A Rare Case of Postoperative Extradural Hematoma in the Posterior Fossa Complicated by Both Stunned Myocardium and Neurogenic Pulmonary Edema.

Acute neurological insult can trigger a cascade of events in other organ systems such as the heart and lung. Neurogenic stunned myocardium (NSM) and Neurogenic pulmonary edema (NPE) are mostly reported after stroke, subarachnoid hemorrhage, or seizures whenever sympathetic storm and autonomic dysregulation occurs. We report here for the first time, a case of postoperative infratentorial extradural hematoma in a patient triggering NSM and NPE at the same time. The challenges involved in the management of such a patient are described in this case report. The patient was successfully managed and discharged home with no new neurological deficits.

Healthcare-associated Infections in Pediatric Patients in Neurotrauma Intensive Care Unit: A Retrospective Analysis.

BACKGROUND: Healthcare-associated infections (HAIs) can impact the outcome following traumatic brain injury (TBI) in children. We undertook a retrospective observational study to see the incidence, risk factors, and microbiological profile for HAIs in pediatric TBI. We also studied the impact of baseline patient characteristics, HAIs on patient outcome, and antibiotic resistance of different types of bacteria. MATERIALS AND METHODS: Data on pediatric TBI patients of age up to 12 years were collected via a computerized patient record system (CPRS) from January 2012 to December 2018. Descriptive Chi-square test and Wilcoxon signed rank test were used to characterize baseline parameters. General linear regression models were run to find an unadjusted and adjusted odds ratio (OR). RESULTS: HAIs were found in 144 (34%) out of 423 patients. The most commonly seen infections were of the respiratory tract in 73 (17.26%) subjects. The most predominant microorganism isolated was Acinetobacter baumannii in 188 (41%) samples. A. baumannii was sensitive to colistin in 91 (48.4%) patients. Male gender (OR 0.630; p-value 0.035), fall from height (OR 0.374; p-value 0.008), and higher injury severity scale (ISS) (OR 1.040; p-value 0.002) were independent risk factors for development of HAIs. Severe TBI, higher ISS and Marshall grade, and HAIs were significantly associated with poor patient outcome. CONCLUSION: Severe TBI poses a significant risk of HAIs. The most common site was the respiratory tract, predominately infected with A. baumannii. HAIs in pediatric TBI patients resulted in poor patient outcome. HOW TO CITE THIS ARTICLE: Prasad C, Bindra A, Singh P, Singh GP, Singh PK, Mathur P. Healthcare-associated Infections in Pediatric Patients in Neurotrauma Intensive Care Unit: A Retrospective Analysis. Indian J Crit Care Med 2021;25(11):1308-1313.

The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position.

Objective Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay. Materials and Methods Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18-60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients ( n = 15) served as control group and received SFT intraoperatively, while patients in group G ( n = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV AI ) and before extubation (CLV BE ). Statistical Analysis and Results CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p -value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G ( p -value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower ( p -value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable. Conclusion GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial].

BACKGROUND: Elective percutaneous tracheostomy [PCT] is the widely performed procedure in neurocritically ill patients as an airway management choice in neurocritical care unit [NICU]. Intracranial pressure [ICP] is a vital parameter to be monitored in these patients while undergoing any surgical procedure including PCT. Optic nerve sheath diameter [ONSD], being a surrogate of ICP, can be done bedside and carries less complications than invasive ICP monitoring. The aim of our study was to assess the effect of PCT on ONSD at different stages of PCT. MATERIALS AND METHODS: A total of 158 patients with various intracranial pathologies scheduled for PCT in NICU were screened for eligibility in our study. We assessed mean values of ONSD, HR, MBP, and SpO2 for changes over various time points during PCT using generalized estimating equation (GEE). A p value of <0.05 was considered significant. RESULTS: A total of 135 patients who underwent PCT were analyzed for the study. The values of ONSD changed significantly at different stages of PCT procedure compared to baseline. The baseline ONSD value was 0.39 ± 0.05 cm. ONSD rose significantly to 0.40 ± 0.06 cm during positioning, 0.41 ± 0.06 cm during skin incision, 0.42 ± 0.07 cm during dilatation of tract, 0.41 ± 0.07 cm during insertion of tracheostomy, and 0.41 ± 0.06 cm at the end of the procedure. CONCLUSIONS: PCT leads to a significant rise of ONSD values during all stages of PCT. The available evidences point toward detrimental rise in ICP during PCT. ICP can be monitored noninvasively by measuring ONSD using bedside ultrasound. HOW TO CITE THIS ARTICLE: Kapoor I, Wanchoo J, Mahajan C, Singhal V, Roy H, Kumar S, et al. Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]. Indian J Crit Care Med 2021;25(4):382-387.

Non-invasive ventilation (NIV) induced bilateral subcutaneous emphysema in SARS COV-2 patient: A rare occurrence.

A patient with coronavirus disease-2019 (COVID-19) developed bilateral subcutaneous emphysema involving the neck and upper chest following the institution of non-invasive ventilation (NIV) for worsening hypoxia. We discuss the various causes, differentials and successful management of this patient.

Pectoral nerve versus erector spinae block for breast surgeries: A randomised controlled trial.

BACKGROUND AND AIMS: Patients undergoing breast cancer surgeries face significant post-operative pain. We aimed to compare pectoral nerve (PECS) block with erector spinae (ESP) block in these patients in terms of analgesic efficacy and adverse effects. METHODS: Sixty four American Society of Anesthesiologists' status I and II female patients between age 18 to 60 years scheduled for unilateral modified radical mastectomy (MRM) under general anaesthesia, were enrolled in this prospective randomised study. Patients in group I received ultrasound guided (USG) ESP block (20 cc 0.2% ropivacaine) while group II received USG guided PECS II block (25 cc 0.2% ropivacaine). General anaesthesia was administered in a standardised manner to both the groups. The various parameters observed included sensory blockade, duration of analgesia and any adverse effects. The primary outcome was the total morphine consumption in 24 hours. RESULTS: The total morphine consumption in 24 hours was less in group II (4.40 ± 0.94 mg), compared to group I (6.59 ± 1.35 mg; P = 0.000). The mean duration of analgesia in patients of group II was 7.26 ± 0.69 hours while that in the group I was 5.87 ± 1. 47 hours (P value = 0.001). 26 patients in group II (PECS) had blockade of T2 as compared to only 10 patients in group I. (P value = 0.00). There was no incidence of adverse effects in either group. CONCLUSION: PECS II block is a more effective block when compared to ESP block in patients of MRM in terms of postoperative analgesia and opioid consumption.

Intraoperative Generalized Tonic-Clonic Seizure and Consequent Severe Brain Bulge During Functional Motor Cortex Mapping: A Case Report.

Intraoperative cortical and subcortical bipolar or monopolar mapping is the gold standard for neurosurgical procedures that involve lesions near functional or "eloquent" cortex. However, the classic Penfield stimulation has a higher intraoperative seizure rate than high-frequency short-train stimulation. As a result, high-frequency monopolar stimulation is now the most widely practiced technique. However, seizure-free mapping cannot be guaranteed even with high-frequency stimulation particularly at high current thresholds. We encountered a case of severe generalized tonic-clonic seizure and consequent severe brain bulge in an 8-year-old child during cortical mapping with the high-frequency protocol.

Post-operative analgesic effect of dexmedetomidine administration in wound infiltration for abdominal hysterectomy: A randomised control study.

BACKGROUND AND AIMS: Local infiltration of the surgical wound is one of the important components of multimodal analgesia for post-operative pain relief. This study determines the post-operative analgesic effect of addition of dexmedetomidine to bupivacaine for local infiltration of the surgical wound. METHODS: Sixty women belonging to American Society of Anesthesiologists' Grade 1 or 2 posted for abdominal hysterectomy were randomly allocated to Group I (control group) where patients received wound infiltration with 30 mL 0.25% bupivacaine at the end of surgery, or Group II, where patients received wound infiltration with 1.0 µg/kg dexmedetomidine diluted in 30 mL 0.25% bupivacaine. The primary objective of the study was to assess post-operative pain scores. Number of patients requiring rescue analgesia and total morphine consumption during 24 h after surgery were also recorded. Statistical significance for analgesic requirement was determined by one-way analysis of variance. RESULTS: Pain scores were lower at rest for 12 h and on cough for 6 h in Group II (<0.01). All patients in Group I required supplemental morphine compared to only 3 patients in Group II (P < 0.003). Post-operative analgesia requirement was significantly less in patients receiving dexmedetomidine in wound infiltration compared to patients receiving bupivacaine alone (P < 0.001). CONCLUSIONS: Wound infiltration of dexmedetomidine with bupivacaine provides superior pain relief compared to bupivacaine alone.

A randomized controlled study between fentanyl and Butorphanol with low dose intrathecal bupivacaine to facilitate early postoperative ambulation in urological procedures.

INTRODUCTION: Opioids are widely used in conjunction with local anesthetics as they permit the use of lower dose of local anesthetics while providing adequate anesthesia and analgesia. It both provides adequate anesthesia as well as lower drug toxicity neuraxial administration of opioids in conjunction with local anesthetics improves the quality of intraoperative analgesia and prolongs the duration of postoperative analgesia. Bupivacaine is the most commonly used drug for subarachnoid block due to its lesser side effects. The present study was conducted to decrease the overall dose of local anesthetics with opioid combination for urological procedure with respect to quality of anesthesia and recovery with patient's satisfaction. MATERIALS AND METHODS: The study population was randomly allocated by computer generated table into two groups; Group A: 5 mg 0.5% bupivacaine + 25 mcg and Group B: 5 mg 0.5% bupivacaine + 25 mg butorphanol. RESULTS: Highest level of sensory block was T9 and T8 with the fentanyl group and butorphanol group, respectively. The onset of sensory block was early in fentanyl group than butorphanol group. Duration of both sensory and motor block was significantly higher in butorphanol group. There was no incidence of itching in both groups. There were two patients in fentanyl group and one in butorphanol with hypotension for which injection mephentermine was given. Two patients in fentanyl group complained of nausea and vomiting, for which injection ondansetron was given. One patient complained of pain in fentanyl group for which injection propofol with injection fentanyl was supplemented. CONCLUSION: Low-dose bupivacaine with butorphanol group was devoid of any side effects in the present study but low dose bupivacaine in addition with fentanyl is superior in terms of early postoperative recovery resulting in early discharge and better outcome in comparison to bupivacaine and butorphanol group, which is beneficial in elderly patients with comorbidity.