Brain and Heart Interactions Delineating Cardiac Dysfunction in Four Common Neurological Disorders: A Systematic Review and Meta-analysis.

Neurological and cardiovascular disorders are the leading causes of morbidity and mortality worldwide. While the effects of cardiovascular disease (CD) on the nervous system are well understood, understanding of the reciprocal relationship has only recently become clearer. Based on disability-adjusted life years, this systematic review and meta-analysis present the pooled incidence and association of CD in 4 selected common, noncommunicable neurological disorders: (1) migraine, (2) Alzheimer disease and other dementias, (3) epilepsy, and (4) head injury. Sixty-five studies, including over 4 and a half million patients, were identified for inclusion in this review. Among the 4 neurological disorders, the majority of patients (89.4%) had epilepsy, 9.6% had migraine, and 0.97% had head injury. Alzheimer disease and other dementias were reported in only 0.02% of patients. The pooled effect estimates (incidence and association) of CD in the 4 neurological disorders was 10% (95% CI: 5.8%-16.9%; I2 = 99.94%). When stratified by the neurological disorder, head injury was associated with the highest incidence of CD (28%). The 4 neurological disorders were associated with a 2-fold increased odds for developing CD in comparison to patients without neurological disorders. Epilepsy was associated with the greatest increased odds of developing CD (odds ratio: 2.25; 95% CI: 1.82-2.79; P = 0.04). In studies that reported this variable, the pooled hazard ratio was 1.64 (95% CI: 1.38-1.94), with head injury having the highest hazard ratio (2.17; 95% CI: 1.30-3.61). Large prospective database studies are required to understand the long-term consequences of CD in patients with neurological disorders.

Task-sharing spinal anaesthesia care in three rural Indian hospitals: a non-inferiority randomised controlled clinical trial.

BACKGROUND: Task-sharing of spinal anaesthesia care by non-specialist graduate physicians, termed medical officers (MOs), is commonly practised in rural Indian healthcare facilities to mitigate workforce constraints. We sought to assess whether spinal anaesthesia failure rates of MOs were non-inferior to those of consultant anaesthesiologists (CA) following a standardised educational curriculum. METHODS: We performed a randomised, non-inferiority trial in three rural hospitals in Tamil Nadu and Chhattisgarh, India. Patients aged over 18 years with low perioperative risk (ASA I & II) were randomised to receive MO or CA care. Prior to the trial, MOs underwent task-based anaesthesia training, inclusive of remotely accessed lectures, simulation-based training and directly observed anaesthetic procedures and intraoperative care. The primary outcome measure was spinal anaesthesia failure with a non-inferiority margin of 5%. Secondary outcome measures consisted of incidence of perioperative and postoperative complications. FINDINGS: Between 12 July 2019 and 8 June 2020, a total of 422 patients undergoing surgical procedures amenable to spinal anaesthesia care were randomised to receive either MO (231, 54.7%) or CA care (191, 45.2%). Spinal anaesthesia failure rate for MOs (7, 3.0%) was non-inferior to those of CA (5, 2.6%); difference in success rate of 0.4% (95% CI=0.36-0.43%; p=0.80). Additionally, there were no statistically significant differences observed between the two groups for intraoperative or postoperative complications, or patients' experience of pain during the procedure. INTERPRETATION: This study demonstrates that failure rates of spinal anaesthesia care provided by trained MOs are non-inferior to care provided by CAs in low-risk surgical patients. This may support policy measures that use task-sharing as a means of expanding anaesthesia care capacity in rural Indian hospitals. TRIAL REGISTRATION NUMBER: NCT04438811.

Impact of Sugammadex Versus Neostigmine Reversal on Postoperative Recovery Time in Patients With Obstructive Sleep Apnea Undergoing Bariatric Surgery: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Residual neuromuscular blockade can be associated with serious postoperative complications. Sugammadex is a newer neuromuscular blocking drug (NMBD) reversal agent that rapidly and completely reverses rocuronium. Whether sugammadex has any advantages over neostigmine in morbidly obese patients with obstructive sleep apnea (OSA) is unclear. We investigated whether sugammadex would reduce discharge time from the operating room (OR) compared with neostigmine in morbidly obese patients with OSA undergoing bariatric surgery. METHODS: This was a prospective, double-blinded randomized controlled superiority trial with 2 parallel groups. Patients were randomized 1:1 into reversal of NMBD with sugammadex or neostigmine. Our inclusion criteria were morbidly obese adult patients with OSA undergoing elective bariatric surgery under general anesthesia. Our exclusion criteria were allergy to rocuronium, sugammadex or neostigmine, malignant hyperthermia, hepatic or renal insufficiency, neuromuscular diseases, and an inability to give consent. The primary outcome was the time from administration of the NMBD reversal agent to discharge from the OR. Secondary outcomes included the time from administration of the NMBD reversal agent to the time the patient opened eyes to command, and the time to extubation. The Mann-Whitney test was used to compare the outcomes between treatment groups. RESULTS: We randomized 120 patients into 2 groups of 60 patients. Overall median body mass index (BMI) was 48.1 kg/m2 ([interquartile range, IQR]) [43.0-53.5]. The time from drug administration to discharge from OR was 13.0 minutes [10.0-17.0] in the sugammadex group and 13.5 minutes [11.0-18.3] in the neostigmine group (P = .27). The treatment effect estimate with a bootstrapped 95% confidence interval [CI] for time from admission to discharge from OR was -0.5 [-2.5 to 3]. No differences were observed in postoperative complications and other secondary outcomes. CONCLUSIONS: No difference was observed in OR discharge time in morbidly obese patients with OSA when sugammadex was administered instead of neostigmine.

Emergency airway management in the prone position: an observational mannequin-based simulation study.

INTRODUCTION: Accidental extubation during prone position can be a life-threatening emergency requiring rapid establishment of the airway. However, there is limited evidence of the best airway rescue method for this potentially catastrophic emergency. The aim of this study was to determine the most effective method to recover the airway in case of accidental extubation during prone positioning by comparing three techniques (supraglottic airway, video laryngoscopy, and fiber-optic bronchoscopy) in a simulated environment. METHODS: Eleven anesthesiologists and 12 anesthesia fellows performed the simulated airway management using 3 different techniques on a mannequin positioned prone in head pins. Time required for definitive airway management and the success rates were measured. RESULTS: The success rates of airway rescue were 100% with the supraglottic airway device (SAD), 69.6% with the video laryngoscope (CMAC), and 91.3% with the FOB. The mean (SD) time to insertion was 18.1 (4.8) s for the supraglottic airway, 78.3 (32.0) s for the CMAC, and 57.3 (24.6) s for the FOB. There were significant differences in the time required for definitive airway management between the SAD and FOB (t = 5.79, p < 0.001, 95% CI = 25.92-52.38), the SAD and CMAC (t = 8.90, p < 0.001, 95% CI = 46.93-73.40), and the FOB and CMAC (t = 3.11, p = 0.003, 95% CI = 7.78-34.25). CONCLUSION: The results of this simulation-based study suggest that the SAD I-gel is the best technique to manage accidental extubation during prone position by establishing a temporary airway with excellent success rate and shorter procedure time. When comparing techniques for securing a definitive airway, the FOB was more successful than the CMAC.

Perioperative Considerations in a Patient with Kleine-Levin Syndrome Undergoing a Neurosurgical Procedure under General Anesthesia.

Kleine-Levin syndrome (KLS) is a rare central disorder of daytime hypersomnolence and is often characterized by a relapsing and remitting course, recurrent episodes of excessive sleep lasting from 12 to 20 hours a day, and symptoms including hyperphagia, hallucinations, derealization, disorientation, and hypersexuality. There are numerous perioperative considerations in dealing with KLS that include challenges during induction of anesthesia, delayed emergence, postoperative sleep disorders, and delirium. However, due to its rare occurrence, the anesthetic considerations of KLS remain poorly described. This case report outlines the anesthetic considerations and management of a young female patient with KLS who underwent transnasal excision of a trigeminal schwannoma under general anesthesia.

The Effectiveness of High-Flow Nasal Oxygen During the Intraoperative Period: A Systematic Review and Meta-analysis.

BACKGROUND: High-flow nasal oxygen (HFNO) is increasingly being used in intensive care units for management of hypoxemia and respiratory failure. However, the effectiveness of HFNO for preventing hypoxemia in the intraoperative period is unclear. The purpose of this systematic review was to compare patient oxygenation and end-tidal CO2 (EtCO2), between HFNO and conventional oxygenation, during the intraoperative period in surgical patients. METHODS: Standard databases were searched from inception to February 2020. Studies involving intraoperative use of HFNO with 1 of the 4 outcomes: (1) oxygen (O2) desaturation, (2) minimum O2 saturation, (3) safe apnea time, or (4) EtCO2 were included. Intraoperative period was divided into 2 phases: at induction with general anesthesia and during surgical procedure under sedation without tracheal intubation. RESULTS: Eight randomized controlled trials (RCTs; 4 induction, 4 procedure, 2314 patients) were included for systematic review and meta-analyses. We found the risk of intraoperative O2 desaturation was lower in HFNO versus conventional oxygenation control group; at induction with an odds ratio (OR; 95% confidence interval [CI]) of 0.06 (0.01-0.59, P = .02), and during procedure, OR (95% CI) of 0.09 (0.05-0.18; P < .001). The minimum O2 saturation was higher in HFNO versus conventional oxygenation; at induction by a mean difference (MD) (95% CI) of 5.1% (3.3-6.9; P < .001), and during procedure, by a MD (95% CI) of 4.0% (1.8-6.2; P < .001). Safe apnea time at induction was longer in HFNO versus conventional oxygenation by a MD (95% CI) of 33.4 seconds (16.8-50.1; P < .001). EtCO2 at induction was not significantly different between HFNO and conventional oxygenation groups. CONCLUSIONS: This systematic review and meta-analysis show that, in the intraoperative setting, HFNO compared to conventional oxygenation reduces the risk of O2 desaturation, increases minimum O2 saturation, and safe apnea time. HFNO should be considered for anesthesia induction and during surgical procedures under sedation without tracheal intubation in patients at higher risk of hypoxemia.

Stigma and Attitudes toward Patients with Psychiatric Illness among Postgraduate Indian Physicians.

BACKGROUND: Due to paucity of psychiatrists in India, psychiatric patients often present to other doctors. We aimed to study nonpsychiatric residents' attitude and stigma toward psychiatric patients. METHODS: A total of 57 postgraduate trainees participated in a cross-sectional study in a tertiary hospital in New Delhi. Attitudes to psychiatric patients were assessed using the attitude to mental illness questionnaire (AMIQ) and the perceived stigma questionnaire. This was correlated with sociodemographic information. RESULTS: Over 70% residents accepted mentally ill patients as friends and felt they were equally employable. However, AMIQ demonstrated a negative attitude towards patients with schizophrenia. Perceived competence in dealing with psychiatric patients was associated with adequate undergraduate exposure (Chi-square = 7.270, P = 0.026) and correlated with positive attitudes (t-test, P = 0.0008). CONCLUSIONS: While the questionnaires revealed some prejudice toward psychiatric patients with schizophrenia, the postgraduate trainees who felt competent to deal with the mentally ill had the most positive attitudes toward them.

Absent external oblique musculo-aponeurotic complex during inguinal hernioplasty: a case report and review of literature.

The external oblique musculo-aponeurotic complex is an important contributor to the strength of the inguinal canal. The present case report describes the bilateral absence of the external oblique muscle in a patient. A 40-year-old male patient presented with a history of intermittent lower abdominal pain for 15 years which had increased over the past 2 years. Abdominal examination revealed bilateral reducible, incomplete, direct inguinal hernia. Elective bilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the bilateral absence of the external oblique musculo-aponeurotic complex. The isolated absence of the external oblique musculo-aponeurotic complex in adults is an exceedingly rare anomaly. The possibility of such an anomaly should be considered in patients without other risk factors for hernia.