A rare case of huge frontoethmoidal encephalocele projecting through mouth, with cleft palate.

Frontoethmoidal encephalocele represents protrusion of meninges and brain in a sac through a defect in the anterior skull base, mostly as swelling over the nose. Rarely it is associated with facial dysmorphism and palatal cleft. There are various perioperative concerns like airway difficulties, leaking from the swelling causing fluid and electrolyte disturbances, risk of infection, compression of the swelling causing a rise in intracranial pressure, bleeding, hypothermia, etc., In neonates, these challenges rise exponentially because of the inherent difficulties in dealing with this group of patients. Frontoethmoidal encephaloceles are common in low socioeconomic strata and are often missed in the antenatal period. We are reporting a rare case of frontoethmoidal encephalocele, with a huge swelling protruding through the cleft palate and occupying more than 50% of the face and oral cavity, making mask ventilation impossible.

Comparison of Oxygen Delivery Devices in Postoperative Patients with Hypoxemia: An Open-labeled Randomized Controlled Study.

Background: Acute hypoxemic respiratory failure is among the more commonly occurring complications in postoperative patients. Supplemental oxygen and addressing the primary etiology form the basis of its treatment. Materials and methods: We conducted an open-labeled randomized control trial with 90 adult patients and compared three oxygen delivery vehicles (ODV), i.e., noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and venturi mask (VM) in postoperative hypoxemic patients. The primary outcome variable was a change in the P/F ratio after 2 hours of use of ODV. Results: It was observed that the change in P/F ratio after 2 hours was similar in all three ODV groups (p = 0.274). The mean values of the post-ODV P/F ratio were comparable with the pre-ODV P/F ratio in all three modalities. The P/F ratio after HFNC was 358.08 ± 117.95; after NIV was 357.60 ± 220.67; and after VM was 355.47 ± 101.90 (p = 0.997). Conclusion: Among HFNC, NIV, and VM, none of the devices proved superior to the other for use in postoperative hypoxemia. How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod D, Meshram T, et al. Comparison of Oxygen Delivery Devices in Postoperative Patients with Hypoxemia: An Open-labeled Randomized Controlled Study. Indian J Crit Care Med 2024;28(3):294-298.

Effects of Different Extubation Strategies on Atelectasis in Older Adults after Major Abdominal Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: Older patients are particularly vulnerable to age-related respiratory changes. This prospective randomized controlled trial studied the effects of high and low fractions of inspired oxygen (FiO2) with the recruitment maneuver (RM) during extubation on lung atelectasis postoperatively in older patients undergoing major abdominal surgery. METHODS: We randomized a total of 126 patients aged >60 years who underwent both elective and emergency major abdominal surgeries and met the inclusion criteria into three groups (H, HR, and LR) using computer-generated block randomization. Group H received high FiO2 (1), Group HR received high FiO2 (1) with RM followed by a positive end-expiratory pressure of 5 cm H2O, and Group LR received low FiO2 (0.4) with RM followed by a positive end-expiratory pressure of 5 cm H2O 10 minutes before extubation. Oxygenation and atelectasis were measured using the arterial partial pressure of oxygen (PaO2)/FiO2 ratios and lung ultrasound score. Postoperative pulmonary complications were recorded up to 24 hours postoperatively. RESULTS: The mean PaO2/FiO2 at 30 minutes post-extubation was significantly higher in Groups LR and HR compared to that in Group H (390.71±29.55, 381.97±24.97, and 355.37±31.70; p<0.001). In the immediate postoperative period, the median lung ultrasound score was higher in Group H than that in Groups LR and HR (6 [5-7], 3 [3-5], and 3.5 [2.25-4.75]; p<0.001). The incidence of oxygen desaturation and oxygen requirements was higher in Group H during the postoperative period. CONCLUSION: The RM before extubation is beneficial in reducing atelectasis and postoperative pulmonary complications, irrespective of the FiO2 concentration used in older adults undergoing major abdominal surgeries. (Trail registration number: Reference No. CTRI/2022/04/042115; date of CTRI registration 25/02/2022; and date of enrolment of the first research participant 05/05/2022).

Comparison of procedural time with two different ultrasound-guided approaches for dorsalis pedis artery cannulation in adult patients: A randomized trial.

BACKGROUND: In adult patients, there has never been an evaluation of short-axis out-of-plane versus long-axis in-plane approaches of ultrasound-guided dorsalis pedis artery cannulation. This research was conducted to compare these two techniques to cannulate the dorsal pedis artery. METHODS: In this trial, 128 adult patients undergoing surgery and necessitating arterial cannulation were examined. Dorsalis pedis artery cannulation was performed utilizing an ultrasound by long-axis in-plane approach (group L) or short-axis out-of-plane (group S) techniques. RESULTS: Group S had a higher first attempt success rate than group L (46.9% vs 28.6%, p = 0.039). The S group had a lower assessment time than the L group (11.48 ± 3.07 vs 19.68 ± 2.79 s; p = 0.000). Cannulation time was higher in the S group (18.91 ± 1.92 s) compared to the L group (12.48 ± 1.61 s; p = 0.000). Nevertheless, the total procedure time was comparable between the L group and the S group (32.16 ± 2.95 vs 30.42 ± 4.07 s; p = 0.107). CONCLUSIONS: In adults, both views of ultrasonography can be used to guide DPA cannulation. The cannulation time for the DPA in L group was less than the S group, whereas the assessment time was less in S group. The total procedure time, however, was similar between both the groups.

A randomized controlled trial comparing ultrasound-guided versus traditional palpatory methods of posterior tibial artery cannulation in adult patients.

BACKGROUND: The palpation method of posterior tibial artery cannulation has not yet been compared to ultrasound-guided posterior tibial artery cannulation in adults. This research examined whether using ultrasound to cannulate the posterior tibial artery enhances first-pass cannulation success and lowers total procedure time. METHODS: In this randomized controlled experiment, 76 adult patients were included who were undergoing surgery under general anesthesia and required artery cannulation. Cannulation of the posterior tibial artery was performed utilizing either an ultrasound-assisted method (group U) or a palpation method (group P). Data were analyzed for cannulation success on the first attempt, number of cannulation attempts, assessment time, cannulation time, and total procedure time. RESULTS: The P group had a considerably shorter mean assessment time than the U group [14.29 ± 2.79 s vs 20.89 ± 2.70 s; p < .001]. Moreover, cannulation time was substantially longer in the P (29.20 ± 12.60 s) than in the U group (15.90 ± 6.50 s) (p < .001). The total procedure time remained statistically more in the P group than in the U group (p = 0.007). The rate of successful posterior tibial artery cannulation on the first attempt was comparable between the two groups (63.2% in the U and 55.3% in the P group, respectively; p = .484)]. CONCLUSIONS: The posterior tibial artery may be a suitable alternative to arterial cannulation for individuals with multiple failed attempts or difficult access. The application of ultrasound during posterior tibial artery cannulation in adult patients is safe and feasible and accompanied by a reduction in cannulation and total procedure time. The rate of first-attempt successful posterior tibial artery cannulation was comparable between the two groups.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

Background and Aims: A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. Material and Methods: This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. Results: The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Conclusion: Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Intravenous cannula for percutaneous rescue needle gastrostomy in a neonate with tracheoesophageal fistula-A case report.

Tracheoesophageal fistula offers concrete difficulties for anesthesiologists, which comprise associated congenital anomalies and more importantly the problems concerning ventilation and oxygenation. Among all the types of tracheoesophageal fistula, ventilatory problems are frequently encountered with type C fistula. Effective ventilation can be a challenge in such cases where the endotracheal tube invariably ventilates the fistula causing stomach inflation and respiratory compromise. Thorough knowledge and experience are of utmost importance when it comes to the successful airway management and better survival of neonates undergoing tracheoesophageal fistula repair. We report a case of a 3-day-old neonate, diagnosed with type C tracheoesophageal fistula and esophageal atresia posted for thoracoscopic repair. We want to highlight our experience of percutaneous needle gastrostomy done using an intravenous cannula, as a rescue measure for stomach decompression, to manage life-threatening hypoxia.

Norepinephrine versus phenylephrine for postspinal hypotension in parturients undergoing cesarean section: a systematic review and meta-analysis.

INTRODUCTION: Multiple studies have compared varying prophylactic and therapeutic doses of norepinephrine and phenylephrine given as either intermittent bolus or fixed-rate infusion to combat postspinal hypotension in patients undergoing cesarean section (CS). We conducted a systematic review to figure out the best alternative to treat postspinal hypotension. EVIDENCE ACQUISITION: PubMed and Cochrane databases were extensively searched for eligible RCTs. A total of 15 studies were found eligible and analyzed for the incidence of maternal bradycardia as the primary outcome and other maternal adverse effects, fetal acidosis and Apgar scores at 1 and 5 min as the secondary outcome. Data was analyzed using Review Manager Version 5.3. software. EVIDENCE SYNTHESIS: There was no significant difference in the efficacy of norepinephrine and phenylephrine for managing postspinal hypotension (OR=1.15 [95% CI: 0.91-1.45], P=0.24, I2=0%,moderate quality) in parturients undergoing CS. Odds of incidence of maternal bradycardia decrease significantly by 61% with norepinephrine versus phenylephrine (OR=0.39 [95% CI: 0.31-0.49], P<0.00001, I2=27%, high quality evidence). Significant higher umbilical artery mean pH values were observed with NE versus PE (MD=0.0 [95% CI: 0.00 to 0.01], P=0.03), although not clinical relevant. However, no significant difference was found in the incidence of other maternal adverse effects and fetal outcomes. CONCLUSIONS: Comparable efficacy for management of postspinal hypotension, though, norepinephrine was found to cause less incidence of maternal bradycardia as compared to phenylephrine.

Airway challenges in an adult with hemifacial microsomia along with neglected cleft palate: what to expect?

A female patient in her early 20s, with a known diagnosis of hemifacial microsomia (unilateral microtia and mandibular hypoplasia) accompanied with an unoperated cleft palate, came for an infected mandibular distraction plate removal. The anticipated difficult airway and lack of enough literature about what to expect in such a scenario, along with the psychological impact on the patient, made this case challenging and thought-provoking. Inability to perform the awake tracheal intubation because of the uncooperative patient, along with the difficult fibreoptic owing to narrowed nostrils, offered an extra set of challenges.

Haemodynamic responses following orotracheal intubation in patients with hypertension---Macintosh direct laryngoscope versus Glidescope®videolaryngoscope.

BACKGROUND AND AIMS: Glidescope®videolaryngoscope (GVL) is a video intubation system with 60° angle blade that provides excellent laryngeal view, does not require alignment of oral, pharyngeal, and laryngeal axes for visualisation of glottis, thus causing less stimulation of orolaryngopharynx. The aim of this study was to compare haemodynamic responses (blood pressure and heart rate) and airway morbidity using the Macintosh direct laryngoscope (MDL) and the Glidescope®videolaryngoscope (GVL) in hypertensive patients. METHODS: Fifty patients with hypertension controlled on antihypertensive medications scheduled for elective surgery under general anaesthesia were randomly assigned to group GVL (n = 25) or group MDL (n = 25). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) were recorded at baseline, after induction, pre-intubation, at intubation, 1, 2, 3, 4, and 5 min after intubation. Time to intubation, number of attempts, complications during intubation, and postoperative airway complications (sore throat, hoarseness, dysphagia, and cough) were also recorded. RESULTS: There was a statistically significant increase in SBP, DBP, and MBP at intubation [(P = 0.003, 0.013, 0.03), 1 min (P = 0.001, 0.012, 0.02), 2 min (P = 0.04, 0.02, 0.04), and 3 min (P = 0.02, 0.01)] in the MDL group as compared to GVL group. The time to intubate was significantly greater in the GVL group as compared to MDL group (P = 0.0006). There was no significant difference in the incidence of intraoperative and postoperative airway complications. CONCLUSION: In the hands of an experienced anaesthesiologist, the use of GVL in controlled hypertensive patients is associated with less haemodynamic response as compared to Macintosh Laryngoscope without any increase in airway complications.

Midazolam versus dexamethasone-ondansetron in preventing post-operative nausea-vomiting in patients undergoing laparoscopic surgeries.

BACKGROUND: Midazolam reduces post-operative nausea and vomiting (PONV) when compared to a placebo or when used as an adjuvant to other antiemetics. The present study was designed to compare midazolam with a combination of dexamethasone-ondansetron in preventing PONV. METHODS: One hundred and twenty patients undergoing laparoscopic surgeries having 2 or more risk factors for PONV (simplified Apfel score) were randomised into 2 groups of 60 each. Patients in group D received 8-mg dexamethasone and 4-mg ondansetron for PONV prophylaxis while those in group M received 2-mg midazolam towards the end of surgery. The proportion of patients (frequency) who had PONV, post-operative nausea (PON) and post-operative vomiting (POV) was noted over 24 hours over the following intervals: 0-2 hours, 2-24 hours and 0-24 hours. RESULTS: The frequency of PONV at 24 hours in group D and group M was 30% and 33.3% respectively and was not significantly different (P = .70). There was no difference in the time to achieve post-anaesthesia discharge score of ≥9 between the two groups {5 minutes (5, 5) in group D; 5 minutes (1.25, 5) in group M, P = .48}. Ten patients in group D and 11 in group M required a rescue antiemetic over 24 hours (P = .81). The frequency of PON, POV and PONV as well as the median PONV score was similar at all time periods. CONCLUSION: Midazolam does not result in significantly different frequency of PONV than a combination of dexamethasone-ondansetron.