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BACKGROUND: Although both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are used for analgesia in acute pancreatitis (AP), the analgesic of choice is not known. We compared buprenorphine, an opioid, and diclofenac, an NSAID, for analgesia in AP. METHODS: In a double-blind randomized controlled trial, AP patients were randomized to receive intravenous diclofenac or intravenous buprenorphine. Fentanyl was used as rescue analgesia, delivered through a patient-controlled analgesia pump. Primary outcome was the difference in the dose of rescue fentanyl required. Secondary outcomes were the number of effective and ineffective demands of rescue fentanyl, pain-free interval, reduction in visual analogue scale (VAS) score, adverse events, and organ failure development. RESULTS: Twenty-four patients were randomized to diclofenac and 24 to buprenorphine. The 2 groups were matched at baseline. The total amount of rescue fentanyl required was significantly lower in the buprenorphine group:130 µg, interquartile range (IQR), 80-255 vs 520 µg, IQR, 380-1065 (P < .001). The number of total demands was 32 (IQR, 21-69) in the diclofenac arm vs 8 (IQR, 4-15) in the buprenorphine arm (P < .001). The buprenorphine group had more prolonged pain-free interval (20 vs 4 hours; P < .001), with greater reduction in the VAS score at 24, 48, and 72 hours compared with the diclofenac group. These findings were confirmed in the subgroup of moderately severe/severe pancreatitis. Adverse events profile was similar in the 2 groups. CONCLUSIONS: Compared with diclofenac, buprenorphine appears to be more effective and equally safe for pain management in AP patients, even in the subcohort of moderately severe or severe pancreatitis (Trial Registration number: CTRI/2020/07/026914).
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Buprenorfina , Pancreatite , Humanos , Diclofenaco/efeitos adversos , Buprenorfina/efeitos adversos , Manejo da Dor , Doença Aguda , Pancreatite/complicações , Pancreatite/tratamento farmacológico , Pancreatite/induzido quimicamente , Anti-Inflamatórios não Esteroides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Dor/etiologia , Dor/induzido quimicamente , Fentanila/efeitos adversos , Método Duplo-CegoRESUMO
BACKGROUND: Preoperative anxiety leads to adverse clinical outcomes and long-term maladaptive behavioural changes. The role of intranasal atomised dexmedetomidine and atomised ketamine as premedication to produce sedation and anxiolysis in paediatric neurosurgical patients has not been extensively studied. OBJECTIVE: To study the efficacy of intranasal atomised dexmedetomidine and intranasal atomised ketamine as premedication in producing sedation and facilitating smooth induction in children undergoing spinal dysraphism surgery. DESIGN: A prospective randomised double-blind trial. SETTING: A tertiary teaching hospital. PATIENTS: Sixty-four children aged 1 to 10âyears undergoing spinal dysraphism surgery. METHODS: Children were randomised to receive intranasal atomised dexmedetomidine 2.5 µg kg -1 (Group D, n â=â32) and intranasal atomised ketamine 5 mg kg -1 (Group K, n â=â32) 30 min before surgery. OUTCOMES MEASURED: The primary outcome was to compare the level of sedation in both groups using the University of Michigan Sedation Score (UMSS). The secondary outcomes included an assessment of the ease of parental separation, intravenous cannulation and satisfactory mask acceptance along with perioperative vitals (heart rate, blood pressure and oxygen saturation). The incidence of emergence agitation and time to discharge were also noted. RESULTS: The degree of sedation was significantly better in Group D as compared to Group K at 20âmin (UMSS, 1.55â±â0.51 versus 1.13â±â0.34, difference, -0.406; 95% CI, -0.621 to -0.191; P â=â0.0001) and 30âmin (2.32â±â0.6 versus 1.94â±â0.50, difference, -0.374; 95% CI, -0.650 to -0.100; P â=â0.007). The ease of parental separation, venous cannulation and mask acceptance ( P â=â0.83, 0.418 and 0.100 respectively) were comparable in both groups. The heart rate was lower in group D at 10, 20 and 30âmin post-drug administration but was clinically insignificant. The incidence of emergence agitation and time to discharge was also similar with no adverse events reported. CONCLUSION: Intranasal atomised dexmedetomidine produces greater sedation as compared to intranasal atomised ketamine with comparable ease of parental separation, venous cannulation and mask acceptance with no adverse effects.
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Dexmedetomidina , Delírio do Despertar , Cardiopatias Congênitas , Ketamina , Defeitos do Tubo Neural , Disrafismo Espinal , Criança , Humanos , Analgésicos , Pré-Medicação , Estudos Prospectivos , Lactente , Pré-EscolarRESUMO
PURPOSE: Regardless of the positive attributes of propofol, it is frequently associated with pain on injection. We compared the efficacy of topical cold thermotherapy using an ice gel pack with intravenous lignocaine pre-treatment for reducing pain on propofol injection. METHODS: This single-blinded randomized controlled trial was conducted in 200 American Society of Anesthesiologists physical status I, II, and III patients scheduled for elective/emergency surgery under general anesthesia. The patients were randomized into two groups: the Thermotherapy group- receiving an ice gel pack proximal to the intravenous cannula for 1 min, or the Lignocaine group-receiving 0.5 mg/kg of lignocaine administered intravenously, with occlusion proximal to the site of the intravenous cannula for 30 s. The primary objective was to compare the overall incidence of pain after propofol injection. The secondary objectives included the incidence of discomfort on the application of an ice gel pack, comparison of dose of propofol needed for induction, and hemodynamic changes at induction, between the two groups. RESULTS: Fourteen patients in the lignocaine group and 15 patients in the thermotherapy group reported pain. The incidence of pain and the distribution of pain scores were comparable among groups (p = 1.00). Patients of the lignocaine group required significantly less amount of propofol for induction as compared to the thermotherapy group (p = 0.001). CONCLUSION: Topical thermotherapy using an ice gel pack was not found superior to lignocaine pre-treatment in alleviating pain on injection of propofol injection. However, topical cold therapy using an ice pack remains a non-pharmacological technique that is easily available, reproducible, and cost-effective. Further studies are required to prove its equivalence to lignocaine pre-treatment. TRIAL REGISTRATION: CTRI (CTRI/2021/04/032950).
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Propofol , Humanos , Propofol/efeitos adversos , Lidocaína/uso terapêutico , Gelo , Método Duplo-Cego , Dor/etiologia , Dor/prevenção & controle , Dor/tratamento farmacológico , Injeções IntravenosasRESUMO
Background and Aims: Prediction of outcome in intensive care unit (ICU) patients is of imperative importance. Our aim was to assess and compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE IV scores in predicting mortality in adult patients suffering from septic shock admitted to our ICU. Material and Methods: This was a prospective observational study conducted in a 14-bedded medical ICU of a tertiary care center from January 2019 to March 2020; 128 patients suffering from septic shock were included and APACHE II and IV scores were calculated. We also calculated the predicted and actual mortality rates and standardized mortality ratios. The receiver operating characteristic curves were used to assess discrimination. Results: Out of the 128 patients, 63 patients (49.21%) died. The mean (± standard deviation) admission APACHE II score was 16.7 ± 5.53, while the mean APACHE IV score was 67.25 ± 25.99. The non-survivors had significantly higher APACHE II and IV scores when compared to those who survived (P < 0.001). APACHE II had a slightly better discriminative power (with the area under the Receiver operating characteristic (ROC) curve of 0.78) than APACHE IV (with the area under the ROC curve of 0.74). The mean predicted mortality rate (PMR) of the patient population calculated on the basis of the APACHE II scoring system was 22.46 ± 15.76, and the mean PMR calculated as per the APACHE IV scoring system was 11.64 ± 15.59. Conclusion: Both APACHE II and APACHE IV underestimated mortality in septic shock patients. Both APACHE II and APACHE IV were comparable in differentiating survivors from non-survivors. However, there was a good correlation between the two models.
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With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker's while two had epiphrenic diverticulum. The median symptom duration was 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280 days (range 98-330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.
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Divertículo Esofágico , Divertículo , Miotomia , Idoso , Divertículo Esofágico/cirurgia , Humanos , Masculino , Miotomia/efeitos adversos , Miotomia/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: Percutaneous nephrolithotomy and placement of nephrostomy tube are performed for renal stones >2 cm in diameter. Attempts have been made to infiltrate local anesthetics with or without adjuvants into the surgical site to reduce pain. We hypothesized that there would be a significant prolongation of the analgesic effect of local anesthetic instillation along the nephrostomy tube due to the adjuvant dexamethasone. METHODS: After ethical approval and Clinical Trials Registry - India registration (CTRI/2020/03/024332), 64 American Society of Anesthesiologists classification 1 and 2 adult patients were enrolled in this randomized double-blinded prospective study divided into Group R-received 20 mL 0.2% Ropivacaine and Group R + D-received 20 mL 0.2% Ropivacaine with dexamethasone 8 mg, injected through a multi-lumen wound infiltration catheter. RESULTS: The demographic profile of patients was similar in both groups. The mean duration of analgesia was longer in Group R + D (21.3 ± 2.1 hrs) versus Group R (10 ± 1.9 hrs, P = 0.001). The mean numeric rating scale scores of Group R + D were significantly lower at all time intervals (P = 0.001). Also, the cumulative dose of ropivacaine and the total use of fentanyl postoperatively in Group R was much higher (70 ± 10.4 vs 56 ± 8.9 µg, P = 0.02). The C-reactive protein levels were significantly lower in Group R + D (13.8 ± 1.5 vs 23.1 ± 1.2 mg/L, P = 0.001 and 16.5 ± 1.3 vs 28.5 ± 1.7 mg/L, P = 0.001, at 24 and 48 hrs, respectively). CONCLUSION: We conclude that dexamethasone can be used as a suitable adjuvant to intermittent local anesthetic infiltration after percutaneous nephrolithotomy with a nephrostomy tube for the prolongation of analgesia.
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Analgesia , Nefrolitotomia Percutânea , Adulto , Amidas , Anestésicos Locais , Dexametasona , Método Duplo-Cego , Humanos , Nefrolitotomia Percutânea/efeitos adversos , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , RopivacainaRESUMO
Re-expansion pulmonary edema (RPE) is a rare complication that may occur after treatment of lung collapse caused by pneumothorax, atelectasis, or pleural effusion. The amount of fluid drained and the degree of pleural suction influence the development of RPE. We present a case of RPE in a critically ill patient of scrub typhus with rheumatic heart disease, after draining only 800 mL of pleural fluid, thereby proving that the complex cardiac and pulmonary interactions play an important role in the development of RPE. How to cite this article: Khanoria R, Chauhan R, Sarna R, Bloria S. Re-expansion Pulmonary Edema-A Rare Entity: A Thin Line between Pulmonary and Cardiac Decompensation. Indian J Crit Care Med 2021;25(3):343-345.
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Acalasia Esofágica , Miotomia , Cirurgia Endoscópica por Orifício Natural , Humanos , Acalasia Esofágica/cirurgia , Cárdia/cirurgia , Esofagoscopia , Esfíncter Esofágico Inferior/cirurgia , Miotomia/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Resultado do TratamentoRESUMO
HIV/AIDS has been an extremely difficult pandemic to control. However, with the advent of antiretroviral therapy (ART), HIV has now been transformed into a chronic illness in patients who have continued treatment access and excellent long-term adherence. Existing indications for ART initiation in asymptomatic patients were based on CD4 levels; however, recent evidence has broken the shackles of CD4 levels. Early initiation of ART in HIV patients irrespective of CD4 counts can have profound positive impact on morbidity and mortality. Early initiation of ART has been found not only beneficial for patients but also to community as it reduces the risk of transmission. There have been few financial concerns about providing ART to all HIV-positive people but various studies have proven that early initiation of ART not only proves to be cost-effective but also contributes to economic and social growth of community. A novel multidisciplinary approach with early initiation and availability of ART at its heart can turn the tide in our favor in future. Effective preexposure prophylaxis and postexposure prophylaxis can also lower transmission risk of HIV in community. New understanding of HIV pathogenesis is opening new vistas to cure and prevention. Various promising candidate vaccines and drugs are undergoing aggressive clinical trials, raising optimism for an ever-elusive cure for HIV. This review describes various facets of tectonic shift in management of HIV.
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BACKGROUND: Sexual dysfunction significantly affects interpersonal relationships and overall quality of life. It remains a matter of concern for risk assessment and counseling in patients with ruptured intracranial aneurysms. OBJECTIVE: To assess the sexual dysfunctions in patients undergoing clipping for ruptured intracranial aneurysms and comparative evaluation among different anterior circulation aneurysms. METHOD: We prospectively included 40 male patients of ruptured intracranial aneurysms of anterior circulation (age range: 20-60 years; sexually active preoperatively), managed with craniotomy and clipping. We evaluated the sexual outcome in patients with excellent Glasgow outcome score (GOS) five at a minimum one year of follow-up. Patients with GOS-5 status at follow-up were broadly classified into two groups: Anterior communicating artery aneurysm (Acom), and non-Acom) aneurysms. We valued sexual outcome with Subjective Sexual Arousal Scale for Men at follow-up, and compared in the two groups. RESULTS: Mean age of patients was 44.78 ± 9.51 years. Besides 20 Acom aneurysms, other groups included 11 middle cerebral artery aneurysms, five internal carotid artery aneurysms, three posterior communicating artery aneurysms, and one distal anterior cerebral artery aneurysm. The mean follow-up was 24.45 ± 13.58 months. Patients with non-Acom aneurysms had an overall better outcome in the sexual performance domain "P = 0.015," mental satisfaction domain "P = 0.009," and sexual assertiveness domain "P = 0.007." However, there was no statistical difference in partner communication domain "P = 0.593," and partner relationship domain "P = 0.378." Overall, the sexual outcome was inferior in patients treated for Acom aneurysms compared to other anterior circulation aneurysms. CONCLUSIONS: In cases of aneurysmal subarachnoid hemorrhage, sexual dysfunctions are common even after good clinical outcomes. The study revealed prominent differences in outcomes on the sexual quality of life in patients harboring Acom aneurysms as compared to anterior circulation aneurysms located off-midline.
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Aneurisma Roto , Doenças das Artérias Carótidas , Aneurisma Intracraniano , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Qualidade de Vida , Aneurisma Roto/complicações , Aneurisma Roto/cirurgia , CraniotomiaRESUMO
INTRODUCTION: With the introduction of transcatheter aortic valve implantation (TAVI), endovascular abdominal aortic aneurysm repair (EVAR), thoracic endovascular aortic aneurysm repair (TEVAR), and frequent use of left ventricular assist devices in complicated percutaneous coronary interventions, the use of large bore arterial access has become a necessity. In the index study, we compared the percutaneous closure of large arteriotomies with open surgical (OS) closure. METHODS: It was a prospective study in which we compared the technical success and vascular complication rate associated with the use of a suture-based vascular closure device (VCD): Perclose ProGlide (PP) with that of OS closure. The study was carried out at Command Hospital Air Force, Bengaluru, India, from January 1, 2016, to December 31, 2020. The inclusion criteria were any percutaneous intervention involving large bore arterial access (≥12 French (F) sheath). The exclusion criteria were any condition where a persistent need for vascular access at the end of the procedure was required. We noted the baseline characteristics and type of anesthesia for all patients. The primary outcome was technical success and major vascular complications, which included major local site bleeding: Bleeding Academic Research Consortium (BARC) 3 or more, failed hemostasis requiring a second intervention, and acute vessel occlusion. Total time taken for the procedure (TTP), time to ambulation (TTA), and time to discharge post-procedure (TTD) were noted for each patient. The secondary outcomes were any bleeding other than major, local hematoma sized >5 cm at 24 hours, pseudo aneurysm formation at 30 days, and acute limb ischemia at 30 days. RESULTS: A total of 120 patients (PP: 60 (males: 54, females: 6), OS: 60 (males: 50, females: 10)) were included in this study. The mean age of patients was comparable in both groups (PP: 71.8 ± 9.62 years and OS: 71.0 ± 7.76 years, p-value: 0.63). Total large arteriotomies (mean size: 18.03F ± 3.34) closed were 184 (PP: 90, OS: 94). The procedures performed were EVAR: 64 (PP: 30, OS: 34), TAVI: 38 (PP: 21, OS: 17), and TEVAR: 18 (PP: 9, OS: 9). All patients in PP group received dual ProGlide with preclose technique. All TEVAR procedures (total arteriotomies: 18) required a vascular sheath of ≥ 24F. There was no statistical difference between the mean size of sheaths used in the two groups. The technical success (PP: 95.55%, OS: 97.87%, 95% CI: -5.78%-10.98%, p-value: 0.48) and rate of major complications were similar in both groups. Three patients in the PP group who had failed hemostasis with two ProGlides were successfully managed with one additional Angioseal (6F) each. The occurrence of hematoma sized larger than 5 cm was significantly more in the PP group compared to the OS group (PP: 7 (7.78%), OS: 0 (0%), p-value: 0.006). While GA was used for all patients who underwent vascular closure with OS, only eight patients (13.33%) in the PP group required GA. The TTP, TTA, and TTD were significantly lower in the PP group as compared to the OS group. CONCLUSION: The percutaneous closure of large bore arteriotomies with suture-based VCDs is equally effective and is not associated with increased major vascular complications. In fact, the TTP, TTA, and TTD are significantly lower in the PP group which can translate to better patient comfort and lower costs.