Is there an optimal place for holding the tracheal tube during intubation? A proof-of-concept randomised clinical trial.

BACKGROUND: The optimal way to hold an endotracheal tube (ETT) during intubation has not been studied. In this randomised clinical trial, we examined the effect of site-holding the ETT in two different positions on time and ease of intubation by anaesthesia trainees. METHODS: A single-centre, randomised trial of intubations of stable patients with uncomplicated airways was conducted from 15 September 2019 to 31 May 2021 in the All India Institute of Medical Sciences, Bhubaneswar, India. A previous pilot study performed in the unit determined the comparator positions for the ETT and the sample size for a 20% difference for the primary outcome of mean time to intubation (TTI). Patients were randomised at the time of the intubation; anaesthesia trainees held the ETT at 19 or 24 cm according to the patient's assignment. Video recordings of intubations were independently reviewed by two assessors blinded to the assignment. Secondary outcomes were intubation success, ease of intubation and complications. Intention-to-treat and per-protocol analyses were performed. RESULTS: 360 adults were randomised (180/arm) and intubated by 19 trainees. In intention-to-treat analysis, there was no significant difference in TTI. Sixteen times, trainees assigned to hold the ETT at 24 cm moved their grip distally (closer to the cuff) during the procedure. In a per-protocol analysis, TTI for those whose grip remained at 24 cm was shorter than those holding at 19 cm: 6.6 (SD 3.0) vs 7.6 (SD 4.2) s (95% CI for the difference 0.2 to 1.7 s), p=0.01. In both intention-to-treat and per-protocol analyses, there was no difference in first-pass success or ease of intubation between techniques. Eight patients assigned to 19 cm group and four assigned to 24 cm developed sore throats. CONCLUSION: In stable patients with uncomplicated airways, there was no significant difference in TTI based on the site at which trainees were assigned to hold the ETT. However, the shorter TTI at 24 cm in per-protocol analysis and fewer sore throat observed suggest this practice change warrants further investigation. TRIAL REGISTRATION NUMBER: CTRI/ 2019/09/021201.

Problems and solutions to conduct of thesis of postgraduate medical students during the COVID-19 pandemic: an insight into the students perspective.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has adversely impacted medical education worldwide. However, its impact on the postgraduate medical thesis and dissertation work is still not evaluated. Through this study, we planned to find out the problems brought by the pandemic and likely alternatives and possible solutions to thrust the academic competence of postgraduate students. METHODS: After obtaining institutional ethics committee approval, we sent a 13-item questionnaire to postgraduate medical students in India via various social media online platforms. Data on the impact of the COVID-19 pandemic on thesis work and alternatives/solutions to improve the research competence were collected on a Likert scale and analyzed. RESULTS: We received a total of 398 responses out of which 377 entries were included for final analysis. The majority of participants (88%) reportedly had an adverse impact on the thesis work and out of 25% of the participants who recently submitted their around 45% had to do so without achieving the estimated sample size. The 6-month departmental review for thesis progress was seen in merely 28% of participants. Possible alternatives suggested were the maintenance of log books, task-based assessment of research methodology, departmental audits, and systematic reviews. Solutions suggested for improving the research competence of students were a compulsory research methodology curriculum, a biostatistics department in each institution, permission to conduct thesis work beyond submission time, exclusive time for research work, and financial incentives. CONCLUSION: Modification in the research aspect of the current postgraduate medical education is the need of the hour and the pandemic has enlightened us regarding the current weaknesses.

Perioperative Management of Pediatric Brain Tumors: A Retrospective Analysis.

Background: Brain tumors are the second most common malignancy in childhood and the surgical excision remains the cornerstone of management. The objective of this study was to analyze the factors associated with the length of intensive care unit (ICU) and hospital stay, and postoperative outcome in such children. Materials and Methods: Three years of data were collected, retrospectively, by detailed review of medical records pertaining to pre-anesthetic evaluation and perioperative course of children less than 16 years of age who underwent excision of intracranial tumors. Results: One hundred sixty-eight medical records were analyzed. One third of the children were found to have developed various intraoperative adverse events; the most common were hemodynamic changes following brainstem handling and brain swelling. 58% of children required postoperative mechanical ventilation. 82.7% of patients had favorable neurologic outcome which was comparable between the two tumor locations (supratentorial vs infratentorial). On multivariate analysis, re-exploration surgery and electrolyte disturbances, such as serum sodium, were found to be the independent risk factors affecting hospital stay. The amount of intraoperative blood loss and postoperative pulmonary complications (POPCs) were independent risk factors affecting the neurologic outcome. Conclusions: Adverse events are fairly common after excision of brain tumors in children. Intraoperative complications did not affect the ICU stay or neurological outcome; however, the postoperative complications increased length of ICU and hospital stays. POPC was the single most important factor responsible for poor neurologic outcome and was more so in children who underwent infratentorial surgery, prolonged mechanical ventilation, and who had a lower cranial nerve palsy.

Effect of Goal-Directed Intraoperative Fluid Therapy on Duration of Hospital Stay and Postoperative Complications in Patients Undergoing Excision of Large Supratentorial Tumors.

Background: Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Materials and Methods: Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. Results: The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. Conclusions: This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. Clinical Trial Registry: CTRI/2016/10/007350.

A Systematic Review and Meta-Analysis of Efficacy of Ultrasound-Guided Single-Shot Quadratus Lumborum Block for Postoperative Analgesia in Adults Following Total Hip Arthroplasty.

STUDY OBJECTIVE: To evaluate the efficacy of ultrasound-guided single-shot quadratus lumborum block (QLB) for postoperative analgesia in adults following total hip arthroplasty (THA). DESIGN: Systematic review and meta-analysis. SETTING: Perioperative period. PATIENTS: Adult patients undergoing THA. METHODS: Studies were identified by performing searches in the following electronic databases, PubMed (Medline), Cochrane Central Registry of Trials (CENTRAL), and Google Scholar. We sought studies in adult patients undergoing THA, comparing QLB with a control group (no block, sham block or any other ultrasound guided regional nerve blocks). A total of 774 patients from 10 studies (7 randomized controlled, one controlled clinical and two retrospective study) were included in this meta-analysis. MAIN RESULTS: The 24 hour opioid consumption was similar in both the groups (WMD -4.09; 95% CI [-9.00, 0.83]; P = 0.10; I2 = 95%). The pain scores at rest at 24 hours was significantly less in QLB group (WMD -0.62; 95% CI [-1.15, -0.10]; P = 0.02; I2 = 75%). The difference in pain scores was however not clinically significant. The pain scores on movement at 24 hours, time to first analgesic request, and time to discharge from hospital were similar in both the groups. CONCLUSIONS: QLB as part of multimodal analgesia did not result in any significant analgesic benefits in patients undergoing hip arthroplasty in terms of either postoperative opioid consumption or pain scores at rest and on movement. Overall, the level of certainty is low. Further, well-designed trials are required to verify the results.

Multidisciplinary management of solitary hypervascular metastatic recurrence of renal cell carcinoma presenting with pathological femoral fracture.

Renal cell carcinoma (RCC) frequently presents with osseous metastasis, predominantly lytic and prone to pathological fracture. The metastatic lesion in the extremity presents with local swelling, pain and immobility due to pathological fracture. The solitary or oligometastatic lesions should be treated with curative intent, which can help the patient to lead a more prolonged and disability-free life. The RCCs and their metastases are hypervascular with an exuberant arterial supply. Surgery can lead to uncontrolled life-threatening haemorrhage. Preoperative transarterial embolisation reduces tumour vascularity significantly and reduces intraoperative blood loss. We present a 46-year-old male patient with solitary hypervascular metastatic recurrence of RCC with a pathological femoral fracture with an infeasible initial surgery due to profuse haemorrhage. He was successfully treated by preoperative transarterial embolisation, followed by surgical resection and implantation of a megaprosthesis. Multidisciplinary management reduces patient morbidity and mortality with successful treatment in solitary hypervascular metastasis from RCC.

Is there an optimal place to hold the endotracheal tube during direct laryngoscopy for patients undergoing surgery under general anesthesia? Protocol for a randomized controlled trial.

BACKGROUND: Endotracheal intubation by direct laryngoscopy is a widely performed lifesaving technique. Although there are guidelines for optimal size and depth of insertion of an endotracheal tube (ETT) for successful intubation, there is no consensus on the point at which it should be held along its length. This will arguably affect the time, ease, and success of the technique due to a difference in visualization and torque applied to the ETT after glottic visualization. We aim to compare the effect of 2 different sites of holding the ETT on time to intubation (TTI), intubation difficulty scale (IDS), and complications. METHODS: ASA 1-2 patients (>18 years) posted for surgery under general anesthesia, undergoing supervised intubation by anesthesia trainees (experience < 18 months), will be included. Patients with an anticipated difficult airway or unanticipated difficulty-CL grade 3 or 4 requiring the use of airway adjuncts-will be excluded. Patients will be randomized by a computer-generated number list, and allocation concealed with opaque sealed envelopes. The two sites for holding the ETT will be group 1 at 19 cm and group 2 at 24 cm. ETT marked at the selected site will be handed by the technician once the optimum position of the table, patient, and laryngoscopic view is confirmed by the intubator. The entire procedure will be video recorded. Two blinded assessors will independently review the videos to document the time to intubation and intubation difficulty score. A postoperative sore throat will be recorded. SAMPLE SIZE: To detect a 20% difference in time to intubation between groups with a significance level of 5% and power of 85%, we will need a total of 298 patients. Accounting for data loss, we plan to recruit 180 patients in each group. DISCUSSION: This will be the first study to assess whether the site of holding the tube has any impact on the ease and time taken for intubation. The findings of this study will provide scientific evidence for suggesting an appropriate place for holding the ETT during direct laryngoscopy procedures. TRIAL REGISTRATION: Clinical Trials Registry India CTRI/2019/09/021201.

A Rare Case of Epileptic Seizure After-effect Resulting in Nontraumatic Spontaneous Subdural Hemorrhage.

Generalized tonic-clonic seizures (GTCS) result in diverse physiological alterations that are mostly short-lived and rarely lead to immediate serious consequences. Some early serious complications reported are head trauma and aspiration. While most cases of seizures are diagnosed readily from clinical history, some cases remain indolent and present later. A brain hemorrhage can have varied manifestations that warrant every clinician to be vigilant in diagnosis and management to prevent life-threatening complications. Furthermore, many reports have described seizures in patients operated for subdural hematoma (SDH), but to the best of our knowledge, none reveals SDH after the seizure. We encountered an unexpected incident of severe SDH in a 32-year-old adult following witnessed GTCS. HOW TO CITE THIS ARTICLE: Singh S, Kaushal A, Datta R, Unnithan RR, Mishra N. A Rare Case of Epileptic Seizure After-effect Resulting in Nontraumatic Spontaneous Subdural Hemorrhage. Indian J Crit Care Med 2020;24(8):722-723.

Effect of Pregabalin on Postcraniotomy Pain in Patients Undergoing Supratentorial Tumor Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial.

Background and Objectives Suboptimal management of postcraniotomy pain causes sympathetic and hemodynamic perturbations, leading to deleterious effects on the neurological system and overall patient outcome. Opioids are the mainstay of postoperative pain management but have various problems when given in high doses, or for prolonged durations in neurosurgical patients. The ideal method of pain control following craniotomy generally relies on a combination of various drugs. Oral pregabalin may be an attractive alternative in these patients. Materials and Methods Sixty, American Society of Anesthesiologists class I and II patients posted for elective supratentorial craniotomy, aged 18 and 60 years, were randomly assigned into three groups of 20 each to receive oral placebo (Group A), pregabalin 75 mg (Group B), or pregabalin 150 mg (Group C) before the induction of anesthesia. At the end of the surgery, patient-controlled analgesia was started with intravenous fentanyl. Visual analog scale (VAS) score was recorded every 2 hours for 24 hours, along with total postoperative fentanyl requirement. Results There were no differences in sex, duration of surgery or anesthesia and total intraoperative fentanyl administered among the three groups. The median postoperative VAS score (Group A-18.0, Group B-20, and Group C-22.0; p = 0.63) was similar in all the groups. However, postoperative fentanyl requirement over 24 hours was least in the group that received 150 mg pregabalin (Group A-190 µg, Group B-240 µg, and Group C-100 µg; p = 0.03). Conclusions Even though pain scores were not significantly different, patients receiving 150 mg oral pregabalin required the least amount of postoperative opioids.

Comparative evaluation of intraoperative use of normal saline, Ringer's lactate, and combination of normal saline and Ringer's lactate in neurosurgical patients - A preliminary randomized clinical trial.

BACKGROUND: Fluid management during intracranial surgery is an important concern. The type of fluid used can have biochemical and metabolic effects during intraoperative management. However, it is yet to be known whether biochemical and metabolic effects have an influence on the clinical outcome of a patient. OBJECTIVE: A prospective evaluation of the effects of normal saline (NS), Ringer's lactate (RL), and a combination of NS and RL on the biochemical, metabolic, and clinical outcomes in patients undergoing intracranial tumor surgery was carried out. MATERIALS AND METHODS: Ninety patients undergoing elective intracranial tumor surgery were randomized to receive NS, RL, or a combination of NS and RL. The biochemical and metabolic parameters were studied at different time points in the intraoperative and postoperative period. The hemodynamic parameters, brain relaxation score at the time of bone flap elevation, postoperative complications, and the duration of hospital stay were the clinical outcome variables of our study. RESULTS: The use of NS was associated with hyperchloremic metabolic acidosis and ionic hypocalcemia. RL caused significant hyponatremia and increase in serum lactate levels. The combination of NS and RL has least influence on biochemical and metabolic parameters. The effects of three fluids were similar on the hemodynamics, brain relaxation score, as well as on postoperative complications and the duration of postoperative hospital stay. CONCLUSION: There are variable effects of NS, RL, or its combination on the biochemical and metabolic parameters in patients undergoing intracranial tumor surgery. However, the clinical outcome of the patients remains similar.