s) (p < .001). The total procedure time remained statistically more in the P group than in the U group (p = 0.007). The rate of successful posterior tibial artery cannulation on the first attempt was comparable between the two groups (63.2% in the U and 55.3% in the P group, respectively; p = .484)]. CONCLUSIONS: The posterior tibial artery may be a suitable alternative to arterial cannulation for individuals with multiple failed attempts or difficult access. The application of ultrasound during posterior tibial artery cannulation in adult patients is safe and feasible and accompanied by a reduction in cannulation and total procedure time. The rate of first-attempt successful posterior tibial artery cannulation was comparable between the two groups.

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension.

BACKGROUND: Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. METHODS: One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. RESULTS: Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p = 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p = 0.615). CONCLUSIONS: Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Nasogastric tube insertion using conventional versus bubble technique for its confirmation in anesthetized patients: a prospective randomized study.

BACKGROUND: Nasogastric tube insertion and confirmation of its position can be difficult in the anesthetized patient. The purpose of the present study was to compare the bubble technique with the conventional method for confirmation of nasogastric tube placement in these patients. METHODS: Two hundred sixty adult patients, aged between 20...70 years, posted for surgeries requiring general anesthesia, tracheal intubation, and a nasogastric tube were enrolled in this study. Patients were randomized into 2 groups: Group B (Bubble group) and Group C (Control group). In Group C, a conventional technique using a lubricated nasogastric tube was positioned through the nostril with head remained neutral. In Group B, 2% lidocaine jelly was added to the proximal end to form a single bubble. The correct placement of the nasogastric tube in the stomach was confirmed by fluoroscopy by an independent observer intraoperatively. RESULTS: The duration of nasogastric tube insertion was 57.2..13.3seconds in Group B and 59.8..11.9seconds in Group C (p=0.111). The confirmation rate of the bubble technique was 76.8% (95% CI: 68.7...83.3), which was significantly better than the conventional method where the confirmation rate was 59.7% (95% CI 50.9...67.9), p<0.001. When compared to fluoroscopy, bubble technique was found to have a sensitivity of 92.3% (95% CI: 85.6...96.1) with specificity of 81.0% (95% CI: 60.0...92.3), positive predictive value of 96.0% (95% CI: 90.2...98.4), and a moderate negative predictive value of 68.0% (95% CI: 48.4...82.8). CONCLUSIONS: The bubble technique of nasogastric tube insertion has a higher confirmation rate in comparison to the conventional technique. TRIAL REGISTRY NUMBER: Clinical Trial Registry of India (CTRI/2018/09/015864).

Nasogastric tube insertion using conventional versus bubble technique for its confirmation in anesthetized patients: a prospective randomized study

Abstract Background: Nasogastric tube insertion and confirmation of its position can be difficult in the anesthetized patient. The purpose of the present study was to compare the bubble technique with the conventional method for confirmation of nasogastric tube placement in these patients. Methods: Two hundred sixty adult patients, aged between 20-70 years, posted for surgeries requiring general anesthesia, tracheal intubation, and a nasogastric tube were enrolled in this study. Patients were randomized into 2 groups: Group B (Bubble group) and Group C (Control group). In Group C, a conventional technique using a lubricated nasogastric tube was positioned through the nostril with head remained neutral. In Group B, 2% lidocaine jelly was added to the proximal end to form a single bubble. The correct placement of the nasogastric tube in the stomach was confirmed by fluoroscopy by an independent observer intraoperatively. Results: The duration of nasogastric tube insertion was 57.2 ± 13.3seconds in Group B and 59.8 ± 11.9seconds in Group C (p = 0.111). The confirmation rate of the bubble technique was 76.8% (95% CI: 68.7-83.3), which was significantly better than the conventional method where the confirmation rate was 59.7% (95% CI 50.9-67.9), p< 0.001. When compared to fluoroscopy, bubble technique was found to have a sensitivity of 92.3% (95% CI: 85.6-96.1) with specificity of 81.0% (95% CI: 60.0-92.3), positive predictive value of 96.0% (95% CI: 90.2-98.4), and a moderate negative predictive value of 68.0% (95% CI: 48.4-82.8). Conclusions: The bubble technique of nasogastric tube insertion has a higher confirmation rate in comparison to the conventional technique. Trial Registry Number: Clinical Trial Registry of India (CTRI/2018/09/015864).

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension

Abstract Background Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. Methods One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. Results Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p= 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p= 0.615). Conclusions Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.