Correlation coefficient between plethysmographic variability index and Systolic Pressure Variation as an indicator for fluid responsiveness in hypotensive patients in the ICU/OT.

Background: Prediction of fluid responsiveness in hypotensive patients is a challenge. The correlation between a novel noninvasive dynamic indicator, Pleth Variability Index (PVI ®), and a gold-standard Systolic Pressure Variation (SPV) as a measure of fluid responsiveness was assessed in the Intensive Care Unit (ICU) or Operation Theatre (OT) in a tertiary care hospital. Methods: A prospective experimental study was conducted over a span of one year on 100 mechanically ventilated patients with hypotension. Vital parameters along with SPV and PVI ® were recorded before and after a standard volume expansion protocol. A 10% SPV threshold was used to define fluid responders and nonresponders. Results: Pearson's correlation graph at baseline showed positive correlation between PVI ® and SPV (r = 0.59, p-value = 0.001). Strength of correlation was comparatively less but still showed positive correlation at 15 (r = 0.39, p-value = 0.009) and 30 (r = 0.404, p-value = 0.004) minutes of fluid bolus. The Bland Altman analysis of baseline values of PVI ® and SPV showed good agreement with a mean bias of 9.05. Percentage change of PVI ® and SPV over 30 min showed a statistically significant positive correlation in the responder group (r = 0.53, p < 0.05). A threshold value of PVI ® more than 18% before volume expansion differentiated fluid responders and nonresponders with a sensitivity of 75% and specificity of 67%, with an area under Receiver Operating Characteristic (ROC) of 0.78. Conclusion: A positive correlation exists between SPV and PVI ®, justifying the use of noninvasive PVI ® in a clinical setting of hypotension.

Concept of BIDI years: Relevance to the perioperative period.

Background: The cumulative effect of cigarette smoking is usually measured by "pack years," but the same is not present for Bidis. This study was conducted to calculate the concept of "bidi years" in comparison to the concept of "pack-years" for a cigarette. Methods: Thirty random samples, each of bidis and cigarettes, were selected through a survey of common brands used by smokers in India. The nicotine and carbon monoxide (CO) contents were analyzed by high-pressure liquid chromatography and gas chromatography methods, respectively. Results: The average nicotine content in thirty samples of different Bidis and Cigarettes was 214.46 ± 57.8 and 616.31 ± 22.6 mg/dL, respectively (P < 0.001). The CO content with a lower mean of 15.57 ± 5.88 was observed in cigarettes as compared to 70.4 ± 22.08 in bidies (P < 0.001). The weight of one cigarette is 0.56 times that of the weight of one bidi. Based on the nicotine content, the equivalent pack years for bidis is calculated as 43 bidis per day per year. Conclusion: Based on the nicotine content, it is proposed that the equivalent for one cigarette pack-year or 20 cigarette years are taken as 43 bidis per day per year. Even though each bidi stick has an average of 0.46 times the nicotine content of cigarettes, longer abstinence as compared to cigarette is required to bring the nicotine level to normal due to the deeper puffs needed. With the CO content of bidis being 4.5 times that of cigarettes, it is advised that the minimum duration of cessation of smoking before operative procedures be 24 h as compared to 6 h for cigarettes.

The changing face of postgraduate anaesthesia teaching curriculum: Need of the hour!

The speciality of anaesthesiology is evolving rapidly. The recent pandemic witnessed anaesthesiologists as the front-liners catering not only as critical care physicians but also as trainers and even administrators. Today, anaesthesiologists are required to have not just sound clinical knowledge but also proficiency in skills and techniques and aptitude for leadership. The recently introduced competency-based postgraduate training programme for anaesthesiology in India with its specific learning objectives envisages the creation of competent specialists with a broad range of skills who are competent not only to handle effectively medical problems but also acquire the basic teaching skills, communication skills and leadership qualities. The curriculum marks a paradigm shift from university-based, passive, teacher-centric to student-centric, active teaching-learning methods including problem-based and self-directed learning. The mindset, lack of adequately trained faculty, infrastructure, learning resources and time constraints form the major impediment in the successful implementation of the new curriculum.

Association of ischemic electrocardiographic changes in high-altitude areas with coronary angiography.

BACKGROUND: Soldiers native to lowlands, while sojourning at high altitude (HA), are referred to tertiary care centers with electrocardiographic (ECG) abnormalities. Exposure to HA may precipitate myocardial ischemia in subjects with underlying coronary artery disease (CAD). Conversely, it may produce physiological ECG changes mimicking those of CAD, causing a diagnostic dilemma. This study sought to correlate the presence of CAD on coronary angiography (CAG) with a putative diagnosis of CAD based on clinical findings and ECG. METHODS: A prospective study was conducted on patient's from HA areas, referred for evaluation for CAD to a single center at near-sea-level. Thirty-five minimally symptomatic/asymptomatic soldiers with ECG changes suggestive of CAD, underwent CAG. Correlation was sought between ECG and CAG evidence of CAD. RESULTS: The association of CAD on CAG with clinical and ECG diagnosis of CAD was not significant, 4 of the 35 soldiers (11.4%) showing CAG evidence of CAD (chi square 3.849, p = 0.697). The association between symptoms and coronary artery lesions was, also, not significant, only four of twenty-three (17.4%) minimally symptomatic subjects having CAD on CAG. CONCLUSION: Insignificant numbers of previously healthy persons, who present with minimal symptoms and ECG changes suggestive of CAD while sojourning at HA, have coronary artery involvement on CAG. Those with incidental ECG changes, without symptomatology, do not have CAD on CAG.

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.

Sigma Metric Evaluation of Drugs in a Clinical Laboratory: Importance of Choosing Appropriate Total Allowable Error and a Troubleshooting Roadmap.

Objectives Stringent quality control is an essential requisite of diagnostic laboratories to deliver consistent results. Measures used to assess the performance of a clinical chemistry laboratory are internal quality control and external quality assurance scheme (EQAS). However, the number of errors cannot be measured by the above but can be quantified by sigma metrics. The sigma scale varies from 0 to 6 with "6" being the ideal goal, which is calculated by using total allowable error (TEa), bias, and precision. However, there is no proper consensus for setting a TEa goal, and influence of this limiting factor during routine laboratory practice and sigma calculation has not been adequately determined. The study evaluates the impact of the choice of TEa value on sigma score derivation and also describes a detailed structured approach (followed by the study laboratory) to determine the potential causes of errors causing poor sigma score. Materials and Methods The study was conducted at a clinical biochemistry laboratory of a central government tertiary care hospital. Internal and external quality control data were evaluated for a period of 5 months from October 2019 to February 2020. Three drugs (carbamazepine, phenytoin, and valproate) were evaluated on the sigma scale using two different TEa values to determine significant difference, if any. Statistical Analysis Bias was calculated using the following formula: Bias% = (laboratory EQAS result - peer group mean) × 100 / peer group mean Peer group mean sigma metric was calculated using the standard equation: Sigma value = TEa - bias / coefficient of variation (CV)%. Results Impressive sigma scores (> 3 sigma) for two out of three drugs were obtained with TEa value 25, while with TEa value 15, sigma score was distinctly dissimilar and warranted root cause analysis and corrective action plans to be implemented for both valproate and carbamazepine. Conclusions The current study evidently recognizes that distinctly different sigma values can be obtained, depending on the TEa values selected, and using the same bias and precision values in the sigma equation. The laboratories should thereby choose appropriate TEa goals and make judicious use of sigma metric as a quality improvement tool.

Optimal management of brain-dead organ donor.

Maintaining a brain stem-dead (BSD) donor is specialized science. It is a daunting task as they are fragile patients who need to be handled with utmost care owing to extreme haemodynamically instability and need the best of monitoring for maintenance of organs. To ensure a successful transplant, a BSD donor first needs to be identified on time. This requires scrupulous monitoring of neurologically compromised patients who tend to be the most frequent organ donors. Once the donor is identified, an all-out effort should be made to legally obtain consent for the donation. This may require numerous sessions of counselling of the relatives. It needs to be performed tactfully, displaying the best of intentions. It is important to understand the physiology of a brain-dead individual. A cascade of changes occurs in BSD donor which result in a catastrophic plummeting of the clinical condition of the donor. All organ systems are involved in this clinical chaos, and best possible clinical support of all organ systems should be available and extended to the donor. Organ support includes cardiovascular, pulmonary, temperature, glycaemic, metabolic and hormonal. This article has been written as a follow-up article of previously published article on identifying an organ donor. It intends to give the reader a concept of what the BSD donor undergoes after brain death and as to how to maintain and preserve various organs for donation for successful transplantation of maximum organs.

A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating?

BACKGROUND: Ultrasonography-guided supraclavicular brachial plexus block has demonstrated safety as compared with landmark or nerve stimulation techniques. However, the minimum effective analgesic volume (MEAV) necessary for adequate blockade has not been determined. This study was undertaken to assess under fluoroscopy the postinjection spread of different drug volumes with clinical correlation. Secondary outcome measures included correlation of onset of block, block quality, and incidence of side effects. METHODS: This randomized, multiarm, cross-sectional, observational study was conducted at a single tertiary care center. A total of 549 patients were randomly allocated to 3 groups (20 ml, 30 ml, and 40 ml of drug mixture). A local anesthetic drug mixture with a radiopaque dye was administered under ultrasonographic guidance, and postinjection fluoroscopic drug spread was studied. RESULTS: Surgical anesthesia was achieved in 494 (89.98%) patients with 85.25%, 92.97%, and 91.71% in 20-, 30-, and 40-ml groups, respectively, being significantly low (p = 0.0317) in the 20-mL group. Cephalad and infraclavicular spread was higher in the 40-mL group than in other two groups (p = 0.103). Horner syndrome (HS) was seen in 51.18% of patients. First, ipsilateral superficial cervical plexus block was also observed in 40.22% of patients. Among patients who developed both, ∼60% of patients (99/167) belonged to the 40-mL group. CONCLUSIONS: Optimal MEAV appears between 20 and 30 mL. Higher drug volumes are associated with more cephalad spread and side effects. Drug spread can predict block efficacy as well. It is postulated that loss of sensation in the ipsilateral neck can be used to predict development of hemidiaphragmatic paresis similar to HS.

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.

COVID-2019: Experience of setting up quarantine center.

Indians stranded in countries reporting widespread transmission of COVID-19 in Jan to Mar 2020 were evacuated at short notice. Unclear and evolving evidence on COVID-19, risk of transmission of the disease from pre-symptomatic, asymptomatic and known cases of COVID-19 has put the spotlight back on the practice of quarantine. The article describes the processes, inter-sectoral coordination and methodology adopted for putting in place all measures for a successful evacuation and subsequent quarantine of the evacuees at the first Quarantine camp set up in India at Manesar, Gurugram near New Delhi by the Armed Forces. No health care worker or support staff contracted any infection with SARS-Cov-2 during the period of care and contact with those quarantined. The archaic practice of quarantine has yet again proven to be a robust and effective Public Health tool with great relevance in the ongoing Pandemic of COVID-19.

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.

Interplay between PAPP-A, inflammation and adiposity in patients with angiographically proven acute coronary syndrome (ACS).

Introduction Studies conducted in the recent past have demonstrated the role of inflammation, obesity and dysfunctional insulin signaling as contributing factors in the pathogenesis of acute coronary syndrome (ACS). However, pharmacological interventions targeting a single pathway have not proven useful in the long run. This indicates that a synergism occurs between the various risk factors and hence calls for a combinatorial approach. This study was planned to study the interplay, if any, between pregnancy associated plasma protein-A (PAPP-A), inflammation and adiposity in patients with ACS. Materials and methods The study was conducted in a tertiary care hospital in Delhi. The study population consisted of 128 subjects, divided into two groups. The control group consisted of 64 healthy subjects without ACS. Cases consisted of 64 subjects with angiographically proven ACS cases. PAPP-A and high sensitivity C-reactive protein (hs-CRP) were estimated by enzyme-linked immunosorbent assay (ELIZA) kits. Results The mean level of PAPP-A and hs-CRP were significantly higher in cases as compared to the controls. A positive correlation of PAPP-A was observed with hs-CRP, insulin, ApoB and Lp(a). The relative risk for ACS was 14.2 with a p value of <0.001 when all the three parameters - hs-CRP, PAPP-A and body mass index (BMI) were considered together. This was significantly higher when each risk factor was assessed standalone. Conclusions Our study results suggest a possible interplay between chronic inflammation, obesity and plaque instability among patients with ACS. This interaction can accelerate the process of plaque rupture in patients with increased BMI as compare to those patients with low/normal BMI.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

BACKGROUND AND AIMS: The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body. MATERIAL AND METHODS: A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point "global rating of change" scale determined the minimal clinically important difference of the DASH score. RESULTS: The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36-63; P = 0.14) to 10.4 (range 10-49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention. CONCLUSIONS: SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.