Effects of aged garlic extract on blood pressure in hypertensive patients: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: There is no consensus based on the existing literature regarding the effect of aged garlic extract (AGE) on blood pressure. The present systematic review and meta-analysis was conducted to synthesize existing data from randomized clinical trials (RCTs) concerning the impact of AGE supplementation on blood pressure in hypertensive patients. METHODS: We searched English web databases including, PubMed, Scopus, Embase, Web of Science until August 2024. Random-effects meta-analysis was used to pool weighted mean differences (WMD) and 95 % CI for the outcomes. RESULTS: Overall, nine RCTs with584 participants met inclusion criteria. AGE tea supplementation reduces systolic blood pressure (SBP) (WMD: -4.03; %95CI: -6.87, -1.20; I2: 57.1 %) and diastolic blood pressure (DBP) (WMD: -1.44; 95 % CI= -2.87, -0.02; P = 0.052; I2: 36.8 %; P: 0.105). Moreover, subgroup analysis indicated that higher doses of AGE supplementation in hypertensive patients significantly decreased DBP, and SBP. CONCLUSION: The results of this study suggest that AGE supplements may be beneficial for improving blood pressure in hypertensive patients, but significant effects are observed only at doses over 1200 mg/day. To confirm these results, well-designed future trials will be needed.

Box-Behnken Design for Mitigation of Cadmium Bivalent Ions from Aqueous Medium.

Statistical analysis is essential for minimizing the time, cost, and number of experiments needed to get the maximum output. In this work, the removal of cadmium bivalent (Cd (II)) ions was optimized using Box-Behnken design methodology. The effects of pH, concentration, time, and temperature were investigated for the removal of cadmium. Maximum removal (85.70 %) was achieved at pH of 5.34, initial Cd(II) ions concentration 46.61,contact time 166.09 (min), and at 59.40 °C temperature on Punica Granatum carpellary membrane powder (PGCMP) and 88.61 % removal was achieved on its modified forms (MPGCMP) at pH of 5.79, initial Cd(II) ions concentration 65.70,contact time 178.96, and at 59.91 °C temperature. The model was validated by analyzing variance (ANOVA). The practical data was well fitted to the quadratic model. PGCMP and MPGCMP were found to be naturally occurring, environmentally friendly adsorbents for the mitigation of Cd (II) ions as well as other toxic heavy metals from drinkable or wastewater.

Author Response: Shifting Paradigms in Vascular Access: A Deep Dive into the Supraclavicular Approach's Uncharted Waters.

How to cite this article: Jaiswal P, Chhabra PH, Saini S. Author Response: Shifting Paradigms in Vascular Access: A Deep Dive into the Supraclavicular Approach's Uncharted Waters. Indian J Crit Care Med 2024;28(6):624.

Subclavian Vein Cannulation via Supraclavicular or Infraclavicular Route Which is Better? A Prospective Randomized Controlled Trial.

Background and objectives: The subclavian vein is frequently cannulated using ultrasound. There are two techniques of subclavian vein catheterization (SVC): Supraclavicular (SC) and infraclavicular (IC). Though the IC route is often preferred, the SC approach offers several distinct advantages. This study was planned to compare the technique of SVC using SC and IC approaches in terms of catheterization technique and complications in elective surgeries in adults. Methods: Sixty American Society of Anesthesiologists (ASA) 1, 2, or 3 adult patients posted for elective surgeries under general anesthesia were recruited. Patients were divided into SC or IC groups randomly. Right-sided subclavian vein was cannulated in both the groups (n = 30). Visualization time, Likert scale, subclavian vein diameter, skin-to-subclavian vein depth, number of attempts, puncture time, ease of guidewire insertion, catheter insertion time, and total procedural time were observed. A comparison of complications for each approach was noted. Results: Total procedural time, time to visualization of the subclavian vein, and puncture time was lower for group SC and higher for group IC. Catheter insertion time was higher with the IC approach than with the SC approach. Better ultrasound view scores were seen in group SC than in group IC. The first attempt success rate was higher in group SC than in group IC. Comparatively, lower complications both during and after the procedure were noted in the SC approach than the IC approach. Conclusion: Ultrasonography (USG) guidance guided SC approach to access the subclavian vein is quicker, relatively secure, and a better technique than the IC approach. Additionally, the SC approach is associated with comparatively fewer immediate and delayed complications. How to cite this article: Jaiswal P, Saini S, Chhabra PH. Subclavian Vein Cannulation via Supraclavicular or Infraclavicular Route Which is Better? A Prospective Randomized Controlled Trial. Indian J Crit Care Med 2024;28(4):375-380.

Airway management in maxillofacial trauma.

Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios.

An Update on Initial Epidemiological Profile, Clinical Course, and Outcome of COVID-19 Patients at a Tertiary Care Center in India.

BACKGROUND AND AIM: Coronavirus disease 2019 (COVID-19) has become a global pandemic with the spectrum of disease from asymptomatic or mild disease to severe cases requiring intensive care unit (ICU) admission. In India, it started with milder presentation affecting younger population. Later on, an increase in disease severity was observed involving older age group as well. However, there is a paucity of published data regarding patients requiring ICU care in India. This case series describes the initial experience of an ICU in India regarding epidemiological profile, clinical course, and outcome of critically ill COVID-19 patients. METHODS: This case series included 27 consecutive laboratory-confirmed COVID-19 patients who were admitted in a tertiary care ICU over 14 days period, followed up till their discharge from ICU. Demographic and clinical data, including laboratory and radiological findings, were compiled with special attention to co-morbidities of the patients. The management of these patients was done as per the institutional protocol for critically ill COVID-19 patients. RESULTS: The median age of the patients was 50 years with no difference in gender. Comorbid conditions were seen in 85% of the patients with diabetes (43.7%) and hypertension (37.5%) as the most common conditions. The median duration of symptoms before admission was 6 days with fever as the most common clinical symptom at presentation. Chest roentogram showed bilateral lung infiltrates in 88.8% of the patients. Mild, moderate, and severe hypoxia were observed in 3, 8, and 16 patients, respectively. Ten patients were managed with oxygen therapy. Seventeen patients (62.9%) required ventilatory support. Mortality rate among patients admitted to our ICU was 59.2%. CONCLUSIONS: This case series shows middle-aged patients with comorbid diseases present with severe COVID-19 disease and have poor outcome.

Comparative diagnostic evaluation of OMP31 gene based TaqMan® real-time PCR assay with visual LAMP assay and indirect ELISA for caprine brucellosis.

Brucellosis is one of the leading causes of abortion in domestic animals that imposes costs on both economy and society. The disease is highly zoonotic and poses risk to animal handlers due to its zoonotic nature. It causes stillbirth, loss of kids and abortion in last term of pregnancy. Reproductive damage includes infertility in does and orchitis and epididymitis in breeding bucks, which result in high financial losses to farmers and the agriculture industry as a whole. It requires highly sensitive and specific assays to diagnose the disease at field level. In the current study, a visual loop-mediated isothermal amplification (LAMP) assay and the TaqMan® real-time PCR were developed with high sensitivity and specificity. For the TaqMan® probe, real-time PCR primers were developed using Omp31 gene as target and primers were designed using discontiguous conserved sequences of Omp31 gene. The Omp31 probes were designed by attaching 6-FAM reporter dye at the 5' end and BHQ-1 quencher at the 3' end. Published primers were used for visual LAMP assay targeting the Omp25 gene. Sensitivity of the standardized visual LAMP assay and TaqMan® real-time PCR assay was determined by serial dilution of positive Brucella melitensis DNA (102 to 10-4 ng) obtained from standard culture. The TaqMan® probe real-time assay can detect as low as 100 fg of B. melitensis DNA, whereas culture from vaginal swab washings has a limit of detection (LOD) of only 1 cfu/ml. Similarly, the visual LAMP assay can detect as low as 10 fg of B. melitensis DNA as compared to an LOD of 30 cfu/ml from culture of vaginal swab washings. Both assays were compared with serological tests (serum tube agglutination test (STAT) and indirect enzyme-linked immunosorbent assay (iELISA)) for diagnostic sensitivity and specificity. Diagnostic sensitivities and specificities for TaqMan® real-time PCR vs. LAMP assays were 98 and 100% vs. 100 and 97.8%, respectively. Results of visual LAMP assay indicated that LAMP is a fast, specific, sensitive, inexpensive and suitable method for diagnosis of B. melitensis infection under field conditions. On the other hand, Omp31 TaqMan® probe real-time assay can be used in conjunction with the other field-based diagnostic tests due to its high specificity.

Comparative evaluation of blind supraglottic airway device insertion versus videolaryngoscope-guided technique in adults undergoing laparoscopic cholecystectomy.

OBJECTIVES: A videolaryngoscope may decrease the high incidence of aberrant positioning of supraglottic airway devices (SAD) inserted with blind techniques. We aimed to compare Igel insertion characteristics between blind and videolaryngoscope-assisted techniques. METHODS: In this study 70 adult patients scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomly divided into blind (Group B, n = 35) and videolaryngoscope-guided (Group V, n = 35) Igel insertion. Oropharyngeal leak pressure (OLP), fiber-optic view score, time for device insertion, first attempt success, ease of insertion, ventilation score, maneuvers, and adverse events were assessed. RESULTS: OLP was significantly higher in group V at 1 and 10 minutes (24.80 ± 1.91 vs 21.71 ± 2.37; p < 0.001 and 32.60 ± 2.32 vs 30.68 ± 2.93; p = 0.006). The mean fiberoptic scoring (3.63 ± 0.49 vs 3.38 ± 0.49; p = 0.043), a fibreoptic score of grade 4 (24 vs 13; p = 0.012) and time-to-device insertion (25.6 ± 3.5 vs 21.7 ± 4.1; p < 0.001) was considerably higher in group V. First-attempt success (p = 0.630), ease of insertion of SAD (p = 0.540) and nasogastric tube (p = 1), ventilation score (p = 1), number of maneuvers required (p = 1), number of attempts (p = 0.592) and postoperative complications (p = 0.800) were comparable in the two groups. CONCLUSION: The videolaryngoscope-guided technique provided superior airway sealing and reduced malposition of Igel without an increase in adverse events compared to the blind technique. However, this was at the cost of increased time of device insertion. CLINICAL TRIAL REGISTRATION: www.ctri.nic.in identifier is CTRI/2022/10/046269.

Comparison of analgesic efficacy of combined external oblique intercostal and rectus sheath block with local infiltration analgesia at port site in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: Conventional fascial plane block approaches for upper abdominal surgeries spare the lateral cutaneous nerve. An external oblique intercostal block (EOIB) may be suitable for upper abdominal incisions as it blocks the lateral and anterior branches of the intercostal nerves T6-T10. However, there is a paucity of studies evaluating this block in clinical settings. The study aimed to compare the analgesic efficacy of combined EOIB and rectus sheath block with local infiltration analgesia (LIA) in laparoscopic cholecystectomy (LC). METHODS: After obtaining written informed consent, 70 patients were randomly allocated to undergo right-sided EOIB with 20 ml and left-sided RSB with 10 ml of 0.25% bupivacaine at the end of surgery (group ER, n = 35). Patients in the LIA group (n = 35) underwent local infiltration at the port site using 20 ml of the same solution (group LIA, n=35). RESULTS: The visual analog scale scores with combined EOI and RSB were significantly lower than those with LIA at 1, 2, 4, 8, and 12 h (P < 0.001). Rescue analgesics were required by 65.7% and 14.3% of the patients in the LIA and block groups, respectively (P < 0.001). The time to first rescue analgesic was significantly greater in the ER group than that in the LIA group (2.8 ± 1.10 vs. 1.6 ± 0.50 h; P = 0.012). The number of times rescue analgesia was required was significantly lower in the ER group than that in the LIA group (1.00 ± 0.00 vs. 1.83 ± 0.72; P = 0.015). Nausea and vomiting scores were higher in the LIA group than those in the ER group (P < 0.001). Patient satisfaction scores were higher in the ER group than those in the LIA group. CONCLUSIONS: EOIB combined with RSB provides superior analgesia compared with LIA and should be considered for LC.

Evaluation of the Analgesic Efficacy of Surgically Assisted Linea Semilunaris Block for Post-operative Analgesia in Patients Undergoing Caesarean Section Under Spinal Anaesthesia.

BACKGROUND: Post-operative pain following a caesarean section has been described as moderate to severe. If left untreated, the pain has a negative impact on maternal recovery and psychology. Surgically assisted linea semilunaris anterior abdominal block has been proposed to be an efficacious analgesic modality in such cases. AIM: The study aims to evaluate the efficacy of post-operative analgesia provided by linea semilunaris block in patients undergoing caesarean section under spinal anaesthesia. METHODS: Eighty parturients planned for elective caesarean section under spinal anaesthesia were randomised into two groups. In group B, a surgically assisted Linea semilunaris anterior abdominal block was given bilaterally after the closure of the uterine incision using 20 mL of 0.375% ropivacaine with 1:200,000 adrenaline. For group C, conventional analgesia protocols were followed in the post-op period. Inj. paracetamol 1 g i.v. was routinely administered, and inj. tramadol 50 mg i.v. was given as a rescue analgesic in both groups. The primary outcome of the present study was the total amount of rescue analgesia consumed over 24 hours. Secondary outcomes included resting and dynamic pain scores [Numerical Rating Scale (NRS)], time to first rescue analgesia, quality of sleep, and patient satisfaction using the Likert scale. RESULTS: The mean total amount of rescue analgesia consumed over 24 hours was significantly higher in group C (150.00 ± 0.00) than in group B (125.75 ± 25.32); p = 0.001. The mean NRS at 2, 4, 12, and 24 hours was significantly higher in group B than in group C. The time to first rescue analgesia was longer in group B, with better sleep quality, patient satisfaction, and fewer complications. CONCLUSION: The linea semilunaris block provided effective analgesia and can be considered an alternative analgesic modality to other conventional abdominal wall blocks for post-caesarean pain relief.

Comparison of analgesic efficacy of shoulder block versus interscalene block for postoperative analgesia in arthroscopic shoulder surgeries: A randomised trial.

BACKGROUND AND AIMS: Arthroscopic orthopaedic surgery may lead to significant postoperative pain. Interscalene block (ISB) is associated with undesirable effects like phrenic nerve palsy. Shoulder block (ShB) is a relatively recent diaphragm sparing alternative for analgesia in these cases. METHODS: This prospective randomised trial was conducted in 70 adult patients posted for arthroscopic Bankart repair surgery. Patients were randomly assigned into two groups: interscalene block [Group ISB (n = 35): 0.5% bupivacaine 10 ml] or shoulder block [Group ShB (n = 35): 0.5% bupivacaine (suprascapular block 10 ml and axillary block 10 ml)] using ultrasound and nerve stimulator. The primary aim of our study was to compare the ISB with ShB for visual analogue score (VAS) in recovery area (zero hour). Time for block performance, VAS, time to first rescue analgesia, total analgesic requirement, patient satisfaction and complications were recorded. RESULTS: VAS was significantly higher in ShB group at 2 and 4 h (P = 0.001 and 0.000) while it was significantly higher in ISB group at 12 h (P = 0.013). The time to first analgesic request was significantly prolonged in ISB group as compared to ShB group (8.22 h vs. 4.69 h; P = 0.002) but total analgesic requirement and patient satisfaction at 24 h were similar. Complications like dyspnoea, ptosis and motor weakness were seen only with ISB group. CONCLUSION: Both ShB and ISB blocks have similar efficacy in terms of postoperative pain scores, cumulative analgesic requirements and patient satisfaction. However, considering the various undesirable effects associated with ISB, like phrenic nerve blockade, prolonged upper limb weakness and the occurrence of rebound pain, shoulder block may be preferred for arthroscopic shoulder surgeries.

Comparison of Analgesic Efficacy of Ultrasound-Guided Interscalene Block Versus Continuous Subacromial Infusion for Postoperative Analgesia Following Arthroscopic Rotator Cuff Repair Surgeries: A Randomized Trial.

BACKGROUND: Arthroscopic rotator cuff repair surgery may lead to significant postoperative pain. Interscalene block (ISB) is an effective analgesic technique in these surgeries but there is a risk of the phrenic blockade. Subacromial local anesthetic infiltration is a phrenic sparing alternative technique for postoperative analgesia. The primary aim of our study was to compare the ISB with a continuous subacromial infusion (SAC) with regard to postoperative analgesia. METHODS:  This prospective randomized, interventional parallel arm trial was conducted in 60 ASA grade I and II, adult patients (30 patients in each group) posted for arthroscopic rotator cuff repair surgery. Patients were randomly assigned to receive either ultrasound-guided ISB (Group ISB: 15 ml of 0.75% ropivacaine) or continuous SAC (Group SAC: 15 ml 0.75% ropivacaine as a subacromial injection by ultrasound guidance and infusion of 3 ml/hour of 0.5% ropivacaine through the catheter placed subacromial by the surgeon). Intraoperative hemodynamic parameters, visual analog scores (VAS), and rescue analgesic requirements for 24 hours, patient satisfaction, and complications were recorded. RESULTS: Rescue analgesic requirement was significantly higher in SAC at zero hours (P=0.000), while it was significantly higher in ISB at 12 hours (P=0.02). The VAS scores were comparable at all time points and patient satisfaction at 24 hours was similar. None of the patients had rated satisfaction related to pain relief as poor in any group. Complications like ptosis and motor weakness were seen only with ISB. CONCLUSION: Both the techniques provided effective analgesia and comparable patient satisfaction with lesser incidence of complications in the SAC group. ISB provided more effective immediate postoperative pain relief while SAC was more effective in delayed analgesia for arthroscopic rotator cuff repair surgeries. SAC can be considered a reasonably safe alternative to ISB in patients with contraindications to the latter.

Adsorption of bivalent lead ions from an aqueous phase system: Equilibrium, thermodynamic, kinetics, and optimization studies.

Punica granatum carpellary membrane powder (PGCM) and its surface modified form (MPGCM) with 2,4-dinitrophenylhydrazine (2,4-DNP) were used as adsorbents for removal of bivalent lead ions from aqueous phase system. Batch mode experiments using various parameters were carried out to assess the adsorption isotherms and dynamics of the process. Langmuir isotherm was well-fitted model for experimental data. Langmuir adsorption capacity using PGCM and MPGCM at pH of 7 was found to be 169.49 and 196.07 mg/g, respectively. Rate constant and thermodynamic parameters were calculated to evaluate the kinetic model and temperature dependence nature of adsorption. Box-Behnken design was applied to optimize the adsorption process of bivalent lead ions for PGCM and MPGCM using pH (3.0-9.0), initial bivalent lead ions concentration (20-100 mg/L), contact time (20-180 min), and temperature (20-60°C) parameters. The optimum conditions for maximum removal of bivalent lead ions on PGCM were found to be at pH of 6.99, initial bivalent lead ions concentration of 98.95, contact time of 176.05, and temperature of 21.20°C and on MPGCM at pH of 6.51, initial bivalent lead ions concentration of 99.99, contact time of 177.89, and temperature of 20.02°C, respectively. PRACTITIONER POINTS: Adsorption of bivalent lead from water using Punica granatum carpellary membrane powder and its modified form MPGCM is discussed. Batch mode experiments using various parameters were carried out to assess the adsorption isotherms and dynamics of the process. Langmuir adsorption capacity using PGCM and MPGCM at pH of 7 was found to be 169.49 and 196.07 mg/g, respectively. Box-Behnken design was applied to optimize the adsorption process of bivalent lead ions.

Comparison of Two Different Volumes of Ropivacaine Used in Nerve Stimulator Guided Inter-scalene Block for Arthroscopic Shoulder Surgery - A Randomized Controlled Trial.

BACKGROUND: This study was conducted to compare the analgesic efficacy of 10 ml versus 20 mL of 0.5% ropivacaine in nerve stimulator guided interscalene brachial plexus block, in patients undergoing arthroscopic shoulder surgery. METHODS: A total of 70 American Society of Anesthesiologists physical status classes 1 and 2 patients, aged 18-65 years, undergoing unilateral arthroscopic shoulder surgery, were randomized into two groups. Group A received single shot inter-scalene block with 20 mL of 0.5% ropivacaine whereas Group B received the same with 10 mL. The primary outcome was difference in the total postoperative fentanyl consumption over 24 h. Secondary outcomes were difference in block onset, intra-operative hemodynamic parameters, intra-operative fentanyl consumption, duration of effective analgesia, visual analogue scale (VAS) scores at various time intervals, duration of motor block, and incidence of hemidiaphragmatic (HD) palsy. RESULTS: Total 24 h fentanyl consumption was significantly higher in Group B (558 ± 112 mcg) compared to Group A (296 ± 88 µg). Block onset was slower in Group B than Group A. There was no difference in intra-operative fentanyl consumption. Postoperative VAS scores were significantly higher in Group B compared to Group A, at 6 h and thereafter. Duration of motor block was significantly shorter in Group B (6.25 ± 1.25 h) compared to Group A. HD palsy was seen in all the cases in both the groups. CONCLUSION: Single shot nerve stimulator guided interscalene block with 10 ml of 0.5% ropivacaine was inferior to 20 mL of 0.5% ropivacaine with respect to postoperative analgesic efficacy.

Infantile Cystic Hygroma: An Unusual Perioperative Course.

Airway management of an infant with a giant cervical lump may be a difficult task. The anesthesiologist must be prepared to face associated challenges during securing the airway in such patients. We report our experience with One year old infant who presented with huge cystic hygroma in the cervical region leading to recurrent episodes of respiratory tract infection and distress. Surgical removal was needed as sclerotherapy proved ineffective in reducing its size. Proseal laryngeal mask airway was used as a conduit after inhalational induction since airway could not be maintained with bag and mask. The child was tracheostomized postoperatively and also had a prolonged Intensive Care Unit stay. Difficulties encountered in intubation and postoperative management of this child are discussed in this report.

Cervical Vagal Schwannoma: Anesthetic Concerns.

Schwannomas arising from cervical vagus nerve is an extremely rare benign neoplasm. The majority of patients present with insidiously growing lateral neck mass without neurological deficit. We report a case of symptomatic cervical vagal nerve schwannoma in a 32-year-old female. Complete surgical resection is the treatment of choice. However, anesthetic management of these tumors can be challenging. We describe here the complications experienced during the management of the patient.

Congenital Lobar Emphysema: Anaesthetic Challenges and Review of Literature.

Congenital Lobar Emphysema (CLE) is a developmental anomaly, characterized by hyperinflation of one or more pulmonary lobes. It presents in infancy with variable degree of respiratory distress due to compression atelectasis. It is most often associated with mediastinal shift with subsequent hypoxia. CLE poses a diagnostic and therapeutic dilemma. We report a case of five-month-old infant of CLE requiring left lobectomy, who was previously being treated for pneumonia which was unresponsive to medical therapy. Anaesthetic challenges experienced during the case and a brief review of literature is presented.