Anaesthetic Management and Physiologic Effects of Pneumoperitoneum in Patients With Chronic Obstructive Pulmonary Disease Undergoing Laparoscopic Cholecystectomy.

OBJECTIVE: This study aimed to assess the physiological changes and clinical outcomes in patients with chronic obstructive pulmonary disease (COPD) undergoing laparoscopic cholecystectomy. METHODS: This prospective cohort study included 50 patients of the American Society of Anesthesiology (ASA) physical status I and II with mild to moderate COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage I-II) scheduled for laparoscopic cholecystectomy. We monitored heart rate, mean arterial pressure, end-tidal carbon dioxide (EtCO2), arterial carbon dioxide (PaCO2), and bicarbonate (HCO3) levels at baseline, 30 minutes after induction or 15 minutes post-insufflation, 15 minutes post-deflation, and 60 minutes post-operative. Perioperative complications and post-operative recovery characteristics were also observed. Descriptive statistics were used to summarise the demographic and clinical characteristics of the patients. The correlation between HCO3 and EtCO2 was plotted on a scatterplot, and Pearson's correlation 'r' was calculated. The changes in physiological parameters over time were analysed using a paired t-test. A p-value of less than 0.05 is considered statistically significant. RESULTS: We observed a statistically significant but transient increase in heart rate, mean arterial pressure, and EtCO2 at 30 minutes after induction or 15 minutes post-insufflation, which returned to baseline levels within 15 minutes of deflation. Similarly, arterial CO2 and bicarbonate levels were also significantly increased at 15 minutes post-insufflation, yet remained within the normal physiological range. The study reported no serious perioperative complications, and all patients had an uneventful recovery. CONCLUSION: While patients with mild to moderate COPD can experience transient physiological changes during laparoscopic cholecystectomy, these changes are generally well-tolerated and not associated with adverse clinical outcomes. Therefore, laparoscopic cholecystectomy can be considered a safe procedure in these patients. Future research should focus on the implications and safety of this procedure in patients with severe COPD.

Effectiveness and Validity of Preoperative Ultrasonographic Airway Assessment and Clinical Screening Tests to Predict Difficult Laryngoscopy: A Prospective, Observational Study.

BACKGROUND: The anticipation of a challenging airway can be demanding in emergency care settings. Due to the patient's clinical condition, executing the pre-intubation clinical screening tests during the management of the airway in an emergency situation can be sometimes troublesome. Ultrasonographic airway assessment may become a helpful tool, but no specific sonographic measurements can precisely visualize the prospect of meeting a difficult airway. Therefore, the present study aimed to verdict some correlation between preoperative sonographic airway assessment parameters and the Cormack-Lehane (CL) grading at laryngoscopic view in patients undergoing general anesthesia with endotracheal intubation. METHODS: This observational study was conducted on 150 elective surgery subjects undergoing general anesthesia. The clinician in the pre-anesthetic clinic performed clinical airway and ultrasonographic airway assessments to predict difficult intubation and correlated with the CL grade viewed at laryngoscopy in the operative room during intubation. The parameters assessed were sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: In this study, the incidence of difficult intubation was 13.3%. The Mallampatti Grading (MPG) showed the maximum receiver operating characteristic (ROC) and area under the curve (AUC) among the clinical predictors, with 86.7% sensitivity. At the same time, the skin-to-hyoid distance has the maximum ROC among the sonographic parameters, and the skin-to-thyroid isthmus has the utmost sensitivity to predict difficult laryngoscopy. CONCLUSIONS: Among the clinical predictors, MPG and the sonographic parameters, like the skin-to-hyoid distance and skin-to-thyroid isthmus, are favorable predictors of difficult laryngoscopy.

Clinical Relevance of Mallampati Grading in Predicting Difficult Intubation in the Era of Various New Clinical Predictors.

Background and aims Management of difficult airway can be associated with serious morbidity and mortality and it is a basic and serious concern for anesthesiologists. The preoperative airway assessment is done by using conventional clinical predictors. The present study was conducted to find the correlation of various new clinical predictors with the Cormack-Lehane (CL) grade at the laryngoscopic view in patients undergoing general anesthesia with endotracheal intubation. Settings and design The prospective, comparative, observational, double-blind study was carried at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow. Materials and methods The study was conducted in 150 patients undergoing elective surgery under general anaesthesia. The primary outcome was the measurement of clinical airway assessment preoperatively based on certain parameters (inter incisor gap (IIG), modified Mallampati grading (MPG), neck circumference/thyromental distance (NC/TMD), ratio of height to thyromental distance (RHTMD)). The secondary outcome was the correlation of clinical airway assessment with CL grading to predict difficult intubation. The sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of the parameters were assessed. Statistical analysis The association between different predictors and difficult laryngoscopy was evaluated using binary univariate logistic regression and multivariate logistic regression and the significant clinical predictors were assessed by using Pearson's correlation. A p-value of < 0.05 was considered significant. Results The incidence of difficult intubation in this study was 13.3%. Among the clinical predictors, the Mallampati grading has the maximum receiver operating characteristic (ROC) and area under the curve (AUC) with 86.7 % sensitivity to predict difficult laryngoscopy followed by NC/TMD and body mass index. Conclusion Modified Mallampati grading still holds its significant value among new predictors in the assessment of difficult laryngoscopy.

Comparison of neutrophil CD64 and monocytic HLA-DR with existing biomarkers for the diagnosis and prognosis of sepsis.

INTRODUCTION: We measured the expression of serum procalcitonin (PCT), quantitative C-reactive protein (QCRP), neutrophil CD64 (nCD64) and monocytic HLA-DR (mHLA-DR) sequentially in patients admitted to the intensive care unit (ICU) and correlated the expression of these biomarkers to predict development of sepsis and its outcome. MATERIAL AND METHODS: Consenting adult patients of more than 18 years of age, who developed sepsis during an observation period of 20 days with a sequential organ failure assessment score (SOFA) score ≥ 2 or those who already had sepsis at admission to the ICU were included. SOFA score, serum PCT, QCRP, nCD64 and mHLA-DR assays were recorded on the first and third day of admission to the ICU. A total of 27 sepsis cases and 24 controls (all admitted to the ICU) were included in the study. RESULTS: SOFA score, serum PCT, QCRP, nCD64 were significantly higher and mHLA-DR was significantly lower in cases compared to controls, both on day 1 and day 3. There was no significant difference in any of the parameters between day 1 and day 3. PCT and nCD64, both with sensitivity of 77.8% and specificity of 70.8% (95% CI, 0.73-0.95), had the best predictive value for diagnosing sepsis. Lower mHLA-DR (< 5000/cell) was associated with higher mortality among cases. CONCLUSIONS: Serum PCT and nCD64 are the best biomarkers with similar sensitivity and specificity in detecting sepsis. mHLA-DR could have a role in prognosis as lower levels were associated with higher mortality.

Comparison of Orotracheal versus Nasotracheal Fiberoptic Intubation Using Hemodynamic Parameters in Patients with Anticipated Difficult Airway.

BACKGROUND: Both nasal and oral routes can be used for fiberoptic intubation. Often it leads to hemodynamic disturbances, which may have a significant effect in patients with limited cardiopulmonary reserve as well as with cerebrovascular diseases. AIMS: The aim of the study was to evaluate whether there is a clinically relevant difference between the circulatory responses to oral and nasal fiberoptic intubation. SETTINGS AND DESIGN: This was a prospective, randomized, and comparative study. MATERIALS AND METHODS: In this study, a total of 90 patients with the American Society of Anesthesiologist physical status I and II of either sex in the age group of 18-60 years and having anticipated difficult airway (DA) posted for elective surgery under general anesthesia were randomly allocated into two groups. Patients underwent fiberoptic intubation via either oral or nasal route under sevoflurane anesthesia with bispectral index guidance. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), time taken to intubation, and need of maneuver were measured. STATISTICAL ANALYSIS USED: All the analyses were carried out on SPSS 16.0 version (Inc., Chicago, USA). Mean and standard deviation were calculated. The test of analysis between two groups was done by unpaired t-test. RESULTS: Demographic and DA characteristics were similar in both the groups. Significantly (P < 0.01) lesser alteration in HR, SBP, DBP, and MAP was seen in oral fiberoptic intubation when compared to nasal fiberoptic intubation in the early phase of postintubation. Time taken to intubation was also significantly (P < 0.01) lesser in the oral route compared to the nasal route. CONCLUSIONS: Oral fiberoptic intubation causes less hemodynamic alteration and takes less time in comparison to nasal fiberoptic intubation.

Study of Tidal Volume and Positive End-Expiratory Pressure on Alveolar Recruitment Using Spiro Dynamics in Mechanically Ventilated Patients.

BACKGROUND AND AIMS: Ventilator setting in the intensive care unit patients is a topic of debate and setting of tidal volume (TV) should be patient-specific based on lung mechanics. In this study, we have evaluated to develop optimal ventilator strategies through continuous and thorough monitoring of respiratory mechanics during ongoing ventilator support to prevent alveolar collapse and alveolar injury in mechanically ventilated patients. METHODS: In our monocentric, randomized, observational study, we had recruited 60 patients and divided them into two groups of 30 each. In Group 1 patients, TV and positive end-expiratory pressure (PEEP) were set according to pressure-volume (P/V) curve obtained by the mechanical ventilator in a conventional manner (control group), and in Group 2, TV and PEEP were set according to P/V curve obtained by the mechanical ventilator using intratracheal catheter. PEEP and TV were set accordingly. TV, PEEP, and PaO2/FiO2 (P/F) ratio at days 1, 3, and 7, mortality within 7 days and mortality within 28 days were measured in each group and compared. RESULTS: We found a significant difference between PEEP and P/F ratio in both groups while intragroup comparison at days 1, 3, and 7. After the intergroup comparison of Group 1 and 2, we observed a significant difference of PEEP and P/F ratio between the groups at day 7 and not on day 1 or 3. CONCLUSION: This study concludes that optimal PEEP is more accurate using an intratracheal catheter than the conventional method of deciding ventilator setting. Hence, it is recommended to use intratracheal catheter to obtain more accurate ventilator settings.

Comparative Evaluation of the Role of Nonbronchoscopic and Bronchoscopic Techniques of Distal Airway Sampling for the Diagnosis of Ventilator-Associated Pneumonia.

BACKGROUND: The diagnosis of ventilator-associated pneumonia (VAP) remains a challenge, with clinicians mainly relying on clinical, radiological, and bacteriologic strategies to manage patients with VAP. AIMS: To compare the results of non-bronchoscopic and bronchoscopic techniques of distal airway sampling for the diagnosis of VAP. SETTINGS AND DESIGN: This was a single-center prospective diagnostic accuracy study done in the 14-bedded intensive care unit of a tertiary care referral hospital. MATERIALS AND METHODS: Patients aged ≥18 years, on mechanical ventilation for ≥48 h, and with clinical suspicion of VAP (fever, leukocytosis, and increased tracheal secretions) either on admission or during their stay were included. Every patient underwent both procedures for sample collection, first non-bronchoscopic protected bronchoalveolar lavage (NP-BAL) and then bronchoscopic BAL (B-BAL). Clinical Pulmonary Infection Score (CPIS) was calculated for each patient and the collected samples were evaluated in laboratory using standard microbiological techniques. STATISTICAL ANALYSIS USED: The sensitivity, specificity, positive predictive value, and negative predictive value of NP-BAL and B-BAL for the diagnosis of VAP were calculated taking CPIS score of >6 as index test for the diagnosis of VAP. RESULTS: Sixty patients were included in the study. Both NP-BAL and B-BAL had concordance with the CPIS at 69.1%. The concordance between NP-BAL and B-BAL was better at 67.6% with a kappa coefficient of 0.064 (P = -0.593). The yield and sensitivity of NP-BAL were comparable to that of B-BAL. CONCLUSIONS: The blind NP-BAL is an equally effective method of airway sampling and could be a better alternative to replace more invasive B-BAL for microbiologic diagnosis of VAP.

A Study of Vitamin D Level in Critically Ill Patients and Effect of Supplementation on Clinical Outcome.

BACKGROUND: Supplementation of Vitamin-D in Vitamin-D deficient patients may reduce morbidity and mortality in critically ill patients in ICU. AIMS AND OBJECTIVES: The aim of this study is to investigate serum level of Vitamin-D in critically ill patients and supplementation of vitamin-D in deficient patients and finally to compare clinical outcomes between two groups. SETTINGS AND DESIGN: Randomized, prospective and comparative study. MATERIALS AND METHODS: In this study, serum vitamin-D level was investigated in recruited patients and vitamin-D deficient patients were randomly allocated into two groups viz; group-1, group-2. Vitamin-D (sachet CALCIROL 60,000 IU) supplementation was done once a week and twice a week in in group-1 and group-2 respectively, clinical outcomes between two groups were compared in terms of length of ICU stay, need for inotropic support, need for mechanical ventilation and 28 days ICU mortality. STATISTICAL ANALYSIS: Mean and standard deviation were calculated. Test of analysis between two groups was done by t-test and then P value was calculated. RESULTS: No significant difference was found between two groups whether vitamin D supplementation done once or twice weekly (P = 0.24) in terms of length of ICU stay. Patients of group-2 required significantly less inotropic support as compared to group-1 (P = 0.037). There was no significant difference found in duration of mechanical ventilation (P = 0.138) and 28 days ICU mortality (P = 0.284). CONCLUSION: From the above results we concluded that vitamin D supplementation in high dosages may be started in all critically ill patients, who are deficient in serum vitamin D level to get better clinical outcomes.

Effect of Celiac Plexus Neurolysis for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study and Review of Literature.

BACKGROUND: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant or non-responsive to the pharmacological management, hence minimal invasive pain intervention like celiac plexus neurolysis or splanchnic nerve rhizolysis may be required to relieve pain of such patients. OBJECTIVE: The aim of this retrospective study is to assess the effect of celiac plexus neurolysis for pain relief in patients with upper gastro-intestinal malignancies. STUDY DESIGN: This is a retrospective, observational study with short review. METHODS: This retrospective observational study was done in the Pain Medicine unit from 2016 and November 2018. Ninety-four patients with upper abdominal malignancy and unrelenting pain, non-responsive or poorly responsive to pharmacological treatment as per WHO ladder of analgesics, received fluoroscopy-guided celiac plexus neurolysis (CPN). All the patients underwent celiac plexus neurolysis through Trans-Aortic approach and the primary outcome measure was pain as assessed with Visual Analogue Scale (VAS) ranging from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses and complications, if any. These were noted and analyzed prior to intervention and then on day 1, and months 1, 2, 3, 4, 5, 6 following CPN. RESULTS: Follow up was completed 6 months after the procedure. VAS score, daily morphine consumption, and the quality of life showed improvement for the duration of the study. There was some relapse in pain and deterioration in QOL during the fourth to sixth month of pain intervention due to disease progression. Some transient known side effects also occurred. CONCLUSION: Trans-Aortic celiac plexus neurolysis with low volume of alcohol is a safe procedure providing up to 6 months of pain relief and is an effective, well established, minimally invasive procedure for abdominal pain due to primary malignancy or metastatic spread.

Predictors of 1 year mortality in adult injured patients admitted to the trauma center.

BACKGROUND: Traditional approach to predicting trauma-related mortality utilizes scores based on anatomical, physiological, or a combination of both types of criteria. However, several factors are reported in literature to predict mortality independent of severity scores. The objectives of the study were to identify predictors of 1 year mortality and determine their magnitude and significance of association in a resource constrained scenario. MATERIALS AND METHODS: Prospective observational study enrolled 572 patients. Information regarding factors known to affect mortality was recorded. Other factors which may be important in resource constrained settings were also included. This included referral from a peripheral hospital, number of surgeries performed on the patient, and his socioeconomic status (below poverty line (BPL) card). Patients were followed till death or upto a period of 1year. Logistic regression, actuarial survival analysis, and Cox proportionate hazard model were used to identify predictors of 1year mortality. Limited estimate of external validity of the study was obtained using bootstrapping. RESULTS: Age of patient, Injury Severity Score (ISS), abnormal activated partial thromboplastin time (APTT), Glasgow Coma Scale (GCS) score at admission, and systolic blood pressure (BP) at admission were found to significantly predict mortality on logistic regression and Cox proportionate hazard models. Abnormal respiratory rate at admission was found to significantly predict mortality in the logistic regression model, but no such association was seen in Cox proportionate hazard model. Bootstrapping of the logistic regression model and Cox proportionate hazard model provide us with a set of factors common to both the models. These were age, ISS, APTT, and GCS score at admission. CONCLUSION: Multivariate analysis (logistic and Cox proportionate hazard analysis) and subsequent bootstrapping provide us with a set of factors which may be considered as valid predictors universally. However, since bootstrapping only provides limited estimates of external validity, there is a need to test these factors against the well accepted requirements of external validity namely population, ecological, and temporal validity.

A comparative study of two different doses of epidural neostigmine coadministered with lignocaine for post operative analgesia and sedation.

BACKGROUND: Adjuvants have been used to prolong analgesic effects of epidural local anaesthetics. We studied two different doses of neostigmine. PATIENTS #ENTITYSTARTX00026; METHODS: A randomized double blind study was conducted on ninety adult females scheduled for lower intra abdominal surgeries. The study was designed to compare two doses of epidural neostigmine co administered with lignocaine, with regard to its analgesic efficacy and its effect on sedation in postoperative period. Patients were divided into three groups of 30 each. Group I received lignocaine 1% (9ml) with normal saline (1ml), group II lignocaine1% (9ml) with neostigmine 100µg in saline (1ml) and group III received lignocaine 1% (9ml) with neostigmine 200µg in NS (1ml). Group I served as a control. In operating room, after putting epidural catheter, general anesthesia was administered with propofol (2mg kg(-1)), succinylcholine (2mg kg(-1)) and maintained with O2, N2O, relaxant technique. At the end of surgery, patients were reversed. Epidural analgesic medication was administered to after proper recovery from anesthesia. Intensity of pain relief on VAS, duration of analgesia, level of sensory block, motor blockade, sedation by sedation score and complications were assessed. RESULTS: The addition of neostigmine resulted in significant longer duration of analgesia (dose independent) and sedation (dose dependent). Sensory and motor blockade were identical in all three groups. There was no incidence of respiratory depression, pruritus, bradycardia or hypotension in any group. Two patients in control group and one, receiving neostigmine (200µg), developed nausea/vomiting. CONCLUSION: Co administration of epidural neostigmine and lignocaine appears to be a useful technique for postoperative analgesia as it increases the duration of analgesia and provides desirable sedation at the same time.

Effect of midazolam premedication on the dose of propofol for laryngeal mask airway insertion in children.

BACKGROUND: The present study was conducted on 120 pediatric patients of ASA Grade I and II of either sex aged 3-12 years scheduled for pediatric surgeries under general anaesthesia. PATIENTS #ENTITYSTARTX00026; METHODS: All patients were randomly divided into Group A and Group B. Group A was further divided into 3 subgroups of unpremedicated patients who received 3, 4 and 5 mg kg (-1) propofol only designated as A1, A2 and A3 respectively. Group B was further divided into subgroups of premedicated patients with midazolam (0.05 mg kg (-1) ) intravenous and received 3, 4 and 5 mg kg (-1) propofol designated as B1, B2 and B3 respectively. RESULTS: Results showed that increasing dose of propofol decreases the adverse events like inadequate jaw relaxation, limb movements, coughing, gagging and laryngospasm. Midazolam when added to propofol further reduces the incidence of adverse events and provides more favorable environment for insertion of LMA. At higher doses of propofol (5 mg kg (-1) ), hypotension is a major problem due to its cardiovascular depressant action. Therefore, 4 mg kg (-1) propofol along with midazolam is the optimum dose because there is more hemodynamic stability and we get better conditions for LMA insertion. CONCLUSION: Midazolam is an effective premedication in children which is synergistic with propofol and reduces its effective dose, required for LMA insertion.