Perfusion index during endotracheal intubation and extubation: A prospective observational study.

Introduction: Perfusion index (PI) can be detected using a pulse oximeter. Its value decreases in response to noxious stimuli. Here, we investigated its efficacy in detecting hemodynamic responses during endotracheal intubation and extubation. Methods: An approval from the institutional ethics committee was obtained along with a written informed consent from the patients involved in this study. A sample size of 30 was calculated. Reading of PI, heart rate, and blood pressures (systolic, diastolic, and mean arterial) were recorded at pre-intubation, post-intubation, during neuromuscular block reversal, pre-extubation and at extubation. Clinically significant heart rate, blood pressure (systolic, diastolic, and mean) and PI was defined as increase by >10 bpm, rise by ≥15 bpm and a decrease by ≥10%, respectively, from pre-intubation value. Results: Clinically significant change in PI was seen at all intervals with maximum decrease in PI occurring during neuromuscular block reversal (42.6% at the start and 56.7% at the end of neuromuscular block reversal). A negative correlation was noted between PI and the other non-invasive hemodynamic parameters. Conclusion: PI decreases on noxious stimuli and correlates negatively with the other non-invasive hemodynamic parameters. Hemodynamic response at neuromuscular block reversal is maximum.

Clinical Presentation and Management of Eyes with Globe Perforation during Peribulbar and Retrobulbar Anesthesia: A Retrospective Case Series.

PURPOSE: To evaluate the clinical presentation, management, and outcome of eyes with an inadvertent globe perforation during peribulbar or retrobulbar block. METHODS: This retrospective study evaluated the eyes which had an accidental globe perforation during local ocular anesthesia from 2012 to 2020. The patients were divided into three groups: group 1, Clear media with no rhegmatogenous retinal detachment (RRD); group 2, significant vitreous hemorrhage (VH) precluding the retinal view without RRD; and group 3, RRD with/without VH. RESULTS: Twenty-five patients were included in the study. The mean axial length (AL) was 24.7 ± 2.7 mm (range, 20.9-31.2 mm). The most common presenting feature was VH (n = 14). The treatment included retinal laser barrage (n = 7) and vitrectomy (n = 17). Retinal breaks were identified in all the eyes (total breaks = 37). The mean presenting best-corrected visual acuity in groups 1, 2, and 3 were logarithm of the minimum angle of resolution 0.79 ± 0.73, 1.82 ± 0.78, and 2.13 ± 0.59 respectively. All the treated patients had an attached retina at the last follow-up. The mean final best-corrected visual acuity for each group was logarithm of the minimum angle of resolution 0.59 ± 0.79, 0.48 ± 0.26, and 1.25 ± 0.64, respectively (p = 0.006). The development of RRD was associated with a larger AL (p = 0.015); while the development of significant VH associated with the superior location of the perforation (p = 0.015), late recognition of the perforation (p = 0.004), and multiple perforations (p = 0.015). CONCLUSIONS: Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer AL, superior, and multiple perforations are at higher risk of developing complications like RRD and VH. Complications like RRD, macular injury, and vascular occlusion are risk factors for poor prognosis.

Analysis of the American Society of Anesthesiologists Physical Status Scale Reliability in Anaesthesia Practice: An Observational Study.

OBJECTIVE: Anaesthesiologists use the American Society of Anesthesiologists physical status (ASA PS) classification to assess patients' overall health. The primary objective of this study was to predict the prognostic value regarding peri-operative variables until discharge from hospital and post-operative outcomes. The secondary objective was to evaluate the inter-rater agreement of the ASA scores assigned at the outpatient department (OPD) vs. operating theatres (OT). METHODS: A total of 227 adults scheduled for elective surgery were assigned the ASA grade in preoperative OPD and on the day of surgery. The type of anaesthesia and surgery were noted. The operating time, post-operative ventilation, intensive care unit (ICU) stay, post-operative stay, bronchopulmonary complications, cardiac complications, renal dysfunction and any mortality until discharge from hospital were noted. Descriptive statistics were used to report the primary objective. For the secondary objective, Pearson's correlation test was used for inter-rater reliability. RESULTS: The ASA grading done at OPD and at OT was the same. It was found that the higher the ASA grade of a patient, the longer was the ICU stay. Patients with higher ASA PS scores were at a comparatively milder risk of developing remaining peri-operative and post-operative complications. CONCLUSION: The correlation was the highest with the ICU stay. The inter-rater ASA grades assignment at the clinics and the OT were found to be almost perfect.

Efficacy of vision therapy in children with learning disability and associated binocular vision anomalies / Eficacia de la terapia visual en niños con trastorno de aprendizaje y anomalías en la visión binocular asociadas

Purpose: To report the frequency of binocular vision (BV) anomalies in children with specific learning disorders (SLD) and to assess the efficacy of vision therapy (VT) in children with a non-strabismic binocular vision anomaly (NSBVA). Methods: The study was carried out at a centre for learning disability (LD). Comprehensive eye examination and binocular vision assessment was carried out for 94 children (mean (SD) age: 15 (2.2) years) diagnosed with specific learning disorder. BV assessment was done for children with best corrected visual acuity of ≥6/9-N6, cooperative for examination and free from any ocular pathology. For children with a diagnosis of NSBVA (n = 46), 24 children were randomized to VT and no intervention was provided to the other 22 children who served as experimental controls. At the end of 10 sessions of vision therapy, BV assessment was performed for both the intervention and non-intervention groups. Results: Binocular vision anomalies were found in 59 children (62.8%) among which 22% (n = 13) had strabismic binocular vision anomalies (SBVA) and 78% (n = 46) had a NSBVA. Accommodative infacility (AIF) was the commonest of the NSBVA and found in 67%, followed by convergence insufficiency (CI) in 25%. Post-vision therapy, the intervention group showed significant improvement in all the BV parameters (Wilcoxon signed rank test, p < 0.05) except negative fusional vergence. Conclusion: Children with specific learning disorders have a high frequency of binocular vision disorders and vision therapy plays a significant role in improving the BV parameters. Children with SLD should be screened for BV anomalies as it could potentially be an added hindrance to the reading difficulty in this special population (AU)

Objetivo: Reportar la frecuencia de las anomalías en la visión binocular (VB) en niños con trastornos específicos de aprendizaje (SLD), y evaluar la eficacia de la terapia visual (TV) en niños con alteraciones en la visión binocular no estrábicas (NSBVA). Métodos: El estudio se llevó a cabo en un centro para discapacidades de aprendizaje (LD). Se realizó un amplio examen ocular y una valoración de la visión binocular en 94 niños (Media (DE) edad: 15 (2,2) años) con diagnóstico de trastorno específico de aprendizaje. Se llevó a cabo una valoración de la VB en los niños, con agudeza visual mejor corregida de ≥6/9-N6, que cooperaron durante el examen, y que carecían de patología ocular. En los niños con diagnóstico de NSBVA (n = 46), se aleatorizaron 24 de ellos para terapia visual, sin realizar intervención alguna en los 22 niños restantes, que sirvieron de controles. Al finalizar las 10 sesiones de terapia visual, se realizó una valoración de VB tanto en el grupo de intervención como en el de no intervención. Resultados: Se encontraron anomalías en la visión binocular en 59 niños (62,8%), de entre los cuales el 22% (n = 13) tenían alteraciones en la visión binocular estrábica (SBVA), y el 78% (n = 46) reflejaron NSBVA. La inflexibilidad acomodativa (AIF) fue la NSBVA más común, estando presente en el 67% de los casos, seguida de la insuficiencia de convergencia (CI) en 25% de ellos. Tras la terapia visual, el grupo de intervención reflejó una mejora significativa en todos los parámetros de VB (prueba de los rangos con signo de Wilcoxon: p < 0,05) exceptuando la vergencia fusional negativa. Conclusión: Los niños con trastorno específico de aprendizaje tienen una elevada frecuencia de anomalías en la visión binocular, y en ellos la terapia visual juega un papel significativo para la mejora de los parámetros de VB. Deberá supervisarse a los niños con SLD, en relación a las anomalías de VB, que podrían suponer un obstáculo añadido a la dificultad lectora en esta población especial (AU)

Efficacy of vision therapy in children with learning disability and associated binocular vision anomalies.

PURPOSE: To report the frequency of binocular vision (BV) anomalies in children with specific learning disorders (SLD) and to assess the efficacy of vision therapy (VT) in children with a non-strabismic binocular vision anomaly (NSBVA). METHODS: The study was carried out at a centre for learning disability (LD). Comprehensive eye examination and binocular vision assessment was carried out for 94 children (mean (SD) age: 15 (2.2) years) diagnosed with specific learning disorder. BV assessment was done for children with best corrected visual acuity of ≥6/9 - N6, cooperative for examination and free from any ocular pathology. For children with a diagnosis of NSBVA (n=46), 24 children were randomized to VT and no intervention was provided to the other 22 children who served as experimental controls. At the end of 10 sessions of vision therapy, BV assessment was performed for both the intervention and non-intervention groups. RESULTS: Binocular vision anomalies were found in 59 children (62.8%) among which 22% (n=13) had strabismic binocular vision anomalies (SBVA) and 78% (n=46) had a NSBVA. Accommodative infacility (AIF) was the commonest of the NSBVA and found in 67%, followed by convergence insufficiency (CI) in 25%. Post-vision therapy, the intervention group showed significant improvement in all the BV parameters (Wilcoxon signed rank test, p<0.05) except negative fusional vergence. CONCLUSION: Children with specific learning disorders have a high frequency of binocular vision disorders and vision therapy plays a significant role in improving the BV parameters. Children with SLD should be screened for BV anomalies as it could potentially be an added hindrance to the reading difficulty in this special population.

Magnesium sulfate for postoperative analgesia after surgery under spinal anesthesia.

BACKGROUND: Magnesium has been proven to have antinociceptive effects in animal and human models of pain. Its effect is primarily based on the regulation of calcium influx into the cell, which is natural physiological calcium antagonism and N-methyl-d-aspartate (NMDA) receptor antagonism. METHODS: One hundred and eight patients undergoing surgery with spinal anesthesia received either 250 mg of intravenous magnesium sulfate followed by an infusion of 500 mg magnesium sulfate (25 mg/mL) at the rate of 20 mL/hour; or the same volume of normal saline (control group) as bolus and infusion. The primary end-points in the study were to evaluate the analgesic effect and duration of sensory and motor blockade. The secondary end-points included assessment of hemodynamic effects of intravenous magnesium sulfate and rescue analgesia requirement. RESULTS: Sensory and motor blockade, respectively, were 25 minutes and 34 minutes shorter in the control group. Less patients in the magnesium group (33% vs. 53.7%) than in control group required rescue analgesia in the postoperative period. The control group required rescue analgesia nearly 3 hours earlier than the magnesium group. Only one patient in the control group experienced bradycardia. There was no event of intraoperative hypotension in either of the groups. CONCLUSION: Intravenous magnesium sulfate when given as a bolus, followed by an infusion, delayed and decreased the need of rescue analgesics after spinal anesthesia.

Comparison of post-operative ICU sedation between dexmedetomidine and propofol in Indian population.

CONTEXT: Critically ill patients requiring mechanical ventilation frequently need sedatives and analgesics to facilitate their care. Dexmedetomidine, a short-acting alpha-2-agonist, possesses anxiolytic, anesthetic, hypnotic, and analgesic properties. AIMS: The objective of this study was to evaluate the efficacy and safety of dexmedetomidine in comparison to propofol in the management of sedation for post-operative intensive care unit (ICU) patients, as a sedative agent. SETTINGS AND DESIGN: Teaching hospital, A phase III, prospective, open, randomized and comparative. MATERIALS AND METHODS: Thirty patients who were ambulatory and who required the post-operative mechanical ventilation or post-operative sedation were enrolled, in which 15 patients received Dexmedetomidine and remaining 15 patients received propofol. All these patients were treated for the period of 8 to 24 h. STATISTICAL ANALYSIS USED: Data were analyzed using Student's t-test and Chi-square test. The value of P < 0.05 was considered as statistically significant. RESULTS: Demographic data were comparable. Pulse rate, respiratory rate and blood pressure were comparable. Depth of sedation and extubation time were similar. To maintain analgesia throughout the study period, patients receiving propofol infusions required significantly more analgesics than patients receiving Dexmedetomidine. CONCLUSIONS: Dexmedetomidine appears to be a safe and acceptable ICU sedative agent when both the clinician's and patient's perspectives are considered.

Depth of central venous catheterization by intracardiac electrocardiogram in adults.

BACKGROUND: Central venous catheterization is done frequently in cardiac surgery and intensive care settings. Faulty positioning of the catheter can cause many complications. OBJECTIVES: The aim of our study was to study the average depth of insertion and formulate a general guideline through the right internal jugular vein (IJV). PATIENTS AND METHODS: The right IJV was cannulated over a period of four months and catheter tip positioning was guided by means of an intracardiac electrocardiogram (ECG). Insertion depth was registered at the position of maximum P wave amplitude and the catheter was fixed after withdrawing 2 cm. Pearson's correlation coefficient was calculated to categorize any relationship between plots of distance versus patient's height, and regression lines and equations were also calculated. Bland-Altman analysis of data was done to compare the old formulae with our derived formulae. RESULTS: A total of 155 adult patients were studied. Distances measured were found to be highly correlated with a patient's height, followed by body surface area (BSA) and weight. For right IJV cannulation in valvular surgeries in adults, the depth of insertion (cm) was (height in cm / 15) + 2 ± 1.58 (SD) and in non-valvular surgeries in adults, it was (height in cm/15) + 1.4 ± 1.47 (SD). The bias was very small when the new formulae were compared to the existing formulae. CONCLUSIONS: The devised formulae predicted the required depth of catheters thereby reducing the possibility of complications and need for radiographic confirmation.

Incidence and predictors of difficult mask ventilation and intubation.

BACKGROUND: This study is aimed to determine the incidence and predictors of difficult and impossible mask ventilation. MATERIALS AND METHODS: Information like age, snoring history, obstructive sleep apnea, dental and mandibular abnormalities, macroglossia, grading like SLUX, Mallampatti, Cormack Lehanne, atlantooccipital extension, presence of beard or moustache, mouth opening were collected. During mask ventilation, the information related to the ventilation and intubation was collected. All variables found to be significant in univariate analysis were subjected to the multivariate logistic regression model to identify independent predictors of measured outcome. RESULTS: Difficult mask ventilation (DMV) was observed in 30 male patients and 9 female patients. Of the 40 patients who had difficult intubation (DI), 7 patients had both DMV and intubation and 1 patient was of impossible mask ventilation/ intubation. Snoring was the lone significant risk factor for DMV. The risk factors identified for DI were snoring, retrognathia, micrognathia, macroglossia, short thick neck, Mallampatti grade [III/IV], abnormal SLUX grade, Cormack Lehanne grade [II,III/IV], abnormal atlantooccipital extension grading, flexion/extension deformity of neck, protuberant teeth, cervical spine abnormality, mouth opening < 3 cm, and BMI > 26 kg/m(2). BMI > 26 kg/m(2) and atlantooccipital extension grade > 3 were independent risk factors for DI and the presence of two of the variables made the sensitivity and specificity of 43% and 99% respectively with a positive predictive value of 74%. CONCLUSIONS: The predictive score may lead to a better anticipation of difficult airway management, potentially deceasing the morbidity and mortality resulting from hypoxia or anoxia with failed ventilation.

Anaesthetic management for caesarean section in a case of previously operated with residual pituitary tumour.

Successful anaesthetic management for caesarean section in a case with previous pituitary tumour resection, with residual tumour, is reported. The pituitary gland undergoes global hyperplasia during pregnancy. Functional pituitary tumours may exhibit symptomatic enlargement during pregnancy. Growth hormone secreting tumour is associated with acromegaly which has associated anaesthetic implications of difficult airway, systemic hypertension, and diabetes and electrolyte imbalance. Intracranial space occupying lesions can increase intra cranial pressure and compromise cerebral perfusion or cause herniation. We report management of this case.