Arterial and venous thrombosis in a patient with Covid-19: A unique presentation.

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) infection not only affects the respiratory system but also induces coagulation abnormalities and thrombosis. We report a middle-aged woman who presented during the Covid-19 pandemic with sudden-onset acute left upper limb ischaemia of short duration, with no history of dry cough, breathlessness or fever, and tested positive on TrueNAT for SARS-CoV-2. Later, she developed deep venous thrombosis of the right lower limb during isolation in the hospital.

A randomised controlled trial of high-flow nasal oxygen versus non-rebreathing oxygen face mask therapy in acute hypoxaemic respiratory failure.

Background and Aims: A major limitation to providing oxygen therapy by high flow nasal oxygen (HFNO) delivery devices is its availability and therefore as an alternative many clinicians use a standard non rebreathing face mask (NRBM) in order to oxygenate their patients where low-flow nasal oxygen or simple facemask oxygen is not providing adequate respiratory support to achieve the target peripheral oxygen saturation (SpO2). We aimed to determine the clinical effectiveness of HFNO versus NRBM in terms of improving patient outcome among patients admitted to our intensive care unit (ICU) during coronavirus disease-2019 (COVID-19) outbreak. Methods: In this prospective open labelled study, 122 COVID-19 patients presenting with acute hypoxaemic respiratory failure (AHRF) were randomised to receive either HFNO or NRBM to achieve the target SpO2. The primary clinical outcome measured was device failure rate and secondary outcome was all-cause 28-day mortality rate. Results: The device failure rate was significantly higher in HFNO group (39% versus 21%, P = 0.030). Oxygen support with NRBM resulted in a reduced all mortality rate over HFNO (26.2% versus 45%) but the mortality rate after treatment failure in either group (HFNO or NRBM) remained high (91% versus 92%). Conclusion: Oxygen support with NRBM results in both reduced device failure rate and higher survival among patients of COVID-19 with AHRF.

Postgraduate examination: How to match your presentation skills with examiner's expectations?

Passing the exit Doctor of Medicine/Diplomate of National Board examination is a significant but challenging milestone in the career of any student. A strong knowledge base is the foundation on which a student can build an impactful performance. Knowledge core is tested in the theory part of the examination and its application to patient care during case presentations and viva in the practical examination. Performance during the practicals has one common denominator: convincing the examiner that the patient during anaesthesia would be safe in the student's hands. The way the student answers, the spontaneity and the confidence that the student exudes in answering, the pointed answers to the questions asked, and setting the priorities right when dealing with a multitude of tasks at hand go a long way in ensuring that. This article describes what examiners expect from students and provides tips to postgraduate students preparing for the examination.

Comparison of effect of intraperitoneal instillation of additional dexmedetomidine or clonidine along with bupivacaine for post-operative analgesia following laparoscopic cholecystectomy.

BACKGROUND AND AIMS: Despite advances in minimally invasive surgery, postoperative pain remains a concern after laparoscopic cholecystectomy. This study aims to compare the effect of intraperitoneal instillation of bupivacaine with alpha-2 agonists (dexmedetomidine and clonidine) for postoperative analgesia. METHODS: One hundred and eight patients scheduled for elective laparoscopic cholecystectomy were randomised to receive either 20 mL of 0.5% bupivacaine (Group B), 20 mL of 0.5% bupivacaine with dexmedetomidine 1 µg/kg (Group BD) or 20 mL of 0.5% bupivacaine with clonidine 1 µg/kg (Group BC). Study drug made to equal volume (40 mL) was instilled before the removal of trocar at the end of surgery. Standard general endotracheal anaesthesia with intra-abdominal pressure of 12-14 mm Hg during laparoscopy was followed uniformly. The primary objective of our study was the magnitude of pain. One way analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical variables was used. RESULTS: The Numerical Rating Scale (NRS) scores for pain intensity did not show any statistical significance at any of the pre-defined time points. Time to first request for analgesia was shortest in group BC (64.0 ± 60.6 min) when compared to the other groups (B, 78.8 ± 83.4 min; BD, 112.2 ± 93.4 min; P < 0.05). Total amount of rescue fentanyl given in groups BD (16.8 ± 29.0 µg) and BC (15 ± 26.4 µg) was significantly less than B (35.7 ± 40.0 µg); P < 0.05). CONCLUSION: The addition of alpha-2 agonists to bupivacaine reduces the post-operative opioid consumption, and dexmedetomidine appears to be superior to clonidine in prolonging time to first analgesic request.

Comparison of effects of dexmedetomidine added to ropivacaine versus ropivacaine alone infiltration scalp block for attenuation of the haemodynamic response to skull pin placement in neurosurgical procedures: A double-blind, randomised clinical trial.

BACKGROUND AND AIMS: Skull pin head holder application is intensely painful and is accompanied with abrupt increase in heart rate and arterial blood pressure. We aimed to determine the effects of adding dexmedetomidine to ropivacaine scalp block in attenuating the haemodynamic response to skull pin insertion in neurosurgical procedures. METHODS: Sixty patients were randomly allocated to receive scalp block with 25 ml of 0.5% ropivacaine added with either normal saline (control group) or dexmedetomidine (1 µg/kg) after anesthesia induction. A standard uniform general endotracheal anaesthesia protocol was followed in all study subjects. Heart rate and blood pressure measurements were made at baseline, 1, 3, 5, 10, and 15 min following skull pin placement. Student's independent t-test, Chi-square test and repeated measure analysis of variance were used to analyse the obtained data. RESULTS: There was no significant attenuation of heart rate (P = 0.418), systolic (P = 0.542), diastolic (P = 0.793) and mean blood pressure (P = 0.478) with addition of dexmedetomidine to ropivacaine. CONCLUSIONS: The addition of dexmedetomidine (1 µg/kg) to 25 ml of 0.5% ropivacaine offers no additional benefit over 25 ml of 0.5% ropivacaine alone scalp block in attenuating the haemodynamic response to skull pin placement in neurosurgical procedures.

Thoracolumbar curve and Cobb angle in determining spread of spinal anesthesia in Scoliosis. An observational prospective pilot study.

BACKGROUND AND AIMS: Disparity in spread of spinal anesthesia is a known complication in scoliosis patients. Our primary aim was to compare this disparity based on Cobb Angle and thorocolumbar spine curvature. Secondary aim was to calculate the appropriate lateral angulation of the spinal needle from midline for successful lumbar puncture. MATERIALS AND METHODS: All poliomyelitis patients with scoliosis posted for lower limb orthopedic contracture release surgeries were enrolled into Group A (Cobb Angle <50°), Group B (Cobb Angle >50°), and on thoracolumbar curve into Group R (Right), Group L (Left). Group A, B, R, and L were studied for bilateral spread of spinal anaesthesia. Lateral angle of the spinal needle from midline was noted with Goniometer in groups A and B. Statistical analysis was done using unpaired t test and Chi-square test. RESULTS: Failures in subarachnoid block (SAB) (unilateral anaesthesia/inadequate/patchy block) was significant in Group B (P = 0.033). Segmental disparity in bilateral spread of spinal anaesthesia was significant in Group R with P value of 0.042. Approximate lateral angle for needle in Group A was (4.1 ± 2.45) and in Group B was (9.14 ± 2.45). CONCLUSIONS: The study showed that there was a strong correlation between right-sided thoracolumbar curve and the spread of spinal anesthesia.

Red Cell Distribution Width as a Severity Marker on the Outcome of Patients with Acute Kidney Injury on Renal Replacement Therapy.

BACKGROUND: Acute kidney injury (AKI) requiring dialysis is associated with high mortality and morbidity. Red blood cell distribution width (RDW) has been shown as a predictor of mortality in different subsets of patients admitted to intensive care unit (ICU). This study compares the predictive ability of RDW and other severity illness prognostic models on 30 days mortality in adult patients admitted to ICUs with AKI necessitating dialysis. MATERIALS AND METHODS: Thirty patients were evaluated using five different prognostic scoring models. Sequential organ failure assessment (SOFA) score, acute tubular necrosis-individual severity index (ATN-ISI), version II of acute physiology and chronic health evaluation (APACHE II), vasoactive-inotropic score (VIS), version II of simplified acute physiology score (SAPS II), and RDW as a marker were used to prognosticate the severity of illness. The scores were calculated using the values of clinical and laboratory parameters at the time of admission. RESULTS: The prognostic abilities of the scores were compared for their discriminatory power using receiver-operating characteristic (ROC) curves. The area under the ROC curve (AROC) of RDW was 0.904, SOFA score was 0.828, ATN-ISI was 0.743, SAPS was 0.857, and APACHE II score was 0.828. Vasoactive-inotropic score has the lowest discriminatory power with AROC of 0.487. Red blood cell distribution width has a strong and significant correlation with APACHE II and SOFA scores and a weak relation with ATN-ISI score and SAPS II. CONCLUSION: Red blood cell distribution width has a better predictive ability than other disease severity scoring systems to predict mortality in an adult AKI patient admitted to ICU with need for renal replacement therapy (RRT). HOW TO CITE THIS ARTICLE: Nanjarapalle S, Samantaray A, Vishnubhotla S. Red Cell Distribution Width as a Severity Marker on the Outcome of Patients with Acute Kidney Injury on Renal Replacement Therapy. Indian J Crit Care Med 2020;24(2):95-98.

Chronic persistent surgical pain is strongly associated with COMT alleles in patients undergoing cardiac surgery with median sternotomy.

OBJECTIVES: Catechol-O-methyl transferase (COMT), a catechol-dependent enzyme, plays pivotal role in the development of pain. In different ethnic populations, it is associated with chronic persistent surgical pain (CPSP). In this context, the present study is aimed to assess involvement of COMT allele (Val158Met) in the development of CPSP. METHODOLOGY: The patients (n = 216) underwent cardiac surgery with median sternotomy were selected to assess the magnitude of the CPSP evaluated with pain questionnaires' after 3 months from surgery. The exon 4 of COMT gene was PCR amplified and sequenced. The quantitative gene expression of COMT using RT-PCR corroborated the COMT enzyme activity. RESULTS: Among 216 patients who underwent sternotomy procedure, 54 patients showed CPSP even after 3 months from surgery. The sequence analysis revealed that, in 25% (54/216) patients having following one or more alleles: c.472G>A (Val158Met) (reported), and novel c.382C>G;c.383G>C (Arg128Ala), c.373C>G (Arg125Gly), c.370G>A (Val124Met), c.359G>C (Gly120Ala), c.349G>A, c.350G>A(Ala117Ser), c.349G>C, c.351C>A (Ala117Pro), c.349G>A (Ala117Thr), c.350G>C (Ala117Gly), and c.405G>C (Ala135Ser) were observed for the first time in Indian population. Distinct CPSP (≥ 4 NRS pain score) was observed in these patients correlating with COMT enzyme activity (7.80 ± 0.92 units/mg) which is 14 times lowered when compared with non-CPSP patient's (n = 162) 110.15 ± 6.41 units/mg. The findings of COMT gene expression using quantitative RT-PCR corroborated the COMT enzyme activity. CONCLUSION: The dominant effect of mutant COMT alleles connecting with low enzyme activity resulted in CPSP, warrants COMT genetic analysis prior to surgery was useful to predict the occurrence of CPSP.

A comparative evaluation of pre-emptive versus post-surgery intraperitoneal local anaesthetic instillation for postoperative pain relief after laparoscopic cholecystectomy: A prospective, randomised, double blind and placebo controlled study.

BACKGROUND AND AIMS: Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic consumption effectively but the timing of instillation remains debatable. This study aims at comparing pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic cholecystectomy. METHODS: Ninety patients belonging to American Society of Anesthesiologists physical status I or II were randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1, 2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data were compared using analysis of variance, Kruskal-Wallis or Chi-square test. RESULTS: For all predefined time points, VAS in group PE was significantly lower than that in groups C (P < 0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain discharge criteria was not statistically different among groups. CONCLUSION: Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and early resumption of normal activity in comparison to post surgery IPLAI and control.

Association of G472A allele of membrane bound catechol-O-methyltransferase gene with chronic post-sternotomy pain.

Chronic persistent surgical pain (CPSP) is a complex disease with strong genetic component. The studies on revealed association of mutations in membrane bound catechol-O-methyltransferase gene with CPSP were reported indifferent ethnic populations across the globe. We identify that one out of four patients who underwent sternotomy procedure showed CPSP even after 3 months of surgery. The Mb.COMT gene sequence analysis revealed of the four patients, three patients had no mutation in Mb.COMT gene, while in one patient exhibited G472A mutation. Interestingly, this patient showed CPSP even after 90 days of surgery. The magnitude of the CPSP was evaluated with pain questionnaires' at the end of 3 months after discharge from the hospital. In this study 25% (1/4) showed presence G472A allele correlating with CPSP. Further the study suggested that evaluation of G472A allele of Mb.COMT gene in the patients undergoing sternotomy for monitoring pain in pre and post-surgical events.

Additional Analgesia for Central Venous Catheter Insertion: A Placebo Controlled Randomized Trial of Dexmedetomidine and Fentanyl.

We aimed to show that a single preprocedural dose of either dexmedetomidine or fentanyl reduces procedural pain and discomfort and provides clinically acceptable sedation. In this prospective, double-blind study, sixty patients scheduled for elective surgery and requiring planned central venous catheter insertion were randomized to receive dexmedetomidine (1 µg/kg), fentanyl (1 µg/kg), or 0.9% normal saline intravenously over ten minutes followed by local anesthetic field infiltration before attempting central venous catheterization. The primary outcome measures are assessment and analysis of pain, discomfort, and sedation level before, during, and after the central venous catheter insertion at five time points. The median (IQR) pain score is worst for normal saline group at local anaesthetic injection [6 (4-6.7)] which was significantly attenuated by addition of fentanyl [3 (2-4)] and dexmedetomidine [4 (3-5)] in the immediate postprocedural period (P = 0.001). However, the procedure related discomfort was significantly lower in dexmedetomidine group compared to fentanyl group in the first 10 min of procedure after local anaesthetic Injection (P = 0.001). Fentanyl is more analgesically efficient for central venous catheter insertion along with local anaesthetic injection. However, dexmedetomidine has the potential to be superior to fentanyl and placebo in terms of providing comfort to the patients during the procedure.

Comparison of the effects of adding dexmedetomidine versus midazolam to intrathecal bupivacaine on postoperative analgesia.

BACKGROUND: Dexmedetomidine and midazolam both modulate spinal analgesia by different mechanisms, and yet, no human studies are available to compare them for postoperative analgesia after neuraxial administration. OBJECTIVES: We investigated the addition of dexmedetomidine or midazolam to intrathecal bupivacaine on the duration of effective analgesia and clinical safety profile. STUDY DESIGN: Prospective, randomized, double blind, placebo controlled study. SETTING: University teaching hospital. METHODS: The study cohort included a consecutive and prospective series of patients, referred for endourological procedures. The patients were randomly allocated into 3 groups (20 patients each) to receive intrathecally 3 mL of 0.5% hyperbaric bupivacaine in combination with 5 mcg of dexmedetomidine (dexmedetomidine group), 1 mg of midazolam (midazolam group) or 0.5 mL of 0.9% saline (control group). The groups were compared to the regression time of sensory block, duration of effective analgesia (defined as the time interval between administration of intrathecal drug to the time of first analgesic request or a numeric rating scale = 4.0), sedation score, and side effects in the first 24 hours. STATISTICS: One way-ANOVA, Kruskal Wallis test, and Chi-square test (χ²), significance level: P < 0.05. RESULTS: The duration of effective analgesia (time to first analgesic request) was significantly prolonged in the dexmedetomidine group (286 ± 64 minutes, P < 0.01) when compared with midazolam group (236.9 ± 64.9 minutes) and the control group (212.7 ± 70.2 minutes). Pairwise comparisons among the 3 groups with Bonferroni adjustment revealed that patients from the dexmedetomidine group were more sedated in comparison to the midazolam and control groups at the end of the first 15 minutes after intrathecal injection [χ² (2) = 7.157, P = 0.028], with a mean rank sedation score of 35.58 for dexmedetomidine, 25.00 for midazolam, and 30.93 for control. No significant differences in the side effects were observed during the study period. Midazolam did not lengthen the time of the two segment sensory regression or the time to first request analgesia. LIMITATION: The study cannot be extrapolated to muscle cutting surgeries under spinal anaesthesia. CONCLUSIONS: The addition of dexmedetomidine (5 mcg) to 3 mL of intrathecal hyperbaric bupivacaine (0.5%) significantly prolongs the duration of effective analgesia in comparison to 1 mg midazolam or placebo (0.9% normal saline) with a comparable incidences of side effects.