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.

Exploring the Impact of Prior Beta-Blocker and Calcium Channel Blocker Usage on Clinical Outcomes in Critically Ill Patients With Sepsis: An Observational Study.

Background Sepsis is associated with increased Ca++ levels in many cell types that can cause cytotoxicity and cell death through multiple mechanisms. In patients with sepsis, limiting beta-adrenergic stimulation may also be beneficial. The intense adrenergic stimulation of sepsis results in cardiac and extra-cardiac effects. In the intensive care unit (ICU), the question of whether to continue calcium channel blockers (CCBs) and beta-blockers in patients with sepsis who were using these medications before ICU admission is of significant concern. Methodology In this prospective observational study, we have included 114 patients who met the inclusion criteria of being diagnosed as having sepsis, aged 18 to 65 years, and expected to stay in the ICU for more than 72 hours. These patients were divided into three groups: group 1 consisted of patients taking CCBs before admission, group 2 included those taking beta-blockers before admission, and group 3 served as the control group, comprising patients who had not taken either of these medications before admission. Disease severity in the ICU was assessed and documented by the Sequential Organ Failure Assessment (SOFA) score. Clinical outcomes among three groups were compared regarding the need for vasopressor support, serum procalcitonin (PCT), serum lactate, serum quantitative C-reactive protein (qCRP), SOFA score, and 28 days mortality. Parametric data were expressed as mean ± standard deviation. The Kruskal-Wallis test was used to analyze parametric data between the two groups and among three groups. Results Mortality was found lower in group 1 (21.05%) and group 2 (26.31%) than in group 3 (47.36%), and this association was found to be statistically significant (P = 0.033). We also found a significant difference in mortality between groups 1 and 3 (P = 0.015) and no significant difference between groups 2 and 3 (P = 0.057). Mortality was found to be significantly associated with high SOFA scores on days 1, 3, and 7. Conclusions From the aforementioned results, we concluded that the mortality rate in patients with sepsis was improved when they were pretreated with beta-blockers or CCBs before admission to the ICU and that medication should be continued if not contraindicated in the ICU course.

A Prospective Evaluation of Percutaneous Vertebroplasty in Osteoporotic Vertebral Compression Fracture Patients.

Background Osteoporotic vertebral compression fracture (OVCF) is a common problem in old age, which causes incapacitating pain and leads to significant disability, morbidity, and mortality. Percutaneous vertebroplasty (PVP), a minimally invasive procedure, results in immediate pain relief with decreased morbidity. The primary aim of this study was to evaluate the quality of life (QOL), as denoted by the Roland-Morris Disability Questionnaire (RMDQ) score. In contrast, the secondary aims were determining pain relief using the 11-point Numeric Pain Rating Scale (NPRS) and vertebral height restoration and wedge angle measurements after PVP. Methodology This prospective, longitudinal, interventional study on the efficacy of PVP was conducted among patients with low back pain due to osteoporotic vertebral collapse in a tertiary care institute. Patients with OVCF were managed by PVP and followed at one week, one month, three months, and six months for improvement in QOL by the RMDQ score and pain relief using the NPRS. The pre and post-vertebroplasty wedge angle and vertebral height (anterior, middle, and posterior columns) at one week and six months were also compared by pre and post-vertebroplasty lateral view skiagrams. Results A total of 24 patients were included in this study based on the inclusion and exclusion criteria. The demographic data were comparable. The RMDQ score showed a statistically significant difference in post-PVP at one week (p = 0.044), one month (p = 0.031), three months (p = 0.022), and six months (p = 0.018). There was a statistically significant difference in the NPRS at six months compared to the pre-PVP status, showing drastic pain relief in patients after PVP. The mean wedge angle (20.5 ± 2.07) measurement was reduced with a statistically significant increase in anterior body height restoration from pre-PVP to six months. There was no significant change in height at the middle and posterior columns compared to the pre-PVP height. Conclusions PVP is an effective, safe, minimally invasive pain and spine intervention for OVCFs with improved QOL and restoration of vertebral height.

Comparative evaluation of visual analogue scale and pupillary diameter for post-operative pain: An observational study.

Background and Aims: An objective understanding of pain guides the effectiveness of various postoperative pain management strategies. The measurement of pain by the visual analogue scale (VAS) is dependent on the individual's cognitive and emotional ability. Pupillary dilatation has been successfully used to measure pain in quantitative terms. The present study was conducted to study the correlation between VAS and pupillary diameter in the evaluation of postoperative pain. Methods: This observational study was carried out on 85 patients 18-65 years of age, scheduled for lower abdominal surgical procedures under general anaesthesia. Postoperative pain assessment was done using the VAS at 6 h, 12 h, 18 h and 24 h. In addition, the pupillary diameter of both eyes was measured simultaneously. Paired t-test and analysis of variance (ANOVA) were used to compare the data, and Pearson's correlation coefficient was calculated to assess the bivariate correlation between VAS score and pupillary diameter. Results: Mean ± standard deviation (SD) of VAS scores at baseline, 6 h, 12 h, 18 h and 24 h postoperatively were 0, 4.88 ± 0.88, 3.39 ± 0.86, 2.19 ± 0.66 and 1.40 ± 0.49, respectively. Mean change was significant at all time intervals (P < 0.001). The mean ± SD change in average pupillary diameter was 0.59 ± 0.64, 0.44 ± 0.54, 0.22 ± 0.34 and 0.07 ± 0.22 mm, respectively, showing a significant change from baseline (P < 0.05). On overall evaluation, mean pupillary diameter showed a significant incremental trend with an increasing VAS score (P < 0.001). Conclusion: Change in pupillary diameter correlated well with the pain scores (VAS) and thus pupillary diameter can be chosen as an objective measurement of postoperative pain severity.

Study of foetomaternal outcomes in COVID-19 afflicted parturients who underwent operative delivery - A retrospective analysis.

Background and Aims: Parturients with coronavirus disease (COVID)-19 are increasingly presenting for operative delivery. The aim of this study was to outline the foetomaternal outcome in COVID-19-afflicted pregnant women who underwent lower segment caeserean section (LSCS). Methods: Data of all COVID-19 positive pregnant females who underwent caesarean section surgery between 1 April and 30 June 2021 was collected. Clinical parameters, including oxygen requirement, laboratory investigations, treatment measures, complications, length of hospital and intensive care unit/neonatal intensive care unit stay, and outcome of parturients and neonates, were collected and analysed. All patients were followed up either during their visits to the obstetric outpatient department or by making phone calls between 1 and 2 months of discharge. Statistical Package for the Social Sciences statistical software 16.0 was used for analysis. Independent group t-test or Mann-Whitney test was used for mean of continuous data. Chi-square test or Fisher's test was used for proportion of categorical data. A P value of <0.05 was considered significant. Results: A total of 71 parturients delivered by caesarean section. 36.51% had mild COVID-19, and 87.5% had moderate COVID-19 at admission. One each with mild and moderate disease expired. The median (interquartile range) length of hospital stay was 7 (5-5.9) days for those with mild disease, and it was significantly longer for those with the moderate disease at 14 (9.5-17.5) days. Our study found that after a mean of 41.72 days of follow-up, of the 69 surviving mothers, 17 complained of fatigue, five complained of myalgia and one needed intermittent supplemental oxygen. Out of 74 babies born, seven died, which is 94.6 per 1000 live births. Conclusion: COVID-19 parturients delivered by LSCS stand a higher risk of maternal and neonatal mortality and adverse effects, including more hospital stay and increased mortality.

Correlation of central venous-to-arterial carbon dioxide difference to arterial-central venous oxygen difference ratio to lactate clearance and prognosis in patients with septic shock: A prospective observational cohort study.

Background: To assess the relationship between the ratio of difference of venoarterial CO2 tension (P (v-a) CO2) and difference of arterio-venous oxygen content (C (a-cv) O2), i.e., ΔPCO2/ΔCaO2 with lactate clearance (LC) at 8 and 24 h, to define a cutoff for the ratio to identify LC >10% and >20% at 8 and 24 h, respectively, and its association with prognosis in septic shock. Methods: Adult patients with septic shock were included in this prospective, observational cohort study. Blood samples for arterial lactate, arterial, and central venous oxygen and carbon dioxide were drawn simultaneously at time zero (T0), 8 h (T8), and 24 h (T24). At T8, patients were divided into Group 8A (LC ≥10%) and Group 8B (LC <10%). At T24, patients were divided into Group 24A (LC ≥20%) and Group 24B (LC <20%). Results: Ninty-eight patients were included. The area under the curve of ΔPCO2/ΔCaO2 at T8 (0.596) and T24 (0.823) was the highest when compared to P(v-a) CO2 and C(a-v) O2. The best cutoff of P(v-a) CO2/C (a-v) O2 as predictor of LC >10% was 1.31 (sensitivity 70.6% and specificity 53.3%) and for LC >20% was 1.37 (sensitivity 100% and specificity 50%). At both T8 and T24, P(v-a) CO2/C (a-v) O2 showed a significant negative correlation with LC. Groups 8A and 24A showed lower intensive care unit mortality than 8B and 24B, respectively. Values of P(v-a) CO2/C (a-v) O2 at T8 were comparable, but at T24, there was a significant difference between the survivors and nonsurvivors (P < 0.001). Conclusion: ΔPCO2/ΔCaO2 predicts lactate clearance, and its 24 h value appears superior to the 8-h value in predicting LC and mortality in septic shock patients.

Comparison of the effects of vitamin C and thiamine on refractory hypotension in patients with sepsis: A randomized controlled trial.

Background: The study aimed to compare the effect of thiamine and ascorbic acid (AA) on mortality, sequential organ failure assessment (SOFA) score, duration and dose of vasopressor support, and need for renal replacement therapy (RRT) in patients with septic shock with refractory hypotension. Methods: Consenting adult patients with septic shock and refractory hypotension were included in this study. Patients were divided into three groups: Group A received 100 ml of balanced salt solution 8 hourly, Group B received 2 mg/kg of thiamine 8 hourly, Group C received 25 mg/kg of AA 8 hourly intravenous (IV) for 72 h. All patients received IV infusion of hydrocortisone 200 mg/day for 72 h. Serum lactate, dose and duration of vasopressor support, SOFA score, need for RRT and hospital mortality were analyzed. Results: The SOFA Score was significantly lower in Group B than in Group A and C at 24, 48, and 72 h. Dosage of norepinephrine was lower in Group B at 66 h and after that, whereas in Groups A and C, it was comparable at all time points. Mortality in Group B was significantly lower but comparable in Groups A and C. The need for RRT was significantly lower in Group B (44%) compared to the control group (88%) but comparable in Group C (76%). Conclusion: In patients with septic shock treated with hydrocortisone, co-treatment with thiamine led to earlier correction of organ dysfunction, reduced need for RRT, and improved mortality compared to patients treated with AA or balanced salt solution. The addition of AA did not yield measurable benefits beyond hydrocortisone alone.

Comparison of LMA Supreme, i-gel, and Baska Mask for Airway Management during Laparoscopic Cholecystectomy: A Prospective Randomized Comparative Study from North India.

Background: The supraglottic airway device (SAD) has proved to be an appropriate alternative to endotracheal intubation in laparoscopic surgeries owing to various advantages, namely, decreased airway manipulation and stable hemodynamics. Aims: We compared the efficacy in terms of oropharyngeal leak pressure (OLP) and safety of laryngeal mask airway (LMA)-Supreme (LMA-S), i-gel, and Baska mask in patients undergoing laparoscopic cholecystectomy. Settings and Design: Ninety patients posted for elective laparoscopic cholecystectomy were selected for a prospective randomized comparative study in a tertiary care center. Materials and Methods: The study comprised three groups of 30 each based on the different SADs used Group-LS with LMA-Supreme, Group-IG with i-gel, and Group-BM with Baska mask. The secondary objectives were device insertion time, ease of insertion, changes in the peak airway pressure (PAP), heart rate, mean arterial pressure, and airway complications (sore throat, dysphagia. dysphonia, lip/tongue or dental injury, etc.) between three groups. Statistical Analysis: The quantitative data were analyzed using the one-way analysis of variance test and Bonferroni post hoc multiple comparison test. Qualitative data were compared using Chi.squared test. Results: OLP was significantly higher (P = 0.005) in the Baska mask than i-gel and LMA-S groups just after insertion and during carboperitonium. There was no significant difference in time for device insertion, number of attempts, ease of insertion, and use of manipulation (P > 0.05). However, the gastric tube insertion time was significantly lower in Group BM (9.59 ± 2.78) than Group IG with 12.79 ± 3.47 and Group LS with 10.84 ± 3.68 (P < 0.05). There were no significant differences between the groups with regard to changes in the PAP, heart rate, mean arterial pressure at different time intervals, and complications. Conclusion: Baska mask provided a significantly higher OLP compared to i-gel and LMA-S without significant airway morbidity in laparoscopic surgeries.

Comparison of Conventional Oxygen Therapy With High-Flow Nasal Oxygenation in the Management of Hypercapnic Respiratory Failure.

INTRODUCTION: The effectiveness of high-flow nasal oxygenation (HFNO) in patients with hypercapnic respiratory failure (RF) remains controversial. The current study compared the effectiveness of HFNO in patients with hypercapnic RF with conventional oxygen therapy (COT). OBJECTIVES: The primary objective was to compare changes in the partial pressure of carbon dioxide (PaCO2) between those receiving COT and HFNO. The secondary objectives were to compare changes in the partial pressure of oxygen (PaO2), oxygen saturation (SpO2), respiratory rate (RR), serum bicarbonate level, base excess, lactate level, and incidence of the need for non-invasive ventilation (NIV) and mechanical ventilation (MV). METHODS: We recruited 30 patients with mild to moderate hypercapnic RF in the HFNO group, and data of 30 patients from historical controls, who matched the inclusion criteria, were obtained from medical records for comparison (COT group). The study was terminated after two hours, and patients were managed per the existing protocol after that. Arterial blood gas (ABG) analysis was repeated at the baseline, first, second, and third hours. RESULTS: In the COT group, the mean RR at the baseline, first, second, and third hours was 24.5 ± 2.61, 24.9 ± 3.03, 26.03 ± 3.4, and 22.90 ± 1.86, whereas, in the HFNO group, it was 25.93 ± 3.91, 23.00 ± 3.54, 22.50 ± 3.38, and 21.90 ± 3.57, respectively. The mean PaCO2 in the COT vs. HFNO groups was 54.45 ± 5.83 vs. 62.22 ± 9.15, 57.74 ± 6.05 vs. 58.65 ± 10.43, 60.79 ± 7.48 vs. 60.41 ± 11.24, and 55.23 ± 6.63 vs. 56.95 ± 10.31. The mean SpO2 in the COT group at these points of time was 94.50 ± 1.46, 95.4 ± 1.28, 96.10 ± 1.84, and 97.53 ± 2.05, whereas, in the HFNO group, it was 95.40 ± 2.55, 98.63 ± 1.43, 99.00 ± 1.66, and 99.50 ± 1.31, respectively. The patients who needed NIV after the study period were 50% and 36.67% in the COT and HFNO groups, respectively. CONCLUSIONS: There was no change in PaCO2 levels with HFNO, but there was a significant improvement in SpO2 and PaO2 levels and a decreased RR. Following the termination of the study protocol, more patients in the COT group needed NIV than those in the HFNO group.

Clinical Relevance of Transorbital Ultrasonographic Measurement of Optic Nerve Sheath Diameter (ONSD) for Estimation of Intracranial Pressure Following Cerebrospinal Fluid Diversion Surgery.

Background and aim Raised intracranial pressure (ICP) can be estimated by various invasive as well as non-invasive techniques. Optic nerve sheath diameter (ONSD ) is a bedside non-invasive technique for assessment of ICP as a regular follow-up tool and has added advantage over CT scan/MRI, which require patient transfer to the suite. Cerebrospinal fluid (CSF) diversion procedures such as a ventriculoperitoneal shunt or external ventricular drainage are commonly done to relieve symptoms of patients with raised ICP. Change in ICP measured through ONSD after CSF diversion procedures may guide the proper functioning of the shunt and immediate post-operative management. The present study was conducted to compare ONSD before and after CSF diversion procedures and correlate the ONSD with ICP. Our secondary objective was to determine the ONSD cutoff for the prediction of ICP >20mm Hg. Setting, design, and methods This prospective, comparative, and observational study was carried out at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India. The present study was conducted on 40 adult patients undergoing CSF diversion surgery under general anaesthesia. Ultrasonographic measurement of the ONSD was performed before induction, after induction, after endotracheal intubation, after completion of shunt surgery, and then every two hours for 12 hours. The direct ICP was measured by the neurosurgeon at the time of the initial ventricular puncture. Statistical analysis The Wilcoxon signed-rank test was used to compare pre and post variables. Qualitative variables were compared using the Chi-Square test/Fisher's exact test as appropriate. Spearman's rho statistical measure of linear association was applied to measure the strength of linear association between parameters to show how close the points lie to a straight line. A p-value of <0.05 was considered statistically significant. Results The mean value of ONSD before induction and after induction was 6.36 ± 0.61 mm and 6.29 ±0.64 mm, respectively. After endotracheal intubation, ONSD slightly increased to 6.34 ±0.62mm, followed by a consistent decrease in ONSD values. The mean direct ICP recorded was 30.93±6.22 mmHg. Comparison of mean ONSD before induction, after induction, and after intubation with ONSD after surgery was statistically significant (p <0.001). We found a strong positive correlation between direct ICP and ONSD after intubation with a correlation coefficient of 0.969 (P <0.001). Receiver operating characteristic (ROC) curve analysis showed an ONSD cutoff of >5.85, predicted ICP>20 mmHg with a sensitivity of 92.3%, and specificity of 85.7%. Conclusion Measurement of ONSD by ultrasonography is an important and reliable tool in the assessment of normalization of ICP post CSF diversion procedure.

Perioperative anesthetic concerns in postcovid mucormycosis patients posted for surgical intervention: An observational Study.

Background: COVID 19 pandemic caused by severe acute respiratory syndrome coronavirus -2 has proven to be the deadliest pandemic till date. Multiple covid waves have hit people hard on each part of the continent throughout the world. The second wave in India turned out to be highly infectious and virulent. Sudden surge in cases of mucormycosis after recovery of COVID surprised many clinician. Mucormycosis being a rapidly progressive and fulminant fungal infection required surgical debridement of necrotic tissue on emergency basis. The fatal combination of immunocompromised status, multisystemic involvement, and difficult airway in these patients pose numerous new challenges regarding anesthetic management. The present study was conducted to outline major concerns and the anesthetic management of patients undergoing surgical resection for rhinoorbital mucormycosis (ROM). Materials and Methods: A retrospective observational study was conducted in our institute for a duration of 2 months (June and July 2021). The data of all the cases posted for ROM was collected from the ENT and Anesthesia record register. Total 70 patients presented with mucormycosis, for surgical debridement out of which 25 patients were posted for surgery under general anesthesia or monitored anesthesia care (MAC). Demographic characteristics, comorbidities, duration of COVID illness, treatment taken during COVID (oxygen therapy/steroid intake), hemodynamic parameters, monitoring methods, and surgical procedures were recorded for each patient. Statistical Evaluation: SPSS version 21.0 was used for data analysis. Mean and SD were used to analyze the difference in mean values, and independent Student's t-test were utilized to compare the quantitative variables. Frequency distribution and percentage were used for qualitative parameters. Significant difference was accepted at P ≤ 0.05 with 95% CI (confidence interval) in the study. Results: Demographic data were comparable with respect to age, gender distribution, and ASA status. Mean duration of Covid illness was (12.18 ± 3.68) days. The mean HbA1C measured was (10.8 ± 1.42). Strong correlation was found between steroid intake and raised HbA1c in all patients (r = 0.77). Regarding the comorbidities, 24 (96%) patients had associated type 2 diabetes mellitus, 16 patients (64%) had pneumonitis, and 1 patient had pulmonary TB and hepatitis. Conclusion: Considering the perioperative risk associated with high HbA1C and pneumonitis, MAC was preferred in majority of cases. Strict hemodynamic monitoring, perioperative glucose control, difficult airway cart, metabolic and electrolyte balance and vigilant peri-operative monitoring are cornerstone for better outcome and short length of hospital stay.

Modified Bain's Circuit as an Alternate to Non-invasive Ventilation in COVID 19.

Introduction COVID-19 is a pandemic that severely affects the lungs. Symptomatically affected individuals often become severely hypoxic, requiring non-invasive ventilation. The scarcity of resources in resource-compromised countries like India led to the adoption of novel strategies like using Bain's circuit for assisting spontaneous ventilation. This study compares the outcome when a standard circuit is replaced with a shortened Bain's circuit. Aims and objectives To compare shortened Bain's circuit and bilevel positive airway pressure (BiPAP) in spontaneously ventilated COVID 19 patients with regards to effects on hemodynamic stability and efficacy of ventilation using blood gas analysis. Methodology Twenty-four COVID patients aged between 35-70 years, requiring non-invasive ventilation but not tolerating BiPAP or not improving on BiPAP were enrolled in the study. Baseline heart rate and arterial blood gases (ABG) were recorded. Patients were then ventilated using shortened Bain's circuit. Heart rate and ABG were then recorded two hours after ventilation. Results Hemodynamic and blood gas parameters were comparable between the two groups at baseline and on BiPAP. Group A showed better hemodynamic and blood gas profiles compared to group B, but the difference was not statistically significant because of small sample size. Conclusion Shortened Bain's circuit may be a viable alternative to non-invasive ventilation in spontaneously breathing hypoxic patients with efficacy comparable to a standard Bain's circuit and reduced chances of carbon dioxide retention. Studies with a larger sample size are needed to further validate the conclusion.

Awake Proning for Nonintubated Adult Hypoxic Patients with COVID-19: A Systematic Review of the Published Evidence.

Objective: Awake proning is an intervention that is being advocated for COVID-19 patients and has been suggested to improve the oxygenation, thereby decreasing oxygen requirements. We performed this systematic review with the aim of appraising the latest published evidence on the clinical effectiveness of awake proning in COVID-19 patients. Data sources: PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar, and one trial registry were searched until September 23, 2020, for studies on the use of awake proning for nonintubated COVID-19 patients. Study selection: Published or in-press peer-reviewed randomized control trials, case-control trials, and prospective or retrospective cohort studies in English language only were sought, assessing the effectiveness of awake proning for nonintubated patients diagnosed with COVID-19. Data results: We included 21 published studies (19 single arm and 2 with comparison group). Twenty-three registered clinical trials were identified. No randomized clinical trial has been published so far. Conclusions: Awake proning is probably safe and effective in enhancing oxygenation in nonintubated COVID-19 patients; however, there is insufficient evidence. Further high-quality clinical trials are urgently needed to assess the effectiveness of awake proning on a variety of patient-centered outcomes. How to cite this article: Parashar S, Karthik AR, Gupta R, Malviya D. Awake Proning for Nonintubated Adult Hypoxic Patients with COVID-19: A Systematic Review of the Published Evidence. Indian J Crit Care Med 2021;25(8):906-916.

Radiofrequency Treatment of Idiopathic Trigeminal Neuralgia (Conventional vs. Pulsed): A Prospective Randomized Control Study.

BACKGROUND: Idiopathic trigeminal neuralgia (TGN) is a chronic pain disorder causing unilateral, severe brief stabbing recurrent pain in the distribution of one or more branches of the trigeminal nerve. Conventional radiofrequency (CRF) and pulsed radiofrequency (PRF) are two types of minimally invasive treatment. CRF selectively ablates the part of ganglion to provide the relief, but it has been found to be associated with some side effects such as dysesthesia or sensory loss in 6%-28% and loss of corneal reflex in 3%-8% of patients. PRF is a comparatively newer modality which is a nondestructive and neuromodulatory method of delivering radiofrequency energy to the gasserian ganglion to produce a therapeutic effect. AIMS: We aimed to compare the efficacy of CRF with long-duration, fixed voltage PRF in the treatment of idiopathic TGN. SETTING: This study was conducted in a tertiary care center research institute. STUDY DESIGN: This was a prospective randomized trial. MATERIALS AND METHODS: Twenty-seven adult patients of TGN were included in the study and randomly allocated into two groups (CRF and PRF). All procedures were performed operation suite with C-arm fluoroscopic guidance. Both, pre- and postprocedure, the patients were assessed for pain on the Visual Analog Scale (VAS) and Barrow Neurological Institute (BNI) Pain Intensity Scale at 1 week and thereafter at 1, 2, 3, and 6 months. Patients with a BNI score ≥4 after 1 month were considered a failure and offered other modes of treatment. A reduction in VAS score ≥50% and a BNI score <4 were considered as effective. STATISTICAL ANALYSIS: Discreet variables were recorded as proportions, ordinal variables and continuous variables with non-Gaussian distribution as medians with interquartile range, and continuous variables with Gaussian distribution as mean ± standard deviation. Association between ordinal variables was tested by Fisher's exact test/Chi-square test whenever appropriate. Equality of means/median was tested by using paired/unpaired t-test or nonparametric tests depending upon the distribution of data. P ≤ 0.5 was considered statistically significant. Data analysis was performed using STATA version 13.04 windows. RESULTS: Efficacy in terms of decrease in VAS ≥50% at 1 month was 33.33% and 83.33% in the PRF and CRF groups, respectively, which was statistically significant(P = 0.036). Effective reduction in BNI scores at the 7th day, 1 month, and 2 months postprocedure was evaluated and found in 41.67% and 83.33% of patients in the PRF and CRF groups, respectively, which was statistically insignificant (P = 0.089). There was a statistically significant reduction in BNI scores in PRF and CRF group patients at 3 and 6 months (at 3 months, 33.33% and 83.33%, P = 0.036 and at 6 months, 25% and 83.33%, P = 0.012). In the CRF group, mild hypoesthesia was evident in three patients which improved by the end of 1 month while no side effects were seen in the PRF group. CONCLUSION: CRF is a more effective procedure to decrease pain in comparison to long-duration, fixed voltage PRF for the treatment of idiopathic TGN. Although the side effects are more with CRF, they are mild and self-limiting.

Effect of Gelfoam Soaked Epidural Dexmedetomidine or Bupivacaine for Postoperative Analgesia in Lumbar Laminectomy: A Prospective Randomized Clinical Study.

BACKGROUND AND AIMS: Postoperative pain is spine surgery can last for an average of two to three days. Epidural catheter management are difficult in spine surgery for postoperative pain. Still, there have been not much studies on epidural administered gelfoam soaked dexmedetomidine or bupivacaine, to enhance postoperative analgesia. METHODS: Ninety six adult patients were randomized into three groups. Gelfoam soaked in 0.1 mg dexmedetomidine (0.02 mg. mL-1) in group D, 0.25% isobaric bupivacaine (5 mL) in group B and gelfoam soaked in 0.9% normal saline (5 mL) in group C. The Primary outcome was to compare the total amount of rescue analgesic consumption till 48 hours. The Secondary outcome was to compare time to first dose of rescue analgesia (duration of analgesia), the visual analogue scale and side effects up to 48 hours. Chi-square test, independent t test and analysis of variance test were used, and P < 0.05 was considered significant. RESULTS: Ninety patients completed the study. Total dose of rescue analgesic consumed in 48 hours was significantly higher in control group (paracetamol 4.17 ± 0.75 gm with tramadol 205 ± 37.94 mg). Bupivacaine soaked gelfoam group (paracetamol 3.04±0.71 gm with tramadol 151.85 ± 35.31 mg) had more rescue analgesic consumption than dexmedetomidine soaked gelfoam group (paracetamol 1.72 ± 0.57 gm with tramadol 86.11 ± 28.73 mg). Time for first rescue analgesic requirement with dexmedetomidine soaked gelfoam group was significantly longer (14.67 ± 7.76 hours) than in bupivacaine soaked gelfoam group (11.33 ± 6.08 hours) and control group (6.40 ± 2.77 hours). Postoperative mean VAS scores were lower in group D and group B compared with group C along with no significant adverse effects. CONCLUSION: Patients undergoing lumbar laminectomy with gelfoam soaked epidural dexmedetomidine or bupivacaine decreases rescue analgesic consumption, prolongs the duration of analgesia and decreases mean VAS score postoperatively.

Comparison of Oral versus Intramuscular Clonidine for Prolongation of Bupivacaine Spinal Anesthesia in Patients Undergoing Total Abdominal Hysterectomy.

BACKGROUND: Clonidine is a commonly used agent for premedication through oral, intravenous, and intramuscular route. Very few studies mentioned intramuscular clonidine as premedication. AIMS AND OBJECTIVES: The aim of the present study is to compare oral and intramuscular clonidine as predication agent in bupivacaine spinal anesthesia patients. MATERIALS AND METHODS: In our study, recruited patients were randomly allocated in three groups of 32 each. All patients received intrathecal bupivacaine heavy 3 mL with oral 150 µg clonidine in Group 1, intramuscular 150 µg clonidine in Group 2, and oral placebo tablet in Group 3 1 h before taking the patient in operation theater. We have assessed for duration of sensory block, duration of motor block, duration of analgesia, sedation score, and hemodynamic changes in groups. STATISTICAL ANALYSIS: The parametric data were expressed as mean ± standard deviation. Primary analysis of parametric data between the two groups was done by student's t-test, and among three groups, analysis of variance was used. RESULTS: Duration of motor block was found significantly high in Group 2 than Group 1 (208.06 ± 9.48 vs. 200.25 ± 9.42; P < 0.05). Duration of sensory block was also found significantly high in Group 2 than Group 1 (219.69 ± 9.44 vs. 210.25 ± 9.68; P < 0.05). Time to give first dose of analgesia was also found greater in Group 2 than Group 1 (234.66 ± 11.76 vs. 217.75 ± 10.09; P < 0.05). Sedation score and other side effects were found statistically nonsignificant between Group 1 and 2. CONCLUSION: We can conclude that preoperative intramuscular clonidine is a better alternate of oral clonidine for bupivacaine spinal anesthesia in terms of long duration of motor and sensory block and less requirement of analgesic with clinically insignificant side effects.

Comparison of the Efficacy of Different Arterial Waveform-derived Variables (Pulse Pressure Variation, Stroke Volume Variation, Systolic Pressure Variation) for Fluid Responsiveness in Hemodynamically Unstable Mechanically Ventilated Critically Ill Patients.

INTRODUCTION: This study was conducted to assess fluid responsiveness in critically ill patients to avoid various complications of fluid overload. MATERIAL AND METHODS: This study was done in an ICU of a tertiary care hospital after approval from the institute ethical committee over 18 months. A total of 54 consenting adult patients were included in the study. Patients were hemodynamically unstable requiring mechanical ventilation, had acute circulatory failure, or those with at least one clinical sign of inadequate tissue perfusion. All patients were ventilated using tidal volume of 6-8 mL/kg, RR-12-15/minutes, positive end expiratory pressure (PEEP)-5 cm of water, and plateau pressure was kept below 30 cm water. They were sedated throughout the study. The arterial line and the central venous catheter were placed and connected to Vigileo-FloTrac transducer (Edward Lifesciences). Patients were classified into responder and nonresponder groups on the basis of the cardiac index (CI) after fluid challenge of 10 mL/kg of normal saline over 30 minutes. Pulse pressure variation (PPV), stroke volume variation (SVV), and systolic pressure variation (SPV) were assessed and compared at baseline, 30 minutes, and 60 minutes. RESULTS: In our study we found that PPV and SVV were significantly lower among responders than nonresponders at 30 minutes and insignificant at 60 minutes. Stroke volume variation was 10.28 ± 1.76 in the responder compared to 12.28 ± 4.42 (p = 0.02) at 30 minutes and PPV was 15.28 ± 6.94 in responders while it was 20.03 ± 4.35 in nonresponders (p = 0.01). We found SPV was insignificant at all time periods among both groups. CONCLUSION: We can conclude that initial assessment for fluid responsiveness in critically ill mechanically ventilated patients should be based on PPV and SVV to prevent complications of fluid overload and their consequences. HOW TO CITE THIS ARTICLE: Kumar N, Malviya D, Nath SS, Rastogi S, Upadhyay V. Comparison of the Efficacy of Different Arterial Waveform-derived Variables (Pulse Pressure Variation, Stroke Volume Variation, Systolic Pressure Variation) for Fluid Responsiveness in Hemodynamically Unstable Mechanically Ventilated Critically Ill Patients. Indian J Crit Care Med 2021;25(1):48-53.

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.

Comparative Study of Postoperative Pain Relief Using Preincisional Versus Postincisional Infiltration With 0.25% Bupivacaine in Abdominal Hysterectomy Under General Anesthesia.

Background and Aims: Hysterectomy, probably the most common non-pregnancy related surgery performed in gynaecology, is associated with moderate to severe post-operative pain. Wound infiltration with local anaesthetic agent reduces the transmission of pain from the wound, in addition, local inflammatory response to the injury is also suppressed. The infiltration of local anaesthesia can be done either pre- or post-operatively. The present study was designed to determine the efficacy of pre-incisional infiltration versus post-incisional infiltration with 0.25% Bupivacaine in providing post-operative pain relief in patients undergoing abdominal hysterectomy. Methods: In Prospective Interventional Randomised study, 90 female patients posted for elective abdominal hysterectomy under general anaesthesia were randomly allocated into three equal groups of 30 patients each. Group I: Patients receiving subcutaneous infiltration with 40 mL of 0.25% Bupivacaine 5 mins before skin incision. Group II: Patients receiving subcutaneous infiltration of surgical area with 40 mL of 0.25% Bupivacaine at end of surgery (after peritoneal closure). Group III Control Group: Patients receiving no local anaesthetic infiltration. Observations were made for the duration of effective analgesia from end of the surgery until the first use of rescue analgesic along with the frequency and cumulative amount of rescue analgesics in 24 hours. Results: We found that at baseline, pain score of patients in Group III (3.87±1.17) was maximum followed by that in Group I (2.57±0.90) and minimum in Group II (2.20±0.61). Requirement of first analgesia was earliest in Group III (79.50±23.90 minutes) followed by Group I (136.83±13.16 minutes) and last in Group II (146.17±12.78 minutes), in addition, cumulative dose of analgesia was required by patients in Group III (152.50±36.76 mg) followed by that in Group I (132.50±37.80 mg) and minimum by that in Group II (115.00±38.06 mg). Conclusion: Subcutaneous infiltration of Bupivacaine either pre-incisional or post-incisional, helped to reduce the immediate post-operative pain intensity, delayed the first rescue analgesic requirement, reduced the post-operative dose and frequency of rescue analgesia. However, post-incisional intervention had an edge over pre-incisional intervention.