Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study.

Background: With the provision of a small positive end-expiratory pressure (PEEP) effect, high-flow nasal oxygen (HFNO) therapy carries a risk of stomach distension. The present study was conducted to find out the air leak in the gastric antrum leading to gastric distension in adult patients with acute respiratory failure receiving HFNO therapy. Materials and methods: Adult patients with early hypoxemic respiratory failure requiring HFNO therapy were enrolled in this trial. Before initiation of HFNO therapy, baseline gastric volume (GV) and the average number of peristaltic contractions over one minute were measured using ultrasound. Once the patient was stabilized on HFNO therapy, a 2nd, 3rd, and 4th ultrasound scans were acquired at 10, 20, and 30 minutes respectively. Vitals and blood gas values were recorded at the baseline and after 30 min of initiation of HFNO therapy. Patient comfort, duration of HFNO therapy, and outcome were also recorded. Results: The GV at 10, 20, and 30 minutes were significantly larger (p < 0.001) compared to baseline. This increase in GV was associated with a significantly increased number of peristaltic contractions and had a significant positive correlation with the HFNO flow (r = 0.541; p < 0.001). The HFNO therapy was well tolerated by most of the patients and led to a significant improvement in the vitals and blood gas parameters at 30 minutes after initiation of HFNO therapy. Conclusion: In adult patients with hypoxemic respiratory failure, the use of HFNO therapy produces gas leaks into the stomach leading to increased gastric volume. The gastric distension increases the peristaltic contraction and higher flows result in more distension. How to cite this article: Ramachandran A, Bhatia P, Mohammed S, Kamal M, Chhabra S, Paliwal B. Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2024;28(4):393-398.

Comparison of the effects of dexmedetomidine and nitroglycerin on cerebral oxygen saturation using near-infrared spectroscopy in patients undergoing controlled hypotensive anaesthesia: A randomised controlled non-inferiority trial.

Background and Aims: There is limited literature wherein the hypotensive drugs have been compared to know the cerebral effects by monitoring regional cerebral oxygen saturation (rScO2). This study aimed to compare the effects of dexmedetomidine and nitroglycerin on rScO2 during controlled hypotensive anaesthesia using near-infrared spectroscopy (NIRS). The primary objective was to evaluate the non-inferiority of dexmedetomidine versus nitroglycerin in the occurrence of cerebral desaturation events (CDEs) during hypotensive anaesthesia. Methods: Adult patients scheduled to undergo head and neck surgery under general anaesthesia randomised to receive either dexmedetomidine or nitroglycerin infusion for controlled hypotensive anaesthesia. Cerebral oximetry was monitored with NIRS, and data regarding CDEs, bilateral rScO2, and peri-operative haemodynamics were collected. Continuous data were analysed using unpaired Student's t-tests except for intra-group analyses, which were analysed using paired t-tests. Categorical data were analysed using the Chi-square test. For comparison of time to CDEs, Kaplan-Meier survival analysis with log-rank test was performed. Results: Of the 82 patients in both groups, CDEs were observed in 15 patients each. A decrease from baseline by 20% was observed in three patients: one in Group N and two in Group D. Statistically, there was an equal risk of getting CDEs in the groups. The time to CDE was comparable (P > 0.05). The difference in heart rate was statistically significant (P < 0.001). Conclusion: Dexmedetomidine is non-inferior to nitroglycerin in terms of the occurrence of cerebral desaturation events when used for controlled hypotensive anaesthesia in head and neck surgeries.

Continuous erector spinae plane block for analgesia and better pulmonary functions in patients with multiple rib fractures: a prospective descriptive study

Abstract Background: The present study explored the role of continuous erector spinae plane (ESP) block for analgesia as well as its impact on pulmonary functions in patients with multiple rib fractures. Methods: Ten patients with multiple rib fractures were enrolled after getting informed and written consent. Ultrasound-guided ESP block was performed at the level midway between the fractured ribs followed by the insertion of the catheter. Pre- and post-block VAS score, hemodynamics, respiratory rate (RR), peripheral oxygen saturation (SpO2), inspiratory capacity (IC), blood gases (PaO2 and PCO2), and complications were compared. Results: Pain scores at rest as well as on movement showed a significant reduction from 5.9 and 7.5 pre block to 1.6 and 2.5 respectively at 96 hours (p < 0.0001). Similarly, RR, SpO2, IC, and PaO2 were significantly better after the block placement (p < 0.001). Conclusion: Continuous ESP block provide adequate analgesia with better respiratory functions in patients with multiple rib fractures.

α/ß-Stereo- and diastereoselective glycosylation with n-pentenyl glycoside donors, promoted by N-iodosuccinimide and catalyzed by chiral Brønsted acid.

A method involving stereoselective glycosylation catalyzed by (+)-isomenthol ester of pentacarbomethoxycyclopentadiene as a chiral Brønsted acid, with n-pentenyl glycosides in the presence of N-iodosuccinimide as the promoter is described; this method offered a chiral recognition of racemic substrates.

Comparison of Clinical Performance of C-MAC Video Laryngoscope Guided vs Blind Placement of I-Gel® in Paediatric Patients: A Randomized Controlled Open-Label Trial.

Objective: Placement of the supraglottic airway devices under direct vision has been shown to decrease the incidence of malposition in adults. This study was designed to compare the clinical performance of C-MAC guided and blind placement of i-gel® in paediatric patients. Methods: The present prospective, randomized controlled study was conducted on 102 paediatric patients scheduled to undergo elective infraumbilical surgeries under general anaesthesia. Patients were randomly divided into group "B" (blind) and group "C" (C-MAC) based on the technique used for placement of i-gel®. The primary objective of the study was to compare the incidence of malposition based on the fiberoptic bronchoscope (FOB) score of the glottic view. Oropharyngeal leak pressure (OPLP), hemodynamic parameters, and insertion characteristics (time taken to insert and the number of attempts) were secondary objectives. Categorical data were presented as ratio or percentage and continuous data were presented as mean ± standard deviation or median [95% confidence interval (CI)]. Results: The incidence of malposition (Brimacombe score 1 or 2) was significantly lower in group C compared to group B (7.8% vs 49% respectively) (P < 0.001); implying a relative risk reduction of 2.42 (95% CI 1.72 to 3.40) with C-MAC. On FOB assessment, the median (interquartile range) Brimacombe score was significantly better in group C [4 (4-4)] compared to group B [3 (2-3)] (P < 0.001). The OPLP was significantly higher in group C compared to group B. Other insertion characteristics were comparable in both the study groups. Conclusion: Compared to blind placement, C-MAC guided placement ensures proper alignment of i-gel® with periglottic structures and proper functioning of i-gel®.

Hydrogen Evolution Activity of Nitrogen-Rich g-C3-xN4+x Synthesized by Solid-Gas Interface Method.

Synthesis of a metal-free carbon nitride (g-C3N4) photocatalyst in the form of nitrogen-rich g-C3-xN4+x derivatives is desirable for efficient solar to hydrogen conversion and remains a challenging task to achieve. Herein we report the development of homogeneous sheets of nitrogen-rich graphitic carbon nitride samples from melamine by a solid-gas interface approach. Using this method, pure g-C3N4 (CN), g-C3-xN4+x under ammonia flow (CN-NH3) and g-C3-xN4+x under nitrogen flow (CN-N2) are prepared. The g-C3-xN4+x (CN-NH3) sample shows better surface conductivity, wide optical absorbance in the visible region, reduced recombination and high electron donor density, and higher performance toward photoelectrochemical hydrogen evolution (HER). The g-C3-xN4+x (CN-NH3) generates a photocurrent of 2.06 µA cm-2, which is 2.5 times higher than that of the pure g-C3N4 (CN) sample (0.85 µA cm-2). It also shows higher photocatalytic water splitting ability compared to the CN and CN-N2 samples, generating 634 µmol g-1 hydrogen without cocatalyst and 1163 µmol g-1 of hydrogen with Pt cocatalyst. Density functional calculations suggest that the progressive band gap reduction with the increase in the N-dopant percentage can be attributed to the gradual increase in the partial π-occupations, which can lead to a significant stabilization of the conduction band minima. The theoretical modeling, however, indicates a saturation in the band gap effect after 75% of N-dopant. The onset potential of g-C3-xN4+x for HER appears at η = 0.43 V in dark and η = 0.34 V vs Ag/AgCl under solar light illumination of 1 sun.

Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey.

Introduction: Appropriate implementation of a ventilator bundle (VB) is the key step in the prevention of ventilator-associated pneumonia (VAP). However, knowledge and compliance of critical care staff for VB are inconsistent in developing countries. This cross-sectional survey was planned to evaluate critical care practitioners' knowledge of, adherence to, and barriers toward implementation of VB in the ICUs of a tertiary care institute. Methodology: All registered nurses and resident doctors who are direct care providers to patients of the ICU were included. Two sets of questionnaires were given to access knowledge and to identify potential barriers in the implementation of VB. To determine compliance with the VB, direct observation was done for three nonconsecutive days, and mean compliance per component of the bundle and overall compliance to VB was determined. Data were analyzed using descriptive and analytic statistics. Results: Of these 75 participants, 43 (57.33%) were resident doctors and 32 (42.67%) were staff nurses. The median knowledge score of resident doctors and staff nurses for VB was 7 (range 3-10) and 6 (range 2-9), respectively, with an overall score of 7 (range 2-10). Self-reported adherence to individual components of VB ranged from 75% to 95%, among these, adherence to oral care protocol, including use of chlorhexidine oral rinse, was most, and adherence to DVT prophylaxis was least. The most common potential barriers identified were fear of potential adverse effects and unawareness of guidelines. Conclusion: Considerable gap is observed between knowledge and implementation of VB among critical care practitioners. Despite knowledge, fear of adverse events and lack of proper training are key barriers in implementation of VB. How to cite this article: Paliwal N, Bihani P, Mohammed S, Rao S, Jaju R, Janweja S. Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey. Indian J Crit Care Med 2023;27(4):270-276.

Comparison of continuous erector spinae plane block and thoracic paravertebral block for postoperative analgaesia in patients undergoing modified radical mastectomy: A randomised controlled non-inferiority trial.

Background and Aims: Modified radical mastectomy (MRM) is associated with significant postoperative pain for which many blocks including thoracic paravertebral (TPV) block are being used. Erector spinae plane (ESP) block is a recently described technique. We planned to compare the efficacy and safety of ultrasound-guided continuous ESP and TPV blocks for postoperative analgaesia following MRM. Methods: Sixty-six patients belonging to American Society of Anaesthesiologists physical status I and II, aged 25-85 years, undergoing MRM were enrolled and randomly allocated into two groups. Ipsilateral block was given preoperatively at T3 or T4 level with 20 ml of 0.5% ropivacaine and 50 µg fentanyl. Infusion of 0.5% and 0.2% ropivacaine with fentanyl 2 µg/ml at a rate of 5 ml/hr was continued during intraoperative and postoperative period, respectively. Pain was assessed using visual analogue scale (VAS) till 24 hours. Block performance time, time to first rescue analgaesia, total amount of rescue analgaesic consumed, the incidence of procedure-related and postoperative complications, failure rate and patient satisfaction score were also recorded. Data collected were analysed using the Chi-square test or Student's t-test with the help of SPSS 22.0. Results: Demographics, baseline vitals, VAS scores both at rest and on movement, block performance time, time to first rescue analgaesia, the total amount of rescue analgaesia and patient satisfaction score were comparable in both groups (P value > 0.05). No complications were observed in either group. Conclusion: In patients undergoing MRM, continuous catheter technique ESP block is as efficacious and safe as TPV block for providing prolonged postoperative analgaesia.

Cardiac Abnormalities in Refractory Status Epilepticus-an Exploratory Study.

Background and Purpose: Cardiac abnormalities have been reported during ongoing seizures and refractory status epilepticus (RSE). Reduced heart rate variability (HRV) and cardiac arrhythmias may contribute to sudden unexpected death in epilepsy. We sought to explore the utility of electrocardiographic and echocardiographic changes in patients with RSE prognosis and functional outcome. Methods: Patients of RSE underwent electrocardiogram (ECG), holter, troponin-I (Trop I), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and 2-dimensional echocardiogram (2D Echo) along with continuous electroencephalogram in first 24 hours and admission. Heart rate changes/arrhythmias, corrected QT interval (QTc) and HRV, ventricular dysfunction or regional motion wall abnormality were studied on 2D Echo. These parameters were also at baseline, at discharge or death and 30 days post discharge. Results: This prospective observational study conducted over 18 months enrolled 20 patients with RSE, fulfilling the inclusion criteria. Mean age was 47.75±17.2 years with male: female ratio of 1:1. Mean time to presentation from seizure onset was 8.80±7.024 hours. Central nervous system infection (35.0%), autoimmune encephalitis (20.0%) and cerebrovascular disease (20.0%) were the common etiologies. Amongst cardiac injury markers, cardiac enzymes and QTc prolongation were the commonest abnormalities in RSE. Both reduced HRV and presence of cardiac injury markers had significant correlation with poor outcome along with poor Glasgow coma scale (GCS) and modified Rankin scale (mRS) at presentation, and presence of non convulsive status epilepticus (NCSE). Conclusions: Presence of poor GCS, poor mRS, markers of cardiac injury, reduced HRV and occurrence of NCSE have a consistent correlation with mortality and poor clinical outcome. Therefore, routine assessment of cardiac abnormalities using affordable, easily accessible and non-invasive tools such as ECG, 2D Echo, holter NT-proBNP and Trop I is recommended in RSE patients.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

Background and Aims: A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. Material and Methods: This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. Results: The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Conclusion: Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

The midpoint transverse process to pleura (MTP) block for postoperative analgesia in patients undergoing modified radical mastectomy: A case series.

Among the various regional anesthesia techniques used for postoperative analgesia in the modified radical mastectomy (MRM), thoracic paravertebral block (TPVB) is presently considered the technique of choice. Nevertheless, TPVB may lead to complications like inadvertent vascular puncture, hypotension, epidural or intrathecal spread, pleural puncture, or pneumothorax. Recently, a newer technique "midpoint transverse process to pleura" (MTP) block has been described in which the tip of the needle is placed at the midpoint between the transverse process and pleura. In this case series, we included ten patients of American Society of Anesthesiologist status I/II scheduled for MRM. Ultrasound-guided MTP block was performed and the catheter was inserted on the side of the surgery at the level of T4 level. The block was successful in the all patients as their median visual analogue score at rest and movement was 2 and 3, respectively, in first 24 h postoperatively. Only three patients required rescue analgesia in the first 24 h. No procedural-related complications were noticed in any patient. We concluded that MTP block provided effective perioperative analgesia with minimal rescue analgesia requirement and satisfactory safety profile.