A comprehensive, bed-side scoring system to predict difficult lumbar puncture.

Background and Aims: Spinal anesthesia (SA) is the most widely practiced neuraxial anesthesia. Lumbar puncture (LP) at multiple levels and multiple attempts due to any reason may cause discomfort and even serious complications. Hence the study was conducted to evaluate the patient variables that can predict difficult LP thus allowing for the use of alternate techniques. Material and Methods: We included 200 patients of ASA physical status I-II, scheduled to undergo elective infra-umbilical surgical procedures under spinal anesthesia. During preanesthetic evaluation, difficulty score was assessed using the 5 variables: Age, abdominal circumference, spinal deformity - assessed as axial trunk rotation (ATR) value, anatomical spine assessed by spinous process landmark grading system (SLGS) and patient position, by assigning a score of 0- 3 for each variable, with a total score of 0 - 15. The difficulty of LP was graded as easy, moderate or difficult based on total number of attempts and spinal levels by independent experienced investigator. The scores obtained during preanesthetic evaluation and the data collected after performing LP were analyzed using multivariate analysis and P value noted. Results: Our study showed that above patient variables correlated well with difficult LP scoring (P < 0.001). SLGS was noted to be a strong predictor, while ATR value a weak predictor. The correlation between the total score and grades of SA had a positive association (R = 0.6832, P < 0.00001) and was statistically significant. A median difficulty score of 2, 5 and 8 predicted easy, moderate and difficult LP respectively. Conclusion: The scoring system provides for a useful tool to predict difficult LP and helps both patient and anesthesiologist to choose an alternative technique.

Development of a preoperative Early Warning Scoring System to identify highly suspect COVID-19 patients.

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) is spreading at an unprecedented speed. Lack of resources to test every patient scheduled for surgery and false negative test results contribute to considerable stress to anesthesiologists, along with health risks to both caregivers and other patients. The study aimed to develop an early warning screening tool to rapidly detect 'highly suspect' among the patients scheduled for surgery. METHODS: Review of literature was conducted using terms 'coronavirus' OR 'nCoV 2019' OR 'SARS-CoV-2' OR 'COVID-19' AND 'clinical characteristics' in PUBMED and MedRxiv. Suitable articles were analysed for symptoms and investigations commonly found in COVID-19 patients. Additionally, COVID-19 patient's symptomatology and investigation profiles were obtained through a survey from 20 COVID-19 facilities in India. Based on literature evidence and the survey information, an Early Warning Scoring System was developed. RESULTS: Literature search yielded 3737 publications, of which 195 were considered relevant. Of these 195 studies, those already included in the meta-analyses were not considered for independent assessment. Based on the combined data from meta-analyses and survey, risk factors of COVID-19 disease identified were as follows: history of exposure, fever, cough, myalgias, lymphocytopaenia, elevated C-reactive protein (CRP)/lactate dehydrogenase (LDH) and radiographic infiltrates. CONCLUSION: Development of this Early Warning Scoring System for preoperative screening of patients may help in identifying 'highly suspect' COVID-19 patients, alerting the physician and other healthcare workers on the need for adequate personal protection and also to implement necessary measures to prevent cross infection and contamination during the perioperative period.

Comparison of ventilatory efficacy and airway dynamics between ProSeal laryngeal mask airway and endotracheal tube in adult patients during general anesthesia.

BACKGROUND AND AIMS: Studies have demonstrated minimal hemodynamic variation and postoperative complications with ProSeal laryngeal mask airway (PLMA) compared to endotracheal tube (ETT). Hence, a study was conducted to compare the ventilatory parameters and airway dynamics required to maintain normocarbia and stable hemodynamics with PLMA and ETT. MATERIAL AND METHODS: A prospective, randomized, single blinded study was conducted on 60 patients aged 20-40 years of American society of anesthesiologists class I and II, divided into Group PLMA and Group ETT. Standard anesthesia protocol was instituted. Group PLMA received PLMA sizes as per manufacturer's recommendations and group ETT received appropriate sized cuffed ETT. Patients were initially ventilated at 14 bpm, I:E ratio 1:2, tidal volume (Vt) 6 ml/kg and later adjusted to maintain end tidal carbon dioxide (EtCO2) between 35 and 40 mmHg. Peak airway pressure (Ppeak), compliance (Compl.), Vt, airway resistance (Raw), hemodynamic parameters, oxygen saturation (SpO2) and EtCO2 were recorded throughout surgery. Postoperative complications if any, were noted. RESULTS: Demographic parameters, Raw, EtCO2, SpO2 were comparable between groups. Ppeak was lower and Vt needed to maintain EtCO2 of 35-40 mmHg was lesser in Group PLMA. Compl was low for 5 min after insertion of PLMA. Heart rate was significantly reduced at 1 min post insertion; blood pressures were significantly lower upto 2 min after insertion and post removal in group PLMA. Incidence of cough was significantly lower in group PLMA. CONCLUSION: ProSeal laryngeal mask airway maintains adequate ventilation at lower Vts and minimal peak pressures, has lesser hemodynamic variations and lower incidence of postoperative cough compared to ETT.

Effect of intraoperative Dexmedetomidine infusion on Sevoflurane requirement and blood glucose levels during entropy-guided general anesthesia.

BACKGROUND: Dexmedetomidine has been shown to blunt the stress response to surgery. Hence a study was designed to evaluate the effect of intravenous (IV) Dexmedetomidine infusion during general anesthesia for abdominal surgeries on blood glucose levels and on Sevoflurane requirements during anesthesia. MATERIALS AND METHODS: Forty patients scheduled for abdominal surgery under general anesthesia were divided into Dexmedetomidine (D) group and Placebo (P) group of 20 each. Group D received a loading dose of Inj. Dexmedetomidine at 1 µg/kg/10 min diluted to 20 mL, followed by maintenance with 0.5 µg/kg/h., till the end of surgery. Group P received similar volume of IV normal saline. Anesthesia was maintained with nitrous oxide in oxygen and Sevoflurane keeping entropy between 40 and 60. Data were analyzed using students t test, chi square test and Fisher Exact test as applicable. RESULTS: During the first postoperative hour, Dexmedetomidine group showed blood glucose levels of 118.2 ± 16.24 mg/dL, compared to placebo group which was 136.95 ± 19.76 mg/dL and it was statistically significant (P < 0.01). Mean hourly Sevoflurane requirement in Group D was 11.10 ± 2.17 mL, compared to 15.45 ± 3.97 mL in placebo group. In peri-operative period, the heart rate and MAP were significantly lower in Group D, when compared to placebo. Patients in Group D were better sedated and post-operative pain score was better in Group D compared to Group P. CONCLUSION: IV Dexmedetomidine was effective in blunting stress response to surgical trauma as indicated by lower blood glucose levels, and reduces Sevoflurane requirements during entropy guided general anesthesia without affecting time for extubation.

Dissertation writing in post graduate medical education.

A dissertation is a practical exercise that educates students about basics of research methodology, promotes scientific writing and encourages critical thinking. The National Medical Commission (India) regulations make assessment of a dissertation by a minimum of three examiners mandatory. The candidate can appear for the final examination only after acceptance of the dissertation. An important role in a dissertation is that of the guide who has to guide his protégés through the process. This manuscript aims to assist students and guides on the basics of conduct of a dissertation and writing the dissertation. For students who will ultimately become researchers, a dissertation serves as an early exercise. Even for people who may never do research after their degree, a dissertation will help them discern the merits of new treatment options available in literature for the benefit of their patients.

Development and validation of a questionnaire for a survey on perioperative fasting practices in India.

BACKGROUND AND AIMS: Perioperative fasting guidelines have been published and updated to standardise practices. Hence, Indian Society of Anaesthesiologists decided to conduct a survey to assess the fasting practices and the food habits across India, which would be subsequently used for developing preoperative fasting guidelines for the Indian population. We detail and discuss herewith the content validity of the questionnaire developed for the survey. METHODS: Thirty-six questions related to perioperative fasting practices were framed based on the collected evidence and relevance to regional diet and concerns. Subsequently, an information sheet was prepared and sent to 10 experts to grade each question. The responses were tabulated, and item-wise content validity index (I-CVI), scale-wise content validity index (S-CVI) and modified kappa statistic were calculated in Microsoft Excel™ sheet. RESULTS: Seven of the 10 experts completed the assessment and grading as per the instructions provided and submitted a completed proforma. S-CVI for relevance, simplicity, clarity and ambiguity was 0.72, 0.86, 0.72 and 0.72, respectively. S-CVI/average or average congruency percentagewas 0.95, 0.97, 0.95 and 0.95 for relevance, simplicity, clarity and ambiguity, respectively. Question 2 received an I-CVI of 0.71 in terms of clarity and question 23 received an I-CVI of 0.71. They were modified as persuggestions of the experts. CONCLUSION: We conclude that our questionnaire designed to ascertain the preoperative fasting practices for a surveymet the content validity criteria both by qualitative and quantitative analyses.

Consensus statement on anaesthesia for day care surgeries.

The primary aim of day-care surgery units is to allow for early recovery of the patients so that they can return to their familiar 'home' environment; the management hence should be focused towards achieving these ends. The benefits could include a possible reduction in the risk of thromboembolism and hospital-acquired infections. Furthermore, day-care surgery is believed to reduce the average unit cost of treatment by up to 70% as compared to inpatient surgery. With more than 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hence, there is an immense opportunity for expansion in day-care surgery in India to ensure faster and safer, cost-effective patient turnover. For this to happen, there is a need of change in the mindset of all concerned clinicians, surgeons, anaesthesiologists and even the patients. A group of nine senior consultants from various parts of India, a mix of private and government anaesthesiologists, assembled in Mumbai and deliberated and discussed on the various aspects of day-care surgery. They formulated a consensus statement, the first of its kind in the Indian scenario, which can act as a guidance and tool for day-care anaesthesia in India. The statements are derived from the available published evidence in peer-reviewed literature including guidelines of several bodies such as the American Society of Anesthesiologists, British Association of Day Surgery and International Association of Ambulatory Surgery. The authors also offer interpretive comments wherever such evidence is inadequate or contradictory.

Art and science of authorship for biomedical research publication.

Completion of research is logically followed by process of submission of the outcomes for publication. The objective of this article is to sensitise the young potential authors to improve their skill of writing so that the acceptance rate of publication is improved without significant comments and efforts of the editors of the journal. The article is based on the available literature combined with the experience of the author himself as reviewer and editor of biomedical journals. The treatment patterns of clinicians are moving towards evidence-based medical practice. Hence, a clinically relevant research question based on the contemporary knowledge gap is studied using appropriate research methodology. The writers are informed about the criteria to be fulfilled to claim authorship. Finally, emphasis is laid on the essentials of good medical writing necessary for publication. The writing for submission to biomedical journal is both an art and science in itself. A scientifically well-conducted study along with a sound knowledge of the mechanics of writing will enable the novices to achieve better acceptance rate for publication.

Intrathecal dexmedetomidine as adjuvant for spinal anaesthesia for perianal ambulatory surgeries: A randomised double-blind controlled study.

BACKGROUND AND AIM: The newer trend in regional anaesthesia for ambulatory anorectal surgeries advocate use of lower dose of local anaesthetic, providing segmental block with adjuvants such as opioids and α2 agonists to prolong analgesia. The current study investigated effects of addition of 5 µg of dexmedetomidine to 6 mg of hyperbaric bupivacaine on duration of analgesia, sensory and motor block characteristics for perianal ambulatory surgeries. METHODS: This study is a prospective randomised controlled double blind study. Forty adult patients between 18 and 55 years of age were divided into 2 groups. Group D received intrathecal 0.5% hyperbaric bupivacaine 6 mg (1.2 ml) with injection dexmedetomidine 5 µg in 0.5 ml of normal saline and Group N received intrathecal 0.5% hyperbaric bupivacaine 6 mg (1.2 ml) with 0.5 ml of normal saline. The parameters assessed were time to regression of sensory blockade, motor blockade, ambulation, time to void, first administration of analgesic. Statistical analysis was done using appropriate tests. RESULTS: Time for regression of sensory level and time for first administration of analgesic were prolonged in Group D (430.05 ± 89.13 min, 459.8 ± 100.9 min, respectively) in comparison to Group N (301.10 ± 94.86 min, 321.85 ± 95.08 min, respectively). However, the duration of motor blockade, time to ambulation, and time to void were also significantly prolonged in Group D (323.05 ± 54.58 min, 329.55 ± 54.06 min, 422.30 ± 87.59 min) than in Group N (220.10 ± 63.61 min, 221.60 ± 63.84 min, 328.45 ± 113.38 min). CONCLUSION: Intrathecal dexmedetomidine 5 µg added to intrathecal bupivacaine 6 mg as adjuvant may not be suitable for ambulatory perianal surgeries due to prolongation of motor blockade.