Laryngoscopic View after Application of Manual In-Line Stabilization - A Comparison with Early Morning Sniffing Position in the Same Patient.

Background: The application of manual in-line stabilization (MILS) for minimizing spinal cord injury is known to increase difficulty in airway management. Aim: The study aims to assess the change in Modified Cormack-Lehane (CL) laryngoscopic view with the application of MILS from the early morning sniffing position (EMSP) in adult patients. Setting and Design: This was a prospective, interventional, self-controlled study conducted on 220 patients aged 18-65 years, belonging to the American Society of Anesthesiologists Physical Status Class I or II, having a normal airway, and scheduled for elective surgery under general anesthesia. Materials and Methods: After inducing general anesthesia, MILS was applied to the patient's neck, and a Modified CL view of the vocal cords was recorded under direct laryngoscopy. The view was again noted after applying backward-upward-rightward pressure (BURP). MILS and BURP were released. The view was obtained again with and without BURP in EMSP. Statistical Analysis: Normality of data was tested by Kolmogorov-Smirnov test. Wilcoxon ranked-sum test for quantitative variables and Chi-square test for qualitative variables were used. Results: On application of MILS, the majority of patients had Modified CL Grade 3a (121 patients) and 3b (53 patients) views. The majority of patients had Modified CL Grade 1 (114 patients) and 2a (71 patients) views on placing in EMSP. These findings were statistically significant (P < 0.0001). Consequent to the placement of BURP upon MILS, patients with lower CL Grade views (2b: 101 patients) were significantly higher (P < 0.0001) in comparison with MILS alone. Conclusion: In patients with a normal airway, MILS leads to a significantly greater incidence of higher grades of laryngoscopic views in comparison to EMSP. Use of BURP after MILS causes significantly less incidence of higher grades of laryngoscopic view when compared with MILS alone. All patients requiring MILS should be considered to be a difficult airway, and hence, preparation should be done accordingly.

Clinico-epidemiological profile of COVID-19 patients admitted during third wave of pandemic in a tertiary care hospital in New Delhi, India.

Even nearly two years after the first reported case, the novel coronavirus (SARS-CoV-2) continues to ebb and flow around the world. A retrospective cohort study was carried out to determine the clinico-epidemiological profile and outcome of the cases. The study analyzed secondary data from 827 patients who presented to our center with COVID-19-related illnesses between December 15, 2021, and February 15, 2022 (third wave in India). There was a significant difference in the vaccination status of patients treated at home and those admitted, with 87.9% having received two doses compared to 74% in the second group being unvaccinated. Patients who were isolated at home recovered at a rate of 99.4%, while hospitalized patients died at a rate of 26.5%. Vaccination reduces the severity of COVID-19; however, constant vigilance for new variants, precautionary measures, and increased vaccination drives are critical moving forward.   *Other members of the Safdarjung Hospital COVID-19 working group: B. Lal (Medicine), Harish Sachdeva (Anaesthesiology), Santvana Kohli (Anaesthesiology), Amandeep Jaswal (Anaesthesiology), Sumitra Bachani (Obstetrics and Gynecology), Ajay Kumar (Pediatrics), Rohit Kumar (Pulmonary Medicine), Vidya Sagar Chaturvedi (Surgery), Vinod Chaitanya (Medicine).

Patient Satisfaction Through an Immersive Experience Using a Mobile Phone-Based Head-Mounted Display During Arthroscopic Knee Surgery Under Spinal Anesthesia: A Randomized Clinical Trial.

BACKGROUND: Patient satisfaction is an important element of high-quality health care. Virtual reality has been studied for its sedative and analgesic effects, as it immerses the patient into an artificial interactive environment. Deriving from this concept, we hypothesized that an immersive experience that engulfs the senses with noninteractive visual and auditory stimuli would have a positive effect on satisfaction and anxiety in patients undergoing spinal anesthesia. METHODS: We enrolled and randomized 90 patients undergoing spinal anesthesia for arthroscopic knee surgery into an immersive experience arm and an intravenous midazolam sedation arm. The immersive experience was provided through a mobile phone-based head-mounted display showing binocular monoscopic video and noise-canceling headphones playing audio. The primary outcome measure was postoperative satisfaction, measured using a visual analog scale and compared using the Mann-Whitney U test; secondary outcomes included anxiety score (measured using the 6-item State-Trait Anxiety Inventory), hemodynamic stability, and additional sedative requirement. RESULTS: The visual analog scale satisfaction score with immersive experience was significantly higher than with midazolam (median [interquartile range {IQR}] of 93 [82-98] and 80 [73-93], respectively, P = .004), with Hodges-Lehmann median difference estimate of 7 (95% confidence interval, 3-14). The change in anxiety scores from the preoperative to postoperative period between the groups was not significantly different (P = .08), with a Hodges-Lehmann median difference estimate of 3.3 (95% confidence interval, 0-6.7). All patients were hemodynamically stable, were without significant adverse events, and did not require additional sedatives. CONCLUSIONS: We have found that an immersive experience is an effective and acceptable intraoperative alternative to pharmacological sedation in patients undergoing arthroscopic knee surgery under spinal anesthesia, with higher satisfaction levels and no detected difference in preoperative to postoperative anxiolytic effect.

Comparison of Videolaryngoscope and Intubating Laryngeal Mask Airway for Tracheal Intubation with Manual-in-line Stabilization in Patients Undergoing Cervical Spine Surgery.

BACKGROUND: This prospective, randomized study compared CMAC® videolaryngoscope with intubating laryngeal mask airway (ILMA) for intubation under manual-in-line-stabilization (MILS) in patients undergoing cervical spine surgery. Settings and Design: Sixty-five ASA Physical Status Classes I and II patients aged 18-65 years undergoing elective cervical spine surgery were randomly allocated into two groups: group CM-intubation with CMAC® videolaryngoscope (n = 33) and Group IL-intubation using ILMA (n = 32). MATERIALS AND METHODS: Intubation was performed in all patients after the application of MILS. The primary outcomes included first attempt and overall intubation success rate, intubation time, and apnea time. The secondary objectives were degree of head movement, hemodynamic response, incidence of desaturation, sore throat, and tissue injury. STATISTICAL ANALYSIS: Normality of data was tested by the Kolmogorov-Smirnov test. Quantitative variables were compared using the unpaired t-test or Wilcoxon Mann-Whitney test and qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. RESULTS: CM group had a higher first attempt (96.97%, P = 0.054) and overall (100%, P = 0.053) intubation success rate than IL group (81.25% and 87.5%, respectively). Group CM had a significantly shorter (P < 0.0001) intubation time (33.13 ± 11.82 s) than IL group (55.71 ± 19.28 s), but group CM had significantly longer (P < 0.0001) apnea time (33.13 ± 11.82 s) than IL group (22.03 ± 7.14 s). The incidence of head movement was significantly lower in IL group (P = 0.011). Hypoxemia did not occur. Postintubation hemodynamic changes and tissue injury were significantly higher in ILMA group. CONCLUSION: CMAC group had higher intubation success rate and significantly shorter intubation time. However, ILMA group had a significantly shorter apnea time and significantly lower incidence of head movements.

Hemodynamic, Airway Pressure, and Capnometric Changes and Perioperative Outcome in Pediatric Laparoscopic Inguinal Herniorrhaphy: A Comparison with Open Inguinal Herniorrhaphy.

BACKGROUND: Laparoscopic procedures which are now established in pediatric population as well exposes the child to supplemental cardiorespiratory changes due to increase in intraabdominal pressure (IAP) and hypercarbia. AIMS: This study aims to analyze the effects of pneumoperitoneum and postural modifications on cardiorespiratory system (primary outcome) during pediatric laparoscopic herniorrhaphy (LH) and its comparison with open herniorrhaphy (OH) and assessment of overall perioperative outcome (secondary outcome). SETTINGS AND DESIGN: A prospective, observational study conducted in a tertiary care hospital. MATERIALS AND METHODS: Fifty children undergoing either LH (n = 25) or OH (n = 25) were included in the study. Anesthetic procedure was standardized. Parameters monitored were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressures (MAP), electrocardiogram lead-II, end-tidal CO2 (ETCO2), airway pressures PPeak, PPlateau, PMean, pulse oximetry, IAP, minute ventilation/respiratory rate alterations. STATISTICAL ANALYSIS USED: Student's t-test and Chi-square test were applied to compare different variables between the two groups. Intragroup analysis was done using the analysis of variance test. RESULTS: The HR was comparable in both groups. The rise in SBP, DBP, and MAP was 9% (102.88 ± 6.91-121.32 ± 6.63), 19% (60.88 ± 4.94-77.00 ± 9.75), and 14.8% (73.92 ± 4.65-90.40 ± 8.42), respectively, in group LH. The rise in peak, plateau, and mean airway pressures was 19.4% (14.20 ± 2.00-18.00 ± 2.54), 20.1% (13.32 ± 1.89-16.89 ± 2.60), and 16.1% (6.20 ± 1.00-7.47 ± 0.96), respectively, in group LH. ETCO2 showed a maximum rise of 19.4% (34.52 ± 3.61-41.21 ± 3.99) in group LH. In laparoscopic group, recurrence was seen in 3 patients. CONCLUSIONS: We found significant hemodynamic, airway pressure, and capnometric changes during pediatric LH with comparable perioperative outcome among the two groups.

Anesthetic Management of Clinically Silent Familial Pheochromocytoma with MEN 2A: A Report of Four Cases.

Familial pheochromocytomas are commonly associated with multiple endocrine neoplasia type 2 (MEN 2) syndrome. Majority of the patients present with normal clinical and biochemical parameters in the preoperative period, the incidence of hypertension being only 50 %. Even though patients may be clinically asymptomatic, surveillance and proper preoperative evaluation is important, as surgery for associated tumors may precipitate a hypertensive crisis and result in severe complications. A family of 19 members, of which 12 were positive for MEN 2A syndrome, presented to our hospital. Seven of the 12 patients had pheochromocytoma and medullary thyroid carcinoma (MTC), while the other 5 had only raised plasma calcitonin levels. Two of the 7 patients presented with bilateral pheochromocytoma and underwent an open adrenalectomy. The other 5 patients had a left-sided adrenal tumor and underwent left laparoscopic adrenalectomy under combined general and epidural anesthesia. We present our experience with four of these five cases. We here state that how paucity of literature on perioperative preparation of clinically and biochemically silent pheochromocytomas led to serious intraoperative complications in one of four cases.

Evaluation of the Analgesic Effect of Bilateral Superficial Cervical Plexus Block for Thyroid Surgery: A Comparison of Presurgical with Postsurgical Block.

Bilateral superficial cervical plexus block may help in reduction of postthyroidectomy pain. The aim of this study was to evaluate the influence of bilateral superficial cervical plexus block (BSCB) given either presurgically or postsurgically on analgesia in postthyroidectomy patients. Sixty adult euthyroid patients were randomly allocated to one of the three groups, to receive BSCB either presurgically (group A) or postsurgically (group B). Both of the above groups were compared with parenteral analgesics (group C). Thyroid surgery was performed according to a standardised procedure. Postoperative pain was assessed by visual analog scale (VAS), with 10 being the worst pain and 0 being no pain, when patient was fully awake and extubated (0) and after 1, 2, 4, 8, 12, 18, 24, 36 and 48 h. VAS was assessed at four phases: at rest, neck movements, vocalisation and swallowing. Total use of intraoperative fentanyl was noted. The time for first rescue analgesic was also noted. There was no significant statistical difference amongst three groups as regards demographic data and duration of surgery. Patients given BSCBs (either presurgically or postsurgically) had significant lower VAS at all four phases of pain assessment as compared to group C. The time for first rescue analgesia was the earliest in group C. We concluded that BSCB whether given presurgically or postsurgically significantly reduce pain intensity and opioids requirement in postoperative period after thyroid surgery.

Palliative Care Tailored Towards the Needs of the Poor in India.

Traditional approaches to palliative care may not meet the unique needs of poor cancer patients in developing countries. Cancer patients treated in India are often unable to make repeat visits to the hospital, pay for drugs, or understand and follow complex treatments. Many are from rural areas and may lack basic financial or social support. Our palliative care clinic has taken a series of innovative first steps towards meeting these unique needs, from providing treatment without complete diagnosis, accelerating through the World Health Organization (WHO) analgesic schedule, systematically simplifying prescriptions, and providing treatment free of charge. This paper describes these first steps, presents an initial evaluation of their impacts, and articulates a number of opportunities for additional improvements.

Granisetron versus ondansetron for post-operative nausea and vomiting prophylaxis in elective craniotomies for brain tumors: A randomized controlled double-blind study.

CONTEXT: Post-operative nausea and vomiting (PONV) pose unique challenges in neurosurgical patients that warrant its study separate from other surgical groups. SETTING AND DESIGN: This prospective, randomized, double-blind study was carried out to compare and to evaluate the efficacy and safety of three antiemetic combinations for PONV prophylaxis following craniotomy. MATERIALS AND METHODS: A total of 75 anesthesiologist status I/II patients undergoing elective craniotomy for brain tumors were randomized into three groups, G, O and D, to receive single doses of dexamethasone 8 mg at induction with either granisetron 1 mg, ondansetron 4 mg or normal saline 2 ml at the time of dural closure respectively. Episodes of nausea, retching, vomiting and number of rescue antiemetic (RAE) were noted for 48 h post-operatively. STATISTICAL ANALYSIS: Analysis of variance with post-hoc significance and Chi-square test with fisher exact correction were used for statistical analysis. P <0.05 was considered to be significant and P < 0.001 as highly significant. RESULTS: We found that the incidence and number of vomiting episodes and RAE required were significantly low in Group G and O compared with Group D; P < 0.05. However, incidence of nausea and retching were comparable among all groups. The anti-nausea and anti-retching efficacy of all the three groups was comparable. CONCLUSIONS: Single dose administration of granisetron 1 mg or ondansetron 4 mg at the time of dural closure with dexamethasone 8 mg provide an effective and superior prophylaxis against vomiting compared with dexamethasone alone without interfering with post-operative recovery and neurocognitive monitoring and hence important in post-operative neurosurgical care.

Comparative evaluation of different doses of propofol preceded by fentanyl on intubating conditions and pressor response during tracheal intubation without muscle relaxants.

BACKGROUND: The aim of our study was to determine the optimal dose of propofol preceded by fentanyl for successful tracheal intubation and to see its effectiveness in blunting pressor response in children aged 3-10 years. METHODS: This prospective, double blind, randomized study was conducted on 60 ASA grade I and II children, between 3 and 10 years undergoing elective surgery who were divided into three groups of 20 each. The children received different doses of propofol (group I, 2.5 mg x kg(-1); group II, 3.0 mg x kg(-1); group III, 3.5 mg x kg(-1)) preceded by a fixed dose of fentanyl (3.0 microg x kg(-1)) 3 min earlier. The tracheal intubating conditions were graded based on scoring system devised by Helbo-Hensen et al. with Steyn modification which includes five criteria; ease of laryngoscopy, degree of coughing, position of vocal cords, jaw relaxation, and limb movement and graded on a 4-point scale. Heart rate (HR), mean arterial pressure (MAP), and oxygen saturation changes were also noted. RESULTS: Tracheal intubating conditions were acceptable in 25% of the patients in group I, while significantly higher (P < 0.001) in group II (80%) and in group III (90%). The pressor response was not effectively blunted in group I (17% increase in HR), while effectively blunted in groups II and III. A fall in cardiac output was seen in group III indicated by a decrease in MAP (16%) and HR (11%). No airway complications were noted. CONCLUSIONS: Propofol 3 mg x kg(-1) (group II) preceded by fentanyl 3 microg x kg(-1) is the optimal dose combination in our study. It provides acceptable intubating conditions in 80% patients, blunts pressor response to intubation without significant cardiovascular depression.