Prevalence and risk factors of post-operative nausea and vomiting in a tertiary-care hospital: A cross-sectional observational study.

Background: Post-operative nausea and vomiting (PONV) is an unpleasant and one of the most distressing symptoms for any patient undergoing surgery. The anaesthetist is usually blamed, despite evidence that PONV results from a variety of factors including patient characteristics, anaesthetic techniques, and the type of surgery and post-operative care. This study had been conducted to find out the current prevalence and to assess various risk factors for PONV in the Indian population. Methods: All patients above 18 years undergoing non-cardiac surgery under anaesthesia were selected from the daily operation theatre list by a systematic random sampling method. Koivuranta score was used to predict PONV in first 24 h post-operatively. Results: Prevalence of PONV in the study population was found to be 25.6%. There was association detected between female gender, non-smokers and occurrence of PONV (CI 95%, p ≤ 0.001, 0.005, respectively). PONV was seen to be more common in patients with history of PONV in prior surgeries, in patients who underwent surgery under general anaesthesia and in patients where opioids were used in the post-operative period (95% CI, p ≤ 0.001, 0.001 and 0.001 respectively). General, laparoscopic, abdominal, orthopaedic, obstetric, breast and urological surgeries showed a significant association with occurrence of PONV (95% CI, p ≤ 0.05). Conclusion: Inspite of use of antiemetics (single or dual) being given as part of the institutional protocol, the incidence of PONV was still high. There is a need to update our knowledge regarding newer antiemetics and their inclusion in PONV management guidelines. There is need for further research to study various other possible risk factors which may contribute to occurrence of PONV.

Interplay between Myasthenia Gravis and Severe COVID-19 Infection: The Missing Links.

Singh S, Vashishtha P, Gupta N, Wadke R, Taank P. Interplay between Myasthenia Gravis and Severe COVID-19 Infection: The Missing Links. Indian J Crit Care Med 2022;26(2):248-249.

Tracheal intubation using the Airtraq video laryngoscope vs. Macintosh laryngoscope in patients with anticipated difficult intubation.

Background: Various types of laryngoscopes have been invented to ameliorate the laryngoscopic view of the glottis, in normal and difficult airway, which helps anaesthesiologists to secure the airway during anaesthesia. In this prospective study, we aimed to compare the efficacy of the Airtraq video laryngoscope (AVL) and the Macintosh curved-blade laryngoscope (MBL), by using a common clinical assessment tool in patients with modified Mallampati class III and IV. Methods: A total of 60 patients [group A (AVL) and group M (MBL)] with modified Mallampati class III and IV listed for general anaesthesia were included. Each patient was intubated with either of the laryngoscope based on the group allotted. Time taken for tracheal intubation, grade of visualisation of glottis and need for manoeuvres to optimise the glottic view were compared. Results: The degree of the glottic view during successful intubation attempt was easily appreciated in group A (p < 0.0001). Difference in the requirement of manoeuvres for optimising the laryngeal view/assisting in intubation as assessed by manoeuvre score was easily appreciated in group A (p < 0.010). Rise in heart rate and mean arterial pressure 1 and 2 min after intubation was more in group M than in group A (p < 0.0001). No event of any airway trauma, as evidenced by visible trauma to lips or oral mucosa or blood on laryngoscope, was observed with either of the laryngoscope. Conclusion: The novel AVL provides better intubation conditions with greater ease of intubation, better glottic view and lesser haemodynamic alterations during laryngoscopy than MBL.

Comparative evaluation of nebulized ketamine and its combination with dexmedetomidine as premedication for paediatric patients undergoing surgeries under general anaesthesia.

Background: Various drugs have been endorsed but no standardised premedication protocol exists for paediatric patients. Nebulised form of drug not only results in better patient acceptability but also has improved clinical effectiveness. The present study delineates and evaluates the efficacy and safety of nebulised ketamine and combination of nebulised dexmedetomidine and ketamine for premedication in paediatric patients. Methods: Prospective randomised controlled study was planned in patients, 3-10 years of age, undergoing surgeries. Patients received either nebulised ketamine (2 mg/kg) (group X, n = 23) or dexmedetomidine 1 µg/kg plus ketamine (1 mg/kg) (group Y; n = 24), 30 min before shifting inside the operation theatre. The sedation level, haemodynamic response and ill-effects were recorded for 30 min. Results: The baseline haemodynamic (HR, MAP, RR and SpO2) parameters were normal and comparable in both the groups. There was no significant variation noticed in terms of HR, MAP, RR and SpO2% in either of the groups at 15 min (p < 0.15, p < 0.20, p < 0.85, p < 0.46) and 30 min (p < 0.21, p < 0.97, p < 0.75, p < 0.61) respectively, after receiving premedication. The level of sedation in group Y (score of 4 or less) was found to be better than that achieved by group X patients (p < 0.001). Face mask acceptance was satisfactory in group Y (score of 2 or less) as compared to group X patients (p < 0.001). The parental separation was comparable in both groups (p = 0.46). Conclusion: Nebulisation is a satisfactory method of premedication for children. A combination of nebulised ketamine with a dose of 1 mg/kg and dexmedetomidine with a dose of 1 µg/kg is capable of producing a satisfactory level of sedation in a more effective manner than sedation induced by nebulised ketamine alone (2 mg/kg).

Compare the efficacy of recommended peripheral intravascular cannula insertion practices with a standard protocol: A randomized control trial.

Background: Millions of patients admitted globally in health care setups require insertion of peripheral intravascular catheter for intravenous drugs or fluid administration. However, if proper precautions are not followed during insertion, it results in significant morbidity. This study was designed to study the efficacy and safety of recommended Centre for Disease Control and Prevention (CDC) guidelines for peripheral intravascular catheter insertion practice and its comparison with a standard insertion protocol being followed and their outcome. Methods: Patients were randomized and catheter was inserted as recommended by CDC guideline (Group 1, n = 100) or followed standard defined steps during insertion (Group 2, n = 100). Results: Almost double the patients had occurrence of thrombophlebitis in Group 1 (p = 0.02). No difference observed between catheter needle size and infection rates (p = 0.3). Infection rate increased significantly if second attempt is taken for insertion. The time required to insert catheter following CDC recommended protocol is less than as by standard surgical complete asepsis cleaning protocol (86.03 vs 109.40 s) (p = 0.001). Study also observed that insertion at wrist joint leads to higher incidence of thrombophlebitis. During 0-24 h, 6% (12) insertions turned positive followed by a dip during 25-48 h, 2% (5) insertions. 80% (159) insertions did not develop thrombophlebitis at the end of 72 h. Conclusion: It is thus amply demonstrated that meticulous adherence to insertion procedure with asepsis plays an important role in decreasing intravascular catheter associated morbidity. Other parameters like needle gauge, sites of insertion, have little bearing. The time required in following standard aseptic technique is significantly more but keeping in view the benefit to the patient it is highly recommended.

Artificial intelligence in critical care: Its about time!

Currently, most critical care information is not expressed automatically at a granular level, rather is continually assessed by overindulged Intensive Care Unit (ICU) staff. Furthermore, due to different confounding morbidities and the uniqueness of the ICU setting, it is difficult to protocolize treatment regimens in the ICU. In highly complex ICU setting where man and resource management becomes extremely challenging, definite advancements are required to implement Artificial Intelligence (AI) for prognosticating the course of the disease to aid in informed decision-making. AI is the intelligence of a computer or computer-supervised robot to execute a piece of work commonly associated with intelligent beings, wherein the machines go beyond the realms of normal information processing by adding the characteristics of learning, sound reasoning, and weighting of the inputs. AI recognizes circuitous, relational time-series blueprint within datasets and this reasoning of analysis transcends conventional threshold-based analysis adapted in ICU protocols. AI works on the principle of a more complex form of Machine Learning by Artificial Neural Networks (ANN). These information-processing paradigms use multidimensional arrays called tensors which aid in 'learning' and 'weighting' all the information made available to it, thereby converting normal machine learning into Deep Learning. Here, the use of AI for data mining in complex ICU settings for protocol formulation and temporal representation and reasoning is discussed.

Evaluation of quality of recovery score in mothers and neonatal outcome assessment after surgery using preoperative dexamethasone for caesarean section.

BACKGROUND: Quality of recovery (QoR) after surgery is an essential measure of early postoperative health status of the patient. The incidence of caesarean section (CS) has increased in the last few decades. Numerous studies have been conducted for reduction of pain after CS but only a few on the effect of preoperative dexamethasone on QoR after CS. This study is designed to evaluate QoR with dexamethasone and neonate outcome assessment after CS. METHODS: This is a prospective, randomised study in which patients undergo CS under spinal anaesthesia (SA). Patients received either 8 mg (2 ml) of dexamethasone IV (group D, n = 30) or 2 ml of 0.9% normal saline (group C; n = 30) before SA. The QoR-40 and Apgar score, neonatal respiratory distress, haemodynamic response and ill effects were recorded. RESULTS: The baseline haemodynamic (heart rate, mean arterial pressure (MRP), Respiratory rate (RR) and pulse oximetry) parameters were comparable in both the groups. The mean global score and each score in group D was better than that of group C (p < 0.001). The mean duration of block in group D (169.83 ± 9.05 min) was more than that in group C (163.33 ± 11.91 min) (p < 0.021). The incidence of neonatal respiratory distress, neonatal intensive care unit admission and Apgar score at 1 min and at 5 min of birth was comparable between the groups. CONCLUSION: Dexamethasone has a positive effect on early postoperative recovery of patients undergoing CS with a delay in regression of spinal block and without any significant adverse effects on neonatal outcomes.

Pulmonary embolism in coronavirus disease 2019: the silent killer.

BACKGROUND: Pulmonary embolism (PE) has been identified as one of the deadliest complications of coronavirus disease 2019 (COVID-19), especially in patients admitted to the intensive care unit (ICU). Western literature reminds us of the high prevalence of PE in COVID. Here, we report a series of 13 cases of PE diagnosed and managed at our hospital. METHODS: Retrospective analysis of medical records of 13 cases of PE admitted at our hospital from February 1, 2020, to September 31, 2020, were done. Their clinical, laboratory, and radiologic data were assessed in detail. RESULTS: Computed tomography pulmonary arteriography was used to make the diagnosis in eight patients (61.53%), and clinical findings with corroborative ultrasound and laboratory parameters were used to label PE in five patients (38.46%). Five patients were hemodynamically unstable, requiring thrombolysis with recombinant tissue plasminogen activator, and four patients (30.76%) suffered a fatal outcome. CONCLUSION: COVID-19 is a highly prothrombotic state, and all physicians should keep a high vigilance for PE. All hospitalized patients with COVID-19, especially those admitted in ICU, should be on prophylactic anticoagulation and, if there is any worsening, should be started on therapeutic regimen. Patients at the time of discharge should be switched to oral anticoagulation, which should be continued for at least 3-6 months.

Similar functional outcome using single anterior portal and standard two portals technique in recurrent dislocation of shoulder.

PURPOSE: Recurrent dislocation of shoulder (RDS) is a common injury in high demand professionals, like athletes and military personnel. The treatment for the patients with Bankart lesion is the arthroscopic repair. This present study compares the outcomes of two different techniques of arthroscopic Bankart repair i.e. a standard two anterior portals technique and a single anterior portal technique in patients with RDS. METHODS: Patients with traumatic RDS met the inclusion criteria were managed with Bankart repair using either two anterior portals (Group A) or a single anterior portal (Group B) technique. Patients were evaluated before the intervention and at the mean follow-up of approximately two years using Rowe score, Oxford shoulder score and Tegner activity scale. RESULTS: The mean age of the patients in Groups A (n = 34) and B (n = 37) was 29.64 years and 29.05 years respectively (p = 0.66). The dominant shoulder was involved in 27 patients in Group A and 22 patients in Group B (p = 0.069). The operative time in Group A and B was 68.52 min and 46.35 min, respectively (p < 0.001). The complications at follow-up, the mean Rowe score and Oxford score improved significantly in both groups compared with the pre-operative values. However, the final outcome scores were not significantly different between the both groups. The median Tegner's score preoperatively and at follow-up was 7 and 6, respectively in Groups A and B. CONCLUSIONS: Single anterior portal technique is an effective treatment modality, yielding a similar outcome as two anterior portals technique in the management of RDS.

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.

Neuroanesthesia and pregnancy: Uncharted waters.

An incidence of 30-40 deaths per triennium in pregnant patients is reported because of brain pathology. Over the last two decades, the obstetric cause of mortality in the pregnant patient has declined, but the trend is rising for non-obstetric cause of mortality. Pregnancy is associated with a host of anatomical and physiological alterations that complicate the conduct of anesthesia. The brain is one of the vital organs of the body, and physiological changes during pregnancy alter the anesthesia management if associated with brain pathology. Malignant brain tumors and trauma remain a leading cause of indirect maternal mortality. Review of literature revealed paucity of evidence-based neuroanesthesia management for such patients. Navigating these uncharted waters remains a challenging exercise. With the lack of guidelines, the management is based largely on few case reports or case series.

Comparison of effect of dexmedetomidine and lidocaine on intracranial and systemic hemodynamic response to chest physiotherapy and tracheal suctioning in patients with severe traumatic brain injury.

PURPOSE: Chest physiotherapy and tracheal suction cause sympathetic stimulation and increase heart rate (HR), mean arterial pressure (MAP) and intracranial pressure (ICP) which may have deleterious effect in the head injured. We planned to compare the effect of intravenous dexmedetomidine and lidocaine on intracerebral and systemic hemodynamic response to chest physiotherapy (CP) and tracheal suctioning (TS) in patients with severe traumatic brain injury (sTBI). METHODS: Prospective, randomized study in patients with sTBI, 18-60 years of age, undergoing mechanical ventilation and intraparenchymal ICP monitoring. Patients were randomized to receive either iv dexmedetomidine 0.5 mcg/kg (group I; n = 30) or iv lidocaine 2 mg/kg (group II; n = 30) over 10 min. After infusion of test drug, CP with vibrator and manual compression was performed for 2 min and TS was done over next 15-20 s. The hemodynamic response was recorded before, during and at interval of 1 min for 10 min after CP and TS. A 20% change in hemodynamic parameters was considered significant. RESULTS: The baseline hemodynamic (HR, MAP), intracranial (ICP, CPP) and respiratory (SPO2, AWPpeak) parameters were normal and comparable in both the groups. After dexmedetomidine infusion, MAP and CPP decreased significantly from baseline value. In group II, there was no significant change in HR, MAP, ICP and CPP. At end of CP and TS, HR, MAP and CPP in group I was lower as compared to group II. During the 10-min observation period following CP and TS, MAP and CPP in group I remained significantly lower as compared to baseline and group II. There was no significant change in value of other measured parameters. CONCLUSIONS: Both dexmedetomidine and lidocaine were effective to blunt rise in HR, MAP and ICP in response to CP and TS in patients with sTBI. However, intravenous dexmedetomidine caused significant decrease in MAP and CPP as compared to the baseline and lidocaine.

Recurrent Metabolic Acidosis during High-dose Midazolam Therapy for Refractory Status Epilepticus.

High-dose continuous midazolam therapy has been used successfully for control of refractory status epilepticus. However, normal anion gap (AG) metabolic acidosis, a deleterious complication of this therapy is underrecognized. Even though previously reported in an isolated case report in a pediatric patient, we observed similar complication in an adult patient. Stereotyped normal AG metabolic acidosis along with hypotension developed on two occasions during high-dose continuous midazolam hydrochloride infusion that reverted rapidly following cessation of the infusion.

Comparison between continuous thoracic epidural block and continuous thoracic paravertebral block in the management of thoracic trauma.

BACKGROUND: Postoperative pain is thought to be the single most important factor leading to ineffective ventilation and impaired secretion clearance after thoracic trauma. Effective pain relief can be provided by thoracic epidural analgesia but may have side effects or contraindications. Paravertebral block is an effective alternative method without the side effects of a thoracic epidural. We did this study to compare efficacy of thoracic epidural and paravertebral block in providing analgesia to thoracic trauma patients. METHODS: After ethical clearance, 50 patients who had thoracic trauma were randomized into two groups. One was a thoracic epidural group (25), and second was a paravertebral group (25). Both groups received 10 ml of bolus of plain 0.125% bupivacaine and a continuous infusion of 0.25% bupivacaine at the rate of 0.1 ml/kg/h for 24 h. Assessment of pain, hemodynamic parameters, and spirometric measurements of pulmonary function were done before and after procedure. Visual analog scale (VAS) scores were accepted as main outcome of the study and taken for power analysis. RESULTS: There was significant decrease in postoperative pain in both the groups as measured by VAS score. However, the degree of pain relief between the groups was comparable. There was a significant improvement in pulmonary function tests in both the groups post-procedure. The change in amount of inflammatory markers between both the groups was not significantly different. CONCLUSION: Paravertebral block for analgesia is comparable to thoracic epidural in thoracic trauma patients and is associated with fewer side effects.