Dorsalis pedis cannulation: An overlooked option-A case report.

Radial artery is mostly used for arterial cannulation because of its location, collateral circulation, and less complications. Dorsalis pedis artery can be an alternative for arterial cannulation in difficult radial or brachial arteries cannulation situations as it is mostly overlooked. We present a case of a 45-year-old female planned for supratentorial craniotomy for excision of meningioma. After induction of anesthesia, the invasive access couldn't be attained after multiple attempts under ultrasound guidance by five senior anesthesiologists. The surgery was abandoned, and the patient awakened. The case was rescheduled after 2 days. The new anesthesia team attained the arterial access in the right dorsalis pedis artery and the central venous access in the right internal jugular vein in the first attempt. No complications were noted post-operatively. The dorsalis pedis artery can be safely used for arterial cannulation when radial artery cannulation is not possible.

Hospital based prevalence of smoking among surgical patients in tertiary care hospitals of Karachi Pakistan.

OBJECTIVE: To determine the prevalence of smoking and to evaluate the knowledge about preoperative smoking cessation in patients coming for elective surgery. METHODS: The cross-sectional study was conducted from July 30, 2019, to March 17, 2020, in the preoperative anaesthesia assessment clinic and surgical wards of Aga Khan University Hospital, Civil Hospital Karachi, and Abbasi Shaheed Hospital, Karachi, and comprised all patients of either gender aged >12 years scheduled for elective surgery having American Society of Anaesthesiologists physical status I-IV. Data was analysed using Stata 13. RESULTS: Of the 811 patients, 478(59%) were male and 333(41%) were female. The overall mean age was 43.4±16.4 years and mean BMI was 25.0±5.8kg/m2. There were 164(20.2%) smokers in the sample. The overall knowledge about preoperative smoking cessation was significantly associated with the level of education and gender (p<0.05). CONCLUSIONS: Smoking in surgical patients was about one-fifth of the overall sample, and knowledge related to preoperative smoking abstinence was significantly associated with educational status and gender.

Incidence and risk factors of delirium in surgical intensive care unit.

BACKGROUND: To evaluate the incidence and modifiable risk factors of delirium in surgical intensive care unit (SICU) of tertiary care hospital in a low-income and middle-income country. METHODS: We conducted a single cohort observational study in patients over 18 years of age who were admitted to the SICU for >24 hours in Aga Khan University Hospital from January to December 2016. Patients who had pre-existing cognitive dysfunction were excluded. Intensive Care Delirium Screening Checklist was used to assess delirium. Incidence of delirium was computed, and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors. RESULTS: The average patient age was 43.29±17.38 and body mass index was 26.25±3.57 kg/m2. Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. Multivariable analysis showed chronic obstructive pulmonary disease, pain score >4 and hypernatremia were strong predictors of delirium. Midazolam (adjusted OR (aOR)=7.37; 95% CI 2.04 to 26.61) and propofol exposure (aOR=7.02; 95% CI 1.92 to 25.76) were the strongest independent predictors of delirium while analgesic exposures were not statistically significant to predict delirium in multivariable analysis. CONCLUSION: Delirium is a significant risk factor of poor outcome in SICU. There was an independent association between pain, sedation, COPD, hypernatremia and fever in developing delirium. LEVEL OF EVIDENCE: IV.

Transversus abdominis plane block as a sole anesthetic technique for open appendectomy in patient with Treacher Collins syndrome: a case report.

Patients with Treacher Collins syndrome (TCS) present serious challenges to anesthetist in securing of airway; upper airway obstruction and difficult tracheal intubation are considered complex entity in these patients. This case report describes the significance of transversus abdominis plane (TAP) block as a sole anesthetic choice in appendectomy where airway management can be avoided. A 17-year-old boy, known case of TCS, presented with acute appendicitis underwent emergency laparotomy. Surgery was successfully performed by TAP block with dexmedetomidine infusion. Open appendectomy can be performed successfully in certain circumstances under TAP block with adjunctive use of dexmedetomidine infusion where airway handling is avoided. Further studies are warranted to distinct its use as sole anesthetic choice in lower abdominal surgeries.

Awareness during Cardiopulmonary Resuscitation.

Checking responsiveness is the mainstay in cardiopulmonary resuscitation (CPR). It is rare in the clinical situation when the patient requires resuscitation despite the presence of wakefulness. We report a case in which the patient presented with flat arterial line and absence carotid pulse while he was awake. A thorough literature review will also be discussed. HOW TO CITE THIS ARTICLE: Asghar A, Salim B, Tahir S, Islam F, Khan MF. Awareness during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020;24(2):136-137.

Attitudes and knowledge of anesthesiology trainees to radiation exposure in a Tertiary care hospital.

BACKGROUND AND AIMS: Ionizing radiation procedures are indispensable in medical clinical practice. Exposure to radiation at any dose could have serious adverse effects. Anesthesiologists working in interventional radiology suites are at a higher risk of radiation exposure than other personnel. The aim of this study was to assess the knowledge and attitude of anesthesiology trainees towards the radiation hazards and current safety practices. METHODS: This prospective cross-sectional survey was conducted at the department of anesthesiology at Aga Khan University. All anesthesiology trainees working in the department were given a 12-question paper-based survey after getting ethical review committee approval and informed consent. The questionnaire contained requests for personal demographic data and specific questions regarding radiation protection. RESULTS: A total of 54 participants were included in this survey. Thirty-two (59.3%) were male, and 22 (40.7%) were female. The average year of experience working in anesthesia of the participants was 2.8 ± 1.65 years (range, one to eight years). Frequency of radiation exposure of 32 (59.3%) participants was 1-5 times per week. Approximately 68.5% (37/54) of participants believed they took adequate precautions for protection against radiation. Only 20.4% (11/54) used both a lead apron and a thyroid shield for prevention of radiation exposure. Most participants using the radiation shield or clothing (70.4%; 38/54) cited concerns about cancer. CONCLUSIONS: A lack of knowledge persists among anesthesiology trainees in our institute regarding the risks associated with ionizing radiation. This study also serves to highlight the need for anesthesiology trainees to protect themselves properly. Radiation dose, hazards, and protection strategies must be included in the basic curriculum of medical colleges.

Correlation of Optic Nerve Sheath Diameter with Direct Measurement of Intracranial Pressure through an External Ventricular Drain.

Background Early diagnosis and management of raised intracranial pressure (ICP) is essential for preventing brain damage and even death. Invasive monitoring is the gold standard to measure raised ICP but it may not be feasible in a heterogeneous group of patients. Noninvasively, a simple bedside ocular ultrasound can detect elevated ICP. The aim of our study was to evaluate the correlation between optic nerve sheath diameter (ONSD) and direct ICP measurements and to determine sensitivity and specificity of ONSD measurements to detect elevated ICP (>15 cm H2O). Methods This prospective study was conducted at the intensive care unit/high dependency units/wards of Aga Khan University Hospital. Patients with external ventricular drain (EVD) for intracranial hypertension were enrolled. Ocular ultrasound was performed with a 7.5 MHz linear probe. For each subject, three measurements on each eye were performed and the mean of the six measurements was determined. EVD was temporarily occluded and the ICP was recorded every minute for five minutes. A receiver operative characteristics (ROC) curve was constructed to determine the optimal ONSD cutoff to detect ICP above 15 cm H2O. Results A total of 35 adult patients were included in this study. The ONSD was linearly correlated with ICP in both right and left eyes (r = 0.662, p = 0.0005 and r = 0.449; p < 0.002) respectively. Pearson correlation of ONSD between two eyes (right and left) was 0.749; p = 0.0005 and 0.726; p = 0.005 at day 1 and day 2, respectively. ROC curve was created and observed that AUC of right and left eyes was 0.815 (95% CI: 0.61 to 0.99) and 0.69 (95% CI: 0.37 to 0.99). Conclusion According to this study, ventriculostomy measurements of ICP are directly correlated with ultrasound ONSD measurements. Hence, we conclude that ONSD measured by ocular ultrasound is a simple yet effective method to detect raised ICP.

Effect of Pharmacological Agents Administered for Attenuating the Extubation Response on the Quality of Extubation: A Systematic Review.

Background Several drugs have been tried to obtund the hemodynamic extubation response but all have variable side effects that may affect the quality of short-term recovery. Objective Our primary objective was to evaluate the effect of pharmacological agents, such as dexmedetomidine, local anesthetics, and so on, administered for attenuating the extubation response on the quality of extubation, as judged by the presence or absence of cough, sedation, and laryngospasm/bronchospasm in adult patients who had undergone general anesthesia. A secondary objective was to evaluate the effect of these drugs on other immediate post-extubation complications such as respiratory depression, desaturation, bradycardia, hypotension, and nausea and vomiting (PONV). Methods This is a systematic review of (randomized controlled trials) RCTs with meta-analysis. The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for RCTs on the effect of pharmacological agents on both the hemodynamic extubation response as well as the quality of extubation. Results Fourteen out of 24 included studies were subjected to a meta-analysis. The risk of cough was less likely in the intervention group as compared to control groups (OR 0.26, 95% CI 0.15 to 0.46, p<0.00001, I2=35%). Sedation, hypotension (OR= 10.47; 95% CI: 1.86, 58.80, p=0.008, I2=0%), and bradycardia (OR= 6.57; 95% CI: 2.09, 20.64, p=0.001, I2=0%) were reported with dexmedetomidine. Only one study reported laryngospasm with dexmedetomidine and two studies with opioids. Conclusion Dexmedetomidine 0.4 to 0.5 ug/kg was associated with smooth extubation, minimal coughing, no laryngospasm/ bronchospasm, and with stable hemodynamics, without causing respiratory depression, PONV, and desaturation. However, in higher doses (more than 0.5 ug/kg), it caused bradycardia, hypotension, and sedation. Other pharmacological agents, such as local anesthetics, calcium channel blockers, and opioids, did not attenuate cough associated with extubation.

Anaesthetic Management in a Child with Goldenhar Syndrome.

Goldenhar syndrome is a congenital disorder involving deformities of the face. It usually affects one side of the face only and poses significant challenges in the airway management. We herein, report an 8-year boy, known case of Goldenhar syndrome, who presented to our radiology suite for a magnetic resonance imaging (MRI) brain, followed by a computed tomography (CT) scan brain. The boy had various features of Goldenhar syndrome, e.g. cleft palate, absent right eye and ear, right mandibular hypoplasia, micrognathia, and preauricular tags. His developmental milestones were delayed. Airway evaluation showed Mallampati class II with limited movements of head and neck, which suggested possibility of difficult laryngoscopy and intubation. He had no vertebral anomalies or cardiac disease. A difficult airway continues to be a major cause of anaesthesia-related morbidity and mortality; and maintaining spontaneous breathing remains a vital technique in its management. Lack of anaesthesia-related complications with supraglottic devices encouraged us to present the advantage of utilising a laryngeal mask airway (LMA) under anaesthesia for successful management of predicted difficult airway.