Comparison of weight-based and pinna size method for ProSeal laryngeal mask airway size selection in children receiving general anesthesia: A randomized clinical study.

Background and Aims: Several methods are in use for LMA ProSeal™ size selection in pediatric patients. Weight-based method is most commonly used. Pinna size-based method is a promising new technique for accurate size selection. Material and Methods: A total of 146 children aged between 6 months and 12 years undergoing surgery under general surgery were included. They were randomized into either pinna-based group (group X) or weight-based group (group Y). Both groups were compared for accurate placement of ProSeal™ laryngeal mask airway (PLMA), ease of insertion, number of attempts needed, and peak airway pressures. Results: A Comparable number of patients had a Brimacombe score of 3 and above, indicating correct placement in both groups (P = 0.407). PLMA was easily inserted in 79.5% and 87.7% of patients of groups X and Y, respectively (P = 0.180). Insertion was found to be difficult in 20.5% of patients in group X, whereas it was difficult in only 12.3% of patients of group Y (P = 0.180). The two groups were comparable as per the number of attempts needed for insertion (P = 0.161). Mean peak airway pressures too were comparable between both groups. Ease of insertion too, was statistically insignificant between both groups. Conclusions: Pinna size-based estimation of LMA size is an effective alternative method to weight-based selection.

Prevalence of Frailty in ICU and its Impact on Patients' Outcomes.

Introduction: Frailty describes a state or syndrome of reduced physical, physiologic, and cognitive reserve that increases vulnerability to acute illness. To study the prevalence of frailty in critically ill patients and find its association with resource utilization and short-term intensive care unit (ICU) outcomes. Material and methods: This was a prospective observational study. All adult patients ≥50 years admitted to the ICU were included and frailty was assessed by the clinical frailty score (CFS). Data were collected on demography, coexisting illness, CFS, Acute Physiology and Chronic Health Evaluation II (APACHE-II), and Sequential Organ Failure Assessment Score (SOFA) scores. Patients were followed for 30 days. Outcome data were collected on organ supports provided, duration of ICU and hospital length of stay (LOS), and ICU and 30-day mortality. Results: 137 patients were enrolled in the study. The prevalence of frailty was 38.6%. Frail patients were older and had a more comorbid illness. APACHE-II and SOFA scores were 22.1 ± 7.0 and 7.2 ± 3.29, significantly higher in frail patients, respectively. There was a trend towards higher requirement for organ supports in frail patients. Median ICU and hospital LOS were 8 vs 6 and 20 vs 12 (frail vs nonfrail) days, respectively (p < 0.05). Intensive care unit mortality in frail and nonfrail patients was 28.3% and 23.8%, respectively (p = 0.56). Thirty-day mortality in frail patients was 49%, significantly higher compared with nonfrail patients (28.5%). Conclusion: The prevalence of frailty in ICU patients was high. Frail patients were quite ill on ICU admission, and they had a prolonged ICU and hospital LOS. Increasing frailty score was associated with higher mortality at 30 days. How to cite this article: Kalaiselvan MS, Yadav A, Kaur R, Menon A, Wasnik S. Prevalence of Frailty in ICU and its Impact on Patients' Outcomes. Indian J Crit Care Med 2023;27(5):335-341.

Comparison of hematologic abnormalities between hospitalized coronavirus disease 2019 positive and negative patients with correlation to disease severity and outcome.

Peripheral blood smear (PBS) changes in coronavirus disease 2019 (COVID-19) are diverse and have been reported in the literature in the form of case series with relatively smaller sample sizes and with a handful of studies showing the association between PBS and clinical severity. This study aims to highlight the numerical and morphological changes in peripheral blood of COVID-19 patients and to compare the same in intensive care unit (ICU) and non-ICU settings as well as with disease severity and outcome. The study included 80 COVID-19 positive (41 ICU and 39 non-ICU) patients and 32 COVID-19 negative ICU patients. Complete blood counts (CBCs) and PBS findings were studied and scored by two pathologists blindfolded. Absolute lymphocyte count (ALC) and absolute eosinophil count (AEC) were significantly lower in COVID-19 positive cases as compared to the COVID-19 negative group (p = 0.001 and p = 0.001). COVID-19 positive group showed significant left myeloid shift (p = 0.021), Dohle bodies (p = 0.025) with significant prominence of acquired pseudo-Pelger-Huët anomaly, ring-shaped neutrophils, monolobate neutrophils, and plasmacytoid lymphocytes as compared to control group (p = 0.000, p = 0.009, p = 0.046, and p = 0.011, respectively). The overall mean white blood cell (WBC) counts were higher in COVID-19 positive ICU patients as compared to non-ICU COVID patients with significant shift to left, presence of ring-shaped neutrophils, monocyte vacuolation, and large granular lymphocytes (p = 0.017, p = 0.007, p = 0.008, and p = 0.004, respectively). Deceased group showed significantly higher WBC count (p = 0.018) with marked neutrophilia (p = 0.024) and toxic granulation (p = 0.01) with prominence of monocyte vacuolization, ring-shaped neutrophils, large granular lymphocytes, and reactive lymphocytes. Parameters like myeloid left shift, ring-shaped neutrophils, monocyte vacuolation, and large granular lymphocytes emerged as highly sensitive markers of disease severity. Therefore, serial CBC with comprehensive PBS analysis should be done in every newly diagnosed hospitalized COVID-19 patient which potentially predicts the course of the disease.

Intraoperative mandibular nerve block with peripheral nerve stimulator for temporomandibular joint ankylosis.

We describe the use of peripheral nerve stimulator for mandibular nerve block intraoperatively in a 4.5year old child with complete temporomandibular joint ankyloses. The block was not possible preoperatively, therefore, it was administered after release of ankyloses. The use of peripheral nerve stimulator increased the chances of a successful block. No intraoperative analgesics and muscle relaxants were required. Postoperative pain relief was excellent. Peripheral nerve stimulator is an easy way of for accurate needle tip placement for mandibular nerve block in patients with distorted anatomy.

Peri-operative concerns in a patient with thyroid storm secondary to molar pregnancy.

Awareness of the presence of thyroid function abnormalities in patients with molar pregnancy is important for its prompt diagnosis and management. We report the development of thyroid storm in the immediate post-operative period in a 25-year-old female who underwent evacuation of her molar pregnancy under saddle spinal block after being controlled for her thyrotoxicosis with a combination of antithyroid drugs, iodine, steroids and adrenergic blocking agents. We advocate the use of esmolol infusions up to a maximum dose of 200 µg/kg/min for immediate haemodynamic management of the patient. Optimum time needed for stabilisation of the hyper metabolic state after initiation of antithyroid drugs is still not known and evacuation of molar pregnancy remains the only definitive management of the thyrotoxic state.

Management of bronchial carcinoid: An anaesthetic challenge.

Carcinoid tumours pose a great challenge to anaesthesiologist, especially if carcinoid syndrome is present. We report peri-operative management of a patient with carcinoid syndrome who underwent upper lobectomy. Pre-operative optimisation for 10 days before surgery with injection octreotide and administration on the day of surgery as per guidelines was followed (North American Neuroendocrine Tumour Society guidelines). Our main goals were to prevent mediator release, avoidance of triggering factors and management of peri-operative carcinoid crisis. During tumour handling patient developed carcinoid crisis which was effectively treated with intravenous bolus octreotide and increasing rate of infusion.

Pneumothorax during laparoscopic repair of giant paraesophageal hernia.

Giant paraesophageal hernia is an uncommon morbid disorder which may present a risk of catastrophic complications and should be repaired electively as soon as possible. Laparoscopic fundoplication is the mainstay of surgical management of this disorder due to several advantages such as lower post-operative morbidity and pain. We report a case of a 70-year-old patient with a giant paraesophageal hernia, who developed subcutaneous emphysema with pneumothorax during laparoscopic fundoplication. Early diagnosis was possible by close clinical evaluation and simultaneous monitoring of end-tidal carbon dioxide levels and airway pressures. Although positive end-expiratory pressure application is an effective way of managing pneumothorax secondary to the passage of gas into the interpleural space, insertion of an intercostal drain may be used in an emergent situation.

Comparative evaluation of different doses of propofol preceded by fentanyl on intubating conditions and pressor response during tracheal intubation without muscle relaxants.

BACKGROUND: The aim of our study was to determine the optimal dose of propofol preceded by fentanyl for successful tracheal intubation and to see its effectiveness in blunting pressor response in children aged 3-10 years. METHODS: This prospective, double blind, randomized study was conducted on 60 ASA grade I and II children, between 3 and 10 years undergoing elective surgery who were divided into three groups of 20 each. The children received different doses of propofol (group I, 2.5 mg x kg(-1); group II, 3.0 mg x kg(-1); group III, 3.5 mg x kg(-1)) preceded by a fixed dose of fentanyl (3.0 microg x kg(-1)) 3 min earlier. The tracheal intubating conditions were graded based on scoring system devised by Helbo-Hensen et al. with Steyn modification which includes five criteria; ease of laryngoscopy, degree of coughing, position of vocal cords, jaw relaxation, and limb movement and graded on a 4-point scale. Heart rate (HR), mean arterial pressure (MAP), and oxygen saturation changes were also noted. RESULTS: Tracheal intubating conditions were acceptable in 25% of the patients in group I, while significantly higher (P < 0.001) in group II (80%) and in group III (90%). The pressor response was not effectively blunted in group I (17% increase in HR), while effectively blunted in groups II and III. A fall in cardiac output was seen in group III indicated by a decrease in MAP (16%) and HR (11%). No airway complications were noted. CONCLUSIONS: Propofol 3 mg x kg(-1) (group II) preceded by fentanyl 3 microg x kg(-1) is the optimal dose combination in our study. It provides acceptable intubating conditions in 80% patients, blunts pressor response to intubation without significant cardiovascular depression.