The Role of Pupillometry in the Assessment of Pain in Children Under General Anesthesia: A Prospective Single-Blinded Observational Study.

Background and objective The management and treatment of nociception remain one of the major challenges in anesthesiology, and hemodynamic variations may occur due to inadequate analgesia, which at times can be injurious. Pupillometry is a new noninvasive tool to assess nociception during anesthesia. The amount of pupillary reflex dilation (PRD) is directly proportional to the intensity of nociceptive stimuli and inversely proportional to the opioid dosage. This study aimed to assess the use of pupillometry as reflex pupillary dilatation in response to surgical stimulus in children under general anesthesia and to guide intraoperative opioid consumption. Materials and methods After obtaining approval from the institutional ethics committee and written consent from parents, children with an American Society of Anesthesiology (ASA) classification of I and II and aged 2-12 years who were undergoing surgery under general anesthesia were enrolled in this prospective randomized observational study. General anesthesia was standardized with propofol, sevoflurane, and O2 and N2O (50:50%), and fentanyl administration was guided by pupil diameter changes. The primary outcome was to measure pupillary dilatation in response to pain and fentanyl administration guided by it. Results A total of 72 patients were included in the study. The mean pupil diameter significantly increased after surgical stimulus from 1.37 ±0.87 to 2.40 ±1.95 mm (p<0.001). The heart rate (116.2 ±12.25 to 118.50 ±8.20 beats/minute, p=0.18) and systolic BP (114.60 ±17.73 to 118.50 ±12.25 mmHg, p=0.12) did not change significantly on stimulus. The mean fentanyl consumption was 2.4 ug/kg and the side effects were not remarkable. Conclusion Based on our findings, pain has a significant influence on the pupil dilatation reflex in anesthetized children, and opioid administration based on pupil diameter can be valuable in clinical settings. We recommend the use of pupillometry as a pain index in children undergoing surgery under general anesthesia, and it can be a beneficial tool for assessing intraoperative pain. Newer techniques and developments are required in this field.

Early versus Late Tracheostomy in Patients with Acute Brain Injury: Importance of SET Score.

Introduction: Patients with acute brain injury presents are unique subset of neurocritical care patients with its long-term functional prognosis difficult to determine. They often have long intensive care unit (ICU) stay and presents as challenge to decide when to transfer out of ICU. This prospective study aims to assess the benefits of early tracheostomy in terms of ICU-length of stay (ICU-LOS), number of days on ventilator (ventilator days), incidence of ventilator-associated pneumonia (VAP), and mortality rates. Materials and Methods: After institutional ethical clearance, 80 patients were randomized into two groups: Group A, early tracheostomy group (tracheostomy within 3 days of intubation) and Group B, standard of care group (tracheostomy after 10 days of intubation: late tracheostomy). A cutoff of 10 in the SET score was used in predicting need of early tracheostomy; both groups were compared with respect to ICU-LOS, number of ventilator days (ventilation time), need of analgesia and sedation, incidence of VAP, and mortality data. Results: Both the groups were comparable in terms of demographic profile and various disease severity scores. ICU-LOS was 14.9 ± 3.6 days in Group A and 17.2 ± 4.6 in Group B. The number of days on ventilator and incidence of VAP was significantly lower in Group A as compared to Group B. There was significantly lower mortality in Group A subset of patients in ICU. Conclusion: SET score is a simple and reliable score with fair accuracy and high sensitivity and specificity in predicting need of tracheostomy in neurocritical patients. A cutoff of 10 in the score can be reliably used in predicting need of early tracheostomy as in few other studies. Early tracheostomy is clearly advantageous in neurocritical patients, but has no advantage in terms of long-term mortality rates.

Comparison of Oral versus Intramuscular Clonidine for the Prolongation of Bupivacaine Spinal Anesthesia in Patients Undergoing Lower Abdominal and Lower Limb Surgeries.

Background: Spinal subarachnoid block (SAB) is the first choice anesthesia in lower abdominal and lower limb surgeries. It produces a varying degree of sensory analgesia, motor blockade, and sympathetic blockade depending on the dose, concentration, and volume of the local anesthetic given. This study was undertaken to assess the degree of sensory and motor block with 150 µg of oral versus intramuscular clonidine as an adjuvant to bupivacaine for spinal anesthesia. Aims and Objective: To compare the efficacy of oral versus intramuscular clonidine as an adjuvant to bupivacaine for the prolongation of sensory and motor block in patients undergoing lower abdominal and lower limb surgeries under SAB. Materials and Methods: After institutional ethical clearance, 90 patients were randomized into three groups scheduled for lower abdominal and lower limb surgeries under spinal anesthesia. • Group O: Bupivacaine 0.5% (heavy) 3.0 mL and oral clonidine 150 µg 1 h before spinal anesthesia. • Group I: Bupivacaine 0.5% (heavy) 3.0 mL and intramuscular clonidine 150 µg 1 h before spinal anesthesia. • Group C: Control group - 3 mL bupivacaine 0.5% (heavy) alone. Result: The onset of sensory block in Group O was 4.9 ± 0.52 min, whereas in Group I, it was 4.6 ± 0.42 min than Group C (5.1 ± 0.60). Onset of motor block was also significantly lower in Group O and Group I (3.9 ± 0.53 and 3.7 ± 0.42 min) than in Group C (4.4 ± 0.6 min) which was a control group. There was also a significant difference in the duration of the sensory block between Group O (206.4 ± 9.2 min), Group I (219 ± 8.6 min), and Group C (184.3 ± 9.1 min). The duration of motor block was significantly higher in Group O (183.6 ± 8.2 min) and Group I (197.8 ± 9.6 min) when compared to Group C (162.8 ± 8.9 min). The timing of rescue analgesia in Group O was 222.4 ± 11.7 min, whereas in Group I, it was 243.46 ± 10.9. Conclusion: On the basis of finding of our study, we conclude that the use of clonidine as a premedication at a dose of 150 µg significantly increased the duration of sensory block, motor block, and duration of analgesia and shortened the time of onset of sensory and motor blockade.

Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses versus Continuous Infusion in Septic Shock: A Prospective Randomized Trial.

Background: Hydrocortisone showed an important role in reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the most common side effects associated with corticosteroid treatment. Aims: This study aimed to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses versus continuous infusion in septic shock patients. Settings and Design: This was a prospective randomized controlled study conducted in a tertiary care teaching hospital. Materials and Methods: One hundred and forty patients with septic shock and who received noradrenaline were enrolled in this randomized study. Group 1 was intermittent bolus hydrocortisone group (n = 70) and Group 2 was continuous infusion group (n = 70). All patients who were admitted with septic shock and who received noradrenaline and hydrocortisone were included in the study. Those patients who had exceeded 200 mg per day of hydrocortisone were excluded from the study. The primary outcome of the study was mean blood glucose. Statistical Analysis Used: Qualitative variables were compared between the two groups with the Chi-square of the Fisher's exact test and continuous variables were compared using the Student's t-test or the Wilcoxon rank-sum test. Results: Out of 112 patients, 54 patients received hydrocortisone as intermittent boluses (48.2%), and 58 patients (51.8%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 154.44 mg.dL-1 (95% confidence interval [CI]: 144.18-166.88) in the bolus group and 160.2 mg.dL-1 (95% CI: 143.82-176.76) in the infusion group with a mean difference of 05.76 mg.dL-1 (95% CI: -13.86-25.38). For the secondary outcomes of the study, no difference was found between the two groups in hyperglycemic or hypoglycemic events, mortality, length of stay in intensive care unit, and reversal of shock. Conclusions: The risk of hyperglycemia is almost equal in both intermittent and continuous infusions of hydrocortisone in septic shock patients.

Would "Suction above Cuff" be a Better Option than the "Standard" Endotracheal Tube for the Prevention of Ventilator-Associated Pneumonia: A Randomized Study in Postoperative Neurological Patients.

CONTEXT: Ventilator associated pneumonia is one the most common nosocomial infection encountered in the ICU patients. Despite of the implementation of the VAP prevention bundle, the incidence remains high. This can be attributed to the peritubal leak and the aspiration of the oropharyngeal secretions. The secretions further forms a nidus for the growth of organisms in the lower respiratory tract. In this study, a specialised tube, named 'suction above cuff endotracheal tube' is used, which has an additional suction port opening above the cuff. This is to facilitate timely aspiration of the secretion which pent-up above the cuff and gradually trickles down the trachea resulting in pneumonia. AIM: to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurological post-operative patients and its impact on clinical outcome. SETTINGS AND DESIGN: 60 patients of post-operative neurological cases aged ≥ 18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. RESULTS: In this study involving neurological population, there was no significant difference in incidence of clinical and microbiological VAP between SETT and SACETT group, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.