The Study of the Feasibility of Ultrasound-guided Catheterization of the Right Brachiocephalic Vein in Adult Patients: A Prospective Observational Study.

Background: The brachiocephalic vein (BCV) is a feasible option for central venous access in the pediatric population and is rapidly developing as an alternative site for insertion of the central line in young children with faster insertion times, fewer attempts, and lower rates of complications. However, studies demonstrating the feasibility of BCV catheterization in adult patients are insufficient. The current study sought to assess the safety and effectiveness of ultrasound-guided supraclavicular right BCV cannulations in adults. Methods: A linear array Ultrasound (US) probe was used to obtain a longitudinal picture of the BCV beginning at the junction of the internal jugular vein and the subclavian vein in the supraclavicular region. Under US supervision, the needle was guided into the BCV using the in-plane approach. A prospective study was performed on 80 adult patients scheduled for elective and emergency operative procedures under general anesthesia requiring a central venous catheter (CVC). Success rates and complications that occurred during catheter insertion were analyzed. Results: CVC placement was successful in all adults. The procedure was successful at the first attempt in 74 cases (92.5%) and after 2 attempts in six patients (7.5%). The time to guide wire insertion was 31.26 s (19-58 s), and catheter insertion took 88.44 s (63-145 s). The mean length of catheter insertion was 10.46 cm. No complications were noted. Conclusion: Ultrasound-guided supraclavicular BCV catheterization offers a new and safe method for central venous line catheterization in adults. However, larger trials and meta-analyses are needed to confirm these findings and evaluate the safety of this technique.

Perioperative concerns in a patient with suspected Creutzfeldt - Jakob disease: A case report and review of literature.

A case of Creutzfeldt-Jakob Disease (CJD), a rare prion disease, posted for surgery is a clinically challenging scenario for an anesthesiologist. In addition to weighing in the consequences of using general versus neuraxial anesthesia for a patient of such a progressive neurodegenerative disorder, the anesthesiologist must also meticulously plan and institute a robust infection control protocol, keeping in mind that prion diseases are transmissible and highly resistant to the standard sterilization process. We hereby report the successful anesthetic management of a 57-year-old patient with suspected CJD presented with intertrochanteric fracture femur for closed reduction and internal fixation and also review the existing literature regarding the anesthetic management of a definite or suspected case of CJD.

A Double-Blind, Randomized Controlled Pilot Trial to Assess the Analgesic Efficacy of Ultrasound-Guided Preemptive Caudal Morphine as an Adjunct to Bupivacaine for Lumbosacral Spine Surgeries in Adults.

Background The analgesic efficacy of preemptive administration of caudal morphine for spine surgeries in adults is not well studied. In a double-blinded, randomized controlled trial, safety and analgesic efficacy of preemptive, single-shot caudal morphine and bupivacaine was compared with caudal bupivacaine alone in lumbosacral spine surgeries. Methods After Institutional Ethics Committee approval, 40 patients aged 18-60 yrs planned for lumbosacral spine surgery were randomized to groups of 20 patients each. After induction and prone positioning, an ultrasound-guided caudal block was performed with morphine 50 µg/kg with 20 ml 0.25% bupivacaine in the study group (LM) and only bupivacaine in the control group (LA). Postoperatively, both groups received intravenous morphine via patient-controlled analgesia (PCA) pump (No basal, 1 mg/bolus, 10 minutes lockout interval). Intraoperative fentanyl use, postoperative 24-h morphine consumption, visual analogue pain scores (VAS) and adverse effects of morphine were noted. Results Demographics and baseline data were comparable. Postoperative 24-hour morphine requirement was more in LA group (34.3 ± 10.7 mg vs 19.65 ± 11.8 mg, p=0.0001). Total intraoperative supplemental fentanyl requirement was similar (79.25 ± 67.60 µg in LA vs 54 ± 50.20 µg in LM group, p=0.28). VAS scores at 2/4/6/12-hour in group-LM were significantly less than group-LA (p=0.005, 0.002, 0.001 and 0.047) but were comparable at 18 and 24 hours (p=0.25, 0.42). Postoperative incidence of adverse effects of morphine was comparable. Conclusions Ultrasound-guided, single-shot preemptive administration of caudal morphine with bupivacaine is a safe and effective modality of analgesia for patients undergoing lumbosacral spine surgeries.

Trauma care and COVID-19 pandemic.

The Coronavirus SARS- CoV-2 (COVID-19) pandemic has overwhelmed the ability of health care systems all over the world. With the spread of the disease, countries have adopted different models to reorganize infrastructure and reallocate the resources to deal with the pandemic. All the nonurgent hospital services have been postponed. But, trauma and emergency services continue to function according to the established protocols with few modifications. During the pandemic, trauma care is based on clinical urgency, safety of the patient as well as health care workers (HCWs) and conservation of resources. The strategies include non-operative management if possible, restricting the number of personnel and utilization of remote consultation or telemedicine. In the present article, we discuss the triage and management of trauma victim during the pandemic, indications for emergency surgery and psychological impact of the pandemic. We also discuss the future challenges during the post-COVID-19 phase.

Mortality Profile of Geriatric Trauma at a Level 1 Trauma Center.

BACKGROUND: The management of geriatric trauma patients is challenging because of the altered physiology and co-existent medical conditions. To study the in-hospital mortality profile of geriatric trauma victims and the parameters associated with the mortality, we conducted this retrospective analysis. METHODS: In a retrospective review of geriatric trauma admissions (above 60 years) over a 3-year period, we studied the association of age, gender, comorbidities, mechanism of injury (MOI), Glasgow coma score (GCS), injury severity score (ISS), systolic blood pressure, and hemoglobin (Hb) level on admission with hospital mortality. Univariate and Multivariable logistic regression was used to estimate odds and find independent associated parameters. P < 0.05 was considered as statistically significant. RESULTS: Out of 881 patients, 208 (23.6%) patients died in hospital. The most common MOI was fall (53.3%) followed by motor vehicle collision (31.1%) and other mechanisms (14.5%). The in-hospital mortality was significantly higher and adjusted odds ratio (OR) for mortality were higher for male gender (2.11 [1.04-4.26]), higher ISS (6.75 [2.07-21.95] for ISS >30), low GCS (<8) (4.6 [2.35-8.97]), low Hb (<9) (1.68 [0.79-3.55]), hypotension on admission (32.42 [10.89-96.52]) as compared to other groups. Adjusted OR was 3.19 (1.55-6.56); 7.67 (1.10-53.49); 1.13 (0.08-17.12) for co-existent cardiovascular, renal, and hepatic comorbidities, respectively. CONCLUSION: Male gender, higher ISS, low GCS, low Hb, hypotension on admission, co-existent cardiovascular, renal and hepatic comorbidities are associated with increased mortality in geriatric trauma patients.

Role of Laparoscopy in Patients With Abdominal Trauma at Level-I Trauma Center.

INTRODUCTION: Abdominal trauma is one of the preventable causes of death in polytrauma patients. Decision and timing of laparotomy is a major challenge. Rate of nontherapeutic laparotomy is still high. Laparoscopy can avoid nontherapeutic laparotomy and also provide a reliable and accurate diagnosis of injury. MATERIALS AND METHODS: This ambispective observational study was conducted in the division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute Medical Sciences, New Delhi. Retrospective analysis of prospectively maintained data of cases from January 1, 2008 through April 30, 2013 and prospective analysis of cases from May 1, 2013 through March 31, 2015 was done using appropriate measures. Hemodynamically stable or responders fulfilling inclusion criteria were included. Selected patients underwent the laparoscopic procedure and if required converted to laparotomy. RESULTS: Of the 3610 patients of abdominal trauma, laparotomy was done in 1666 (46.14%) patients and laparoscopy was done in 119 (3.29%) patients. Rate of reduction of nontherapeutic laparotomy in patients with abdominal trauma using diagnostic laparoscopy was 55.4%. However laparotomy could be avoided in 59.7%. Laparoscopy was 100% accurate in identifying injuries in our study. No injuries were missed in these patients. Fever and wound infection were significantly higher in laparotomy group. Chest infection and sepsis were also higher in laparotomy group but the difference was not statistically significant. Median length of hospital stay in laparoscopy group was 4 days (range: 1 to 28 d) and in laparotomy group was 9.5 days (range: 2 to 55 d) with P-value of 0.001. CONCLUSIONS: Laparoscopy has a role in management of hemodynamically stable patients with suspected abdominal injury to prevent nontherapeutic laparotomies, and thereby decreasing postoperative complications.

Topographic Sonoanatomy of Infraclavicular Brachial Plexus: Variability and Correlation with Anthropometry.

OBJECTIVE: The aim of the study was to assess the effectiveness of ultrasound in analyzing topographic relationship of nerve cords with axillary artery at lateral infraclavicular level, their variations, and the distance from the skin and to correlate findings with anthropometric parameters. MATERIALS AND METHODS: Two hundred patients aged 18-75 years were enrolled for the study after informed written consent. A 7-12 MHz linear ultrasonic transducer was used for scanning of the brachial plexus at lateral infraclavicular fossa. The results of the cord positions were expressed on a 12-section pie chart, and the number of arteries and veins was reported. Measurements included the vertical distance from the upper part of the artery to the skin, diagonal distance to the apical corner of the ultrasound image, and distances from center of cords to the center of artery. Age, sex, weight, height, body mass index, and biceps girth were recorded. Data were expressed as mean with standard deviation or frequency and percentage for categorical variables, and statistical analysis was done using correlation analysis and two-sample t-test. RESULTS: The most frequent positions of the cords were observed in 2-4 sections (92%) for the medial cord, 6-7 sections (92%) for the posterior cord, 10-11 sections (89%) for the lateral cord, and 4-5 sections (95%) for the axillary vein. More than one axillary vein was seen in 12.5% and two axillary arteries were seen in 1.5% of cases. Cord visibility and distance between artery and apical corner of the ultrasound image correlated with anthropometric parameters. CONCLUSIONS: A topographical study of brachial plexus at lateral infraclavicular fossa showed anatomical variations and abnormal vascular formations. This sonoanatomic knowledge can be helpful in improving safety and success of nerve blocks.

Impact of Preoperative Echocardiography on Perioperative Management in Geriatric Hip Trauma: A Retrospective Observational Study.

BACKGROUND AND AIM: Hip fractures are associated with a significant risk of morbidity and mortality in the elderly population. Current guidelines propose that these patients should be operated as early as possible. Preoperative cardiac investigations, especially echocardiography, have been considered to delay surgery with few changes in the patient management. The present study has been conducted to evaluate whether preoperative echocardiography improve or worsen the prognosis in such hip trauma surgery. MATERIALS AND METHODS: In this retrospective study, we reviewed the records of elderly patients with hip trauma operated in the tertiary care trauma center of our institute over a period of 1 year. Out of 120 patients, preoperative echocardiography was done in 30 patients. We compared the patients for whom echocardiography was done with the patients who did not undergo echocardiography. Descriptive statistical methods were used to analyze the results and observations. RESULTS: We observed that preoperative transthoracic echocardiography led to an escalation in cardiac medication in 53% patients when compared with 23.3% in patients who did not undergo echocardiography. No preoperative cardiac intervention was done in any patient. However, there was a delay of 2.5 days in surgery in the echocardiography group as compared to the patients of nonechocardiography group. Rate of regional anesthesia was comparable in both the groups (54% vs. 56.6%). CONCLUSIONS: In the present study, it was observed that echocardiography significantly delays surgery without a significant change in preoperative cardiac medication or anesthesia technique. This may have a potential possible adverse effect on the outcome in geriatric hip trauma which was not observed to a significant limit in the present study as the study was not a longitudinal study. For "fast tracking" of geriatric hip trauma, institutional guidelines should be developed depending on the resources available.

Benefits and Pitfalls of Cadavers as Learning Tool for Ultrasound-guided Regional Anesthesia.

Ultrasound-guided regional anesthesia (UGRA), like other basic skills, should be learnt in a simulation laboratory before performing on the patient. Cadavers provide an ideal tool for learning sonoanatomy and skills required for performing UGRA. On the basis of preservation technique used, the cadavers can be formalin embalmed cadavers, Thiel cadavers (soft cadavers), and fresh frozen cadavers. We compared three types of cadavers for performing ultrasound-guided upper and lower limb blocks. We observed that fresh frozen and Thiel cadavers were less smelling and had more realistic appearance as compared to formalin embalmed cadavers. It was seen that Thiel cadavers were more flexible and hence, rotation of neck, shoulder and knee was easier. Although images seen in most cadavers were comparable with live subjects but, Thiel cadavers provided more realistic model.

Preparing manuscript: Scientific writing for publication.

Publication has become a burning issue among Indian medical fraternity owing to certain academic and professional necessities. The large number of submissions to the anaesthesia journals has resulted in accumulation of too much below average scientific material. A properly written manuscript is the dream of every editor and reviewer. The art of preparing a manuscript can be acquired only by following certain basic rules and technical aspects, besides knowledge and skills. Before preparing the manuscript, a target journal should be considered. All the instructions to the authors pertaining to that particular journal should be followed meticulously before preparing the manuscript for submission. The basic structure of the manuscript to be followed can be summarised by the acronym IMRaD (introduction, methods, results and discussion). The current review article aims to highlight all those mandatory and desirable features which should be kept in consideration while preparing a scientific manuscript for publication.

Does community emergency care initiative improve the knowledge and skill of healthcare workers and laypersons in basic emergency care in India?

BACKGROUND: Due to lack of training in emergency care, basic emergency care in India is still in its infancy. We designed All India Institute of Medical Sciences basic emergency care course (AIIMS BECC) to address the issue. AIM: To improve the knowledge and skill of healthcare workers and laypersons in basic emergency care and to identify impact of the course. MATERIALS AND METHODS: Prospective study conducted over a period of 4 years. The target groups were medical and nonmedical personnel. Provider AIIMS BECC is of 1 day duration including lectures on cardio-pulmonary resuscitation, choking, and special scenarios. Course was disseminated via lectures, audio-visual aids, and mannequin training. For analysis, the participants were categorized on the basis of their education and profession. A pre- and a post-course evaluation were done and individual scores were given out of 20 and compared among all the groups and P value was calculated. RESULTS: A total of 1283 subjects were trained. 99.81% became providers and 2.0% were trained as instructors. There was a significant improvement in knowledge among all the participants irrespective of their education level including medicos/nonmedicos. However, participants who had higher education (graduates and postgraduates) and/or belonged to medical field had better knowledge gain as compared to those who had low level of education (≤12(th) standard) and were nonmedicos. CONCLUSION: BECC is an excellent community initiative to improve knowledge and skill of healthcare and laypersons in providing basic emergency care.

Sonographic assessment of predictors of depth of the corner pocket for ultrasound-guided supraclavicular brachial plexus block.

BACKGROUND AND AIMS: There is wide variation in depth of brachial plexus in patient population at supraclavicular region. We plan to find the depth of the corner pocket and correlate it with age, weight, height and body mass index (BMI). MATERIAL AND METHODS: After approval from Ethics Committee, right-sided supraclavicular region of volunteers was scanned. Once an optimal image, which included subclavian artery, pleura, first rib and nerve bundles, was obtained, the corner pocket was kept in the middle of the screen and the image was frozen. Depth of the corner pocket from the skin was measured. Thereafter longest distance (LD) approximating needle trajectory was calculated. The Pearson correlation was used to calculate the relation between these two distances and various predictors such as weight, height, and BMI. RESULTS: Mean shortest distance that is, vertical distance from skin to corner pocket for all volunteers was found to be 1.7 ± 0.8 cm and the mean LD that is, distance traveled by needle entering 1 cm from the edge of foot process to the corner pocket in an in-plane approach was 3.7 ± 0.2 cm. We did not find any significant correlation between age, height versus measured distances. However, significant correlation (0.11) was found between weights, BMI versus two lengths. CONCLUSION: Prescanning of supraclavicular region for estimating depth of corner pocket should be done before choosing an appropriate size needle. Furthermore, the needle should not be advanced more than the predicted corner pocket depth.

Management of Young Patients with Temporomandibular Joint Ankylosis-a Surgical and Anesthetic Challenge.

Temporomandibular joint ankylosis is a unique disease where fracture of the mandibular condyle or any other cause leading to ankylosis of the joint can lead to multiple problems if not detected and treated early. If affected in early years of life, it may cause facial dysmorphism, restricted mouth opening, and difficulty in eating, speech, and sleep. Early surgery and physiotherapy can restore the joint function to a great extent. Anesthetizing a pediatric patient with this disorder is a definite challenge which needs expertise in difficult airway management.

Early versus delayed decompression in acute subaxial cervical spinal cord injury: A prospective outcome study at a Level I trauma center from India.

AIMS: This study was done with the aim to compare the clinical outcome and patients' quality of life between early versus delayed surgically treated patients of acute subaxial cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute subaxial cervical spinal cord trauma is safe and is associated with improved outcome as compared to delayed surgical decompression. MATERIALS AND METHODS: A total of 69 patients were recruited and divided into early decompression surgery Group A (operated within 48 h of trauma; n = 23) and late/delayed decompression surgery Group B (operated between 48 h and 7 days of trauma; n = 46). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion. RESULTS: The early surgery group spent lesser days in the intensive care unit and hospital (Group A 28.6 vs. Group B 35 days) had lesser postoperative complications (Group A 43% vs. Group B 61%) and a reduced mortality (Group A 30% vs. Group B 45%). In Group A, 38% patients had 1 American Spinal Injury Association (ASIA) grade improvement while 31% experienced >2 ASIA grade improvement. In Group B, the neurological improvement was 27% and 32%, respectively (P = 0.7). There was a significant improvement in the postoperative quality of life scores in both groups. CONCLUSION: Early surgery in patients with acute subaxial cervical spine injury should be considered strongly in view of the lesser complications, early discharge, and reduced mortality.

Effect of anaesthesia on the perioperative outcomes of pelvi-acetabular fracture surgeries in the apex trauma centre of a developing country-a retrospective analysis.

BACKGROUND: Regional anaesthesia has been proposed to reduce intraoperative blood loss, duration of hospital stay and in-hospital complications with improved postoperative pain control. General anaesthesia is advantageous for prolonged surgeries. We hypothesized that combined regional and general anaesthesia would offer advantages of both in pelvi-acetabular fracture surgeries. METHODS: We identified 71 patients who underwent open reduction and internal fixation of pelvi-acetabular fractures from May 2012 to 2013 in our trauma centre. We excluded patients with incomplete records (n = 4) and other injuries operated along (n = 8). Hence, 59 patients were divided into three groups: G group (general anaesthesia), R group (regional anaesthesia) and GR group (combined regional and general anaesthesia). Main outcome measurements studied were intraoperative blood loss, duration of hospital stay, duration of surgery and intraoperative and postoperative complications. RESULTS: No differences were obtained in between the groups in terms of age, gender, Injury Severity Score, number of comorbidities, or duration from injury to surgery. No significant differences were found between the three groups for intraoperative blood loss, days of hospital stay and duration of surgery. Intraoperative and postoperative complications were also comparable between the groups (p > 0.05). CONCLUSIONS: There is no specific significant advantage of the technique of anaesthesia on the observed perioperative complications in pelvi-acetabular fracture surgeries.

Critical care issues in solid organ injury: Review and experience in a tertiary trauma center.

BACKGROUND AND AIM: Solid organ (spleen and liver) injuries are dreaded by both surgeons and anesthesiologists because of associated high morbidity and mortality. The purpose of this review is to describe our experience of critical care concerns in solid organ injury, which otherwise has been poorly addressed in the literature. MATERIALS AND METHODS: Retrospective cohort of solid organ injury (spleen and liver) patients was done from January 2010 to December 2011 in tertiary level trauma Center. RESULTS: Out of 624 abdominal trauma patients, a total of 212 patients (70%) were admitted in intensive care unit (ICU). Their ages ranged from 6 to 74 years (median 24 years). Nearly 89% patients in liver trauma and 84% patients in splenic trauma were male. Mechanism of injury was blunt abdominal trauma in 96% patients and the most common associated injury was chest trauma. Average injury severity score, sequential organ failure assessment, lactate on admission was 16.84, 4.34 and 3.42 mmol/L and that of dying patient were 29.70, 7.73 and 5.09 mmol/L, respectively. Overall mortality of ICU admitted solid organ injury was 15.55%. Major issues of concern in splenic injury were hemorrhagic shock, overwhelming post-splenectomy infection and post-splenectomy vaccination. Issues raised in liver injury are damage control surgery, deadly triad, thromboelastography guided transfusion protocols and hemostatic agents. CONCLUSIONS: A protocol-based and multidisciplinary approach in high dependency unit can significantly reduce morbidity and mortality in patients with solid organ injury.