Simulation in airway management teaching and training.

There is a gradual shift in training and teaching methods in the medical field. We are slowly moving from the traditional model and adopting active learning methods like simulation-based training. Airway management is an essential clinical skill for any anaesthesiologist, and a trained anaesthesiologist must perform quick and definitive airway management using various techniques. Airway simulations have been used for the past few decades. It ensures active involvement, upgrading the trainees' airway management knowledge and skills, including basic airway skills, invasive procedures, and difficult clinical scenarios. Trainees also learn non-technical skills such as communication, teamwork, and coordination. A wide range of airway simulators are available. However, texture surface characteristics vary from one type to another. The simulation-based airway management training requires availability, understanding, faculty development, and a structured curriculum for effective delivery. This article explored the available evidence on simulation-based airway management teaching and training.

Impact of fluid and haemodynamic management in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on postoperative outcomes - A systematic review.

Background and Aims: Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgery associated with significant fluid shift and blood loss. The haemodynamic management and fluid therapy protocol may impact postoperative outcomes. This systematic review was conducted to find the effect of haemodynamic monitoring and perioperative fluid therapy in CRS-HIPEC on postoperative outcomes. Methods: We searched PubMed, Scopus and Google Scholar. All studies published between 2010 and 2022 involving CRS-HIPEC surgeries that compared the effect of fluid therapy and haemodynamic monitoring on postoperative outcomes were included. Keywords for database searches included a combination of Medical Subject Headings terms and plain text related to the CRS-HIPEC procedure. The risk of bias and the certainty assessment were done by Risk of Bias-2 and the methodological index for non-randomised studies. Results: The review included 16 published studies out of 388 articles. The studies were heterogeneous concerning the design type and parameter measures. The studies with goal-directed fluid therapy protocol had a duration of intensive care unit (ICU) stay that varied from 1 to 20 days, while mortality varied from 0% to 9.5%. The choice of fluid, crystalloid versus colloid, remains inconclusive. The studies that compared crystalloids and colloids for perioperative fluid management did not show a difference in clinical outcomes. Conclusion: The interpretation of the available literature is challenging because the definitions of various fluid regimens and haemodynamic goals are not uniform among studies. An individualised approach to perioperative fluid therapy and a justified dynamic index cut-off for haemodynamic monitoring seem reasonable for CRS-HIPEC procedures.

Who Cares About Me? The Need of the Hour is to Improve Awareness and Quality of End-of-life Care Practices in Indian Intensive Care Units.

How to cite this article: Singh U, Maurya I, Gurjar M. Who Cares About Me? The Need of the Hour is to Improve Awareness and Quality of End-of-life Care Practices in Indian Intensive Care Units. Indian J Crit Care Med 2023;27(8):523-525.

Efficacy of flupirtine for postoperative pain: A systematic review and meta-analysis.

Background and Aims: Flupirtine has been used for various chronic pain conditions, but its utility in the perioperative period as an analgesic is still inconclusive. This systematic review and meta-analysis aimed to assess the efficacy of flupirtine for postoperative pain. Methods: PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were explored for the randomised controlled trials (RCTs) which compared flupirtine with other analgesic/placebo for perioperative pain in adult patients undergoing surgery. The standardised mean difference (SMD) of pain scores, the need for rescue analgesia and all adverse effects were assessed. Heterogeneity was assessed using Cochrane's Q statistic test and I2 statistic. Cochrane Collaboration's tool was used to evaluate the risk of bias and the quality of the RCTs. Results: A total of 13 RCTs (including 1,014 patients) that evaluated the use of flupirtine for postoperative pain were included in the study. The pooled SMD of postoperative pain scores revealed that flupirtine and other analgesics were comparable at 0, 6, 12 and 24 hours (P > 0.05), while at 48 hours, flupirtine showed poor pain control (P = 0.04) as compared to other analgesics. There were no significant differences at other time points and on comparison of flupirtine with placebo. The side effect profile was comparable between flupirtine and other analgesics. Conclusion: The current evidence suggests that perioperative flupirtine was not superior to other most commonly used analgesics and placebo for the treatment of postoperative pain.

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review.

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.

Structural Risk Factors for Hospital-Acquired Infections in Intensive Care Unit.

There are risk factors related to architecture and designing labeled as "structural risk factors," causing hospital-acquired infections (HAIs) which are less highlighted in the literature. Through this communication, we wish to reiterate the importance of structural risk factors such as space surrounding the patient, furniture with focus on construction and finishing materials used, and ventilation systems surrounding the patient as risk factors for HAIs and expect that these find a place in HAI prevention guidelines in the future.

Comparison of the Glottic Views in a Head Elevated Laryngoscopy Position with the Patient in Supine or 25º Backup: An Observer-Blinded Randomised Clinical Trial.

BACKGROUND: Simple manoeuvres such as Head elevated laryngoscopy position (HELP) can facilitate a better glottic view. We conducted this prospective randomized clinical trial to compare the glottic view in a head elevated laryngoscopy position with the same patient in supine and 25° backup position. METHODS: A total of 180 patients aged between 18-65 years, planned for elective surgery under general anaesthesia with endotracheal intubation using Macintosh laryngoscope were included. Any patient with anticipated airway difficulty, emergency surgeries or rapid sequence induction was excluded. All patients were randomized into two groups (Group B=90, Group S= 90). In group S, the glottic view was assessed while the patients were in 25° back up HELP position (1st position). Then the patients were repositioned and intubated in supine HELP (2nd position) position after reassessing the glottic view. In group B, the glottic view was assessed while the patients were in the supine HELP position (1st position). Then the patients were repositioned and intubated in 25° backup HELP position (2nd position) after reassessing the glottic view. Percentage of glottis opening score (POGO), Cormack Lehane (CL) Grade, laryngoscopy time, intubation time, attempts for intubation, anaesthesiologists comfort, use of ancillary devices/ manoeuvres and ease of intubation were recorded. RESULTS: The mean POGO score was significantly more in 25° backup than supine position (n=180; 25° backup HELP: 64.78 ±26.83 % vs Supine HELP: 46.96±27.71 %, p- value< 0.0001). The Cormack Lehane grade was significantly higher in the supine HELP position than 25° backup HELP position (n=180, p-value<0.0001). The mean laryngoscopy time was comparable between two positions (n=180, Supine with HELP: 9.38±3.80 sec, 25° backup with HELP: 9.47±3.80 sec; p-value: 0.608). The mean intubation time was significantly shorter (p-value: 0.001) in Group B (7.7±2.2 seconds) than Group S (9.2± 3.6 seconds). CONCLUSIONS: This study has shown that 25° backup HELP position provides improved glottic view in comparison to the supine HELP position.

Heating, ventilation and air conditioning (HVAC) in intensive care unit.

The aim of this review is to describe variation in standards and guidelines on 'heating, ventilation and air-conditioning (HVAC)' system maintenance in the intensive care units, across the world, which is required to maintain good 'indoor air quality' as an important non-pharmacological strategy in preventing hospital-acquired infections. An online search and review of standards and guidelines published by various societies including American Institute of Architects (AIA), American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Centers for Disease Control and Prevention (CDC), Department of Health Estates and Facilities Division, Health Technical Memorandum 2025 (HTM) and Healthcare Infection Control Practices Advisory Committee (HICPAC) along with various national expert committee consensus statements, regional and hospital-based protocols available in a public domain were retrieved. Selected publications and textbooks describing HVAC structural aspects were also reviewed, and we described the basic structural details of HVAC system as well as variations in the practised standards of HVAC system in the ICU, worldwide. In summary, there is a need of universal standards for HVAC system with a specific mention on the type of ICU, which should be incorporated into existing infection control practice guidelines.

Development of a scoring system for predicting difficult intubation using ultrasonography.

BACKGROUND AND AIMS: Ultrasound measurement of anterior neck soft tissue thickness by skin to epiglottis distance (SED) has been shown to predict difficult laryngoscopy. In this study, we developed an airway scoring system incorporating SED into three clinical predictors and assessed whether it would improve accuracy in prediction of difficult intubation. METHODS: Mentohyoid distance, mandibular subluxation, head extension and ultrasound measurement of skin to epiglottis distance were measured a day before surgery in 310 adult patients. During direct laryngoscopy, Cormack-Lehane grading was noted (Grade 1 and 2 = Easy, Grade 3 and 4 = Difficult). We constructed a score named MSH, which included mentohyoid distance, mandibular subluxation and head extension. Then, SED was added to the MSH score to form another new score named USED-MSH. Student's t-test, Mann-Whitney U test and Chi-square test or Fisher exact tests were used. Both scoring systems were compared under the receiver-operating characteristic curve and area under the curve (AUC) were calculated. RESULTS: Difficult intubation was observed in 62/310 patients (20%). The AUC for USED-MSH score was greater than the MSH score (0.93, 95% CI [0.89-0.97] vs 0.76, 95% CI [0.69-0.84], P value <0.001). USED-MSH score had higher sensitivity (93.6% vs 59.7%) and lower specificity (85.9% vs 91.1%) with similar positive predictive value (62.7% vs 62.4%) in comparison with MSH score. CONCLUSION: An airway scoring system using the ultrasound measurements of skin-to-epiglottis distance along with the clinical predictors would be helpful in the prediction of difficult intubation.

Ipsilateral hemidiaphragmatic paresis after a supraclavicular and costoclavicular brachial plexus block: A randomised observer blinded study.

BACKGROUND: The costoclavicular brachial plexus block (BPB) produces faster onset of sensory motor blockade than the lateral sagittal approach. However, the incidence of phrenic nerve palsy (PNP) after a costoclavicular BPB is not known. OBJECTIVES: The current study compared the incidence of ipsilateral hemidiaphragmatic paresis, and thus PNP, between a supraclavicular and costoclavicular BPB. DESIGN: Randomised observer blinded study. SETTING: Operating room. PATIENTS: Forty patients undergoing right-sided upper extremity surgery. INTERVENTION: All patients received either a supraclavicular group or costoclavicular group BPB using 20 ml of an equal mixture of 0.5% bupivacaine and 2% lidocaine with 1 : 200 000 epinephrine. MAIN OUTCOME MEASURES: Measurements included ipsilateral hemidiaphragmatic excursion and peak expiratory flow rate (PEFR) taken before and at 30 min after the BPB. Diaphragmatic excursion was measured using M-mode ultrasound during normal breathing, deep breathing and with the sniff manoeuvre. Ipsilateral PNP was defined as a reduction in hemidiaphragmatic excursion by at least 50% during deep breathing at 30 min after the BPB. RESULTS: The incidence of ipsilateral PNP was lower (P = 0.008) in the costoclavicular group (5%) than in the supraclavicular group (45%). Fewer (P = 0.04) patients in the costoclavicular group [1(5%)] exhibited a positive sniff test, with paradoxical movement of the diaphragm, than in the supraclavicular group [7(35%)]. PEFRs were similar (P = 0.09) between the groups. When ipsilateral hemidiaphragmatic paresis was present, the median reduction in PEFR was 32% (interquartile range 23.6 to 45.5%). CONCLUSION: Costoclavicular BPB produces a lower incidence of ipsilateral PNP than a supraclavicular BPB. NAME OF REGISTRY: Clinical Trial Registry of India. IDENTIFIER: CTRI/2017/09/009763.

Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding - continuous vs. intermittent in head-injured critically ill patients.

INTRODUCTION: Measurement of respiratory quotient (RQ) and resting energy expenditure (REE) has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE. METHODS: After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds (30 kcal/kg/day) were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds (30 kcal/kg/day) were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. RESULTS: Demographic profile and SOFA score were comparable in the two groups. Base line RQ (0.8 vs. 0.86) and REE (1527 vs. 1599 kcal/day) were comparable in both the groups (P>0.05). RQ was comparable in both groups during the study period at any time of the day (P>0.05). Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups (P>0.05). REE was comparable in both the groups throughout the study period (P>0.5). Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups (P>0.05). CONCLUSION: We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup.

Filgrastim as a rescue therapy for persistent neutropenia in a case of dengue hemorrhagic Fever with acute respiratory distress syndrome and myocarditis.

Pathogenesis of dengue involves suppression of immune system leading to development of characteristic presentation of haematological picture of thrombocytopenia and leucopenia. Sometimes, this suppression in immune response is responsible for deterioration in clinical status of the patient in spite of all specific and supportive therapy. Certain drugs like steroids are used for rescue therapy in conditions like sepsis. We present a novel use of filgrastim as a rescue therapy in a patient with dengue hemorrhagic fever (DHF) with acute respiratory distress syndrome (ARDS), myocarditis, and febrile neutropenia and not responding to standard management.