A case report on anesthetic challenges in the post-Covid complication of active mucormycosis: Patient preparedness for family physicians.

Mucormycosis is a well-known yet complicated illness that seems benign but behaves malignantly. This article discusses the anesthesia challenges in providing care for a 49-year-old male who presented with post-Covid pneumonia and uncontrolled diabetes along with active mucormycosis and scheduled for functional endoscope sinus surgery (FESS) and debridement of necrotic tissue. We want to illustrate the importance of anticipated difficult airway, while highlighting the toxicity of intravenous amphotericin-B and its combination against anesthesia drugs.

Anesthetic Considerations for Elective Laparoscopic Cholecystectomy in a Patient With Previous Pneumonectomy.

Patients presenting for surgery after pneumonectomy pose significant challenges to anesthesiologists. The disease process necessitating pneumonectomy may involve the surviving lung too. Cholecystectomy is a major surgery, and the open approach has significant risks of post-operative pulmonary complications in these patients partly owing to the large incision and postoperative atelectasis, associated with inadequate post-operative analgesia. Contemplating a laparoscopic procedure in patients with a single, possibly damaged lung, involves a good understanding of the physiology of the single lung as well as the challenges posed by capnoperitoneum. Here, we present a case of a female with a history of previous pneumonectomy undergoing laparoscopic cholecystectomy. There are very few reports of patients after pneumonectomy who have subsequently undergone a laparoscopic cholecystectomy successfully and this report highlights some crucial factors to be kept in mind during anesthetic management of such patients.

Moderate to Severe Thrombocytopenia in Four Pregnant Women With Asymptomatic COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) pandemic is one of the biggest healthcare crises faced globally. Since its emergence, uncertainty about its progress and treatment options has challenged clinicians around the world. Pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection pose a higher challenge due to the concerns of an already altered immune system during pregnancy and the disease's effect on the fetus. Thrombocytopenia is associated frequently with moderate to severe coronavirus disease and is also an established marker of worsening of the disease. However, it is infrequently seen in mild or asymptomatic cases. Neuraxial anesthesia is the preferred choice of anesthesia in COVID-19 positive patients but thrombocytopenia in a parturient with coronavirus disease can cause a dilemma for the obstetric anesthesiologist. Here we describe the management of four pregnant women with asymptomatic COVID-19 disease who had moderate to severe thrombocytopenia. These cases highlight the importance of careful monitoring of the platelet count of pregnant women with COVID-19 infection even if asymptomatic.

A Prospective, Comparative Study to Evaluate the Diagnostic Accuracy of Mallampati Grading in Supine and Sitting Positions for Prediction of Difficult Airway.

Background & aim Difficult airway is a major concern for all anaesthesiologists because failure to secure airway could lead to devastating complications or may increase morbidity and mortality. Airway assessment, therefore, is of paramount importance and anticipating a difficult airway prior to anesthetic administration, could help us in better preparation as well as avoidance of life-threatening complications. There are various tests available to assess the airway, out of which, modified Mallampati test (MLPT) is one of the common, easy and reliable methods to predict difficult airway. Mallampati test, usually is done with patient in sitting position. However, in certain group of patients in whom sitting position is not possible (suspected cervical spine injury, pelvic injury, patients in shock, etc.), the Mallampati test can be done in supine position. Few studies were available which concluded that Mallampati test in supine position was not only reliable but also superior to sitting position, whereas, few other studies contradicted this opinion. We, therefore, wanted to address this issue and tried to find out whether Mallampati test in supine position could offer better diagnostic accuracy or not. Materials & methods Mallampati test (MLPT) in sitting position was done in 100 patients initially in preoperative period and subsequently in supine position inside operating room prior to induction of anesthesia. During laryngoscopy, Cormack-Lehane (CL) grading was noted in all patients. Correlation of Mallampati test in sitting and supine position with Cormack-Lehane grading was obtained. A receiver operating characteristics (ROC) analysis was done to determine the area under the curve, the sensitivity and the specificity. Positive predictive value (PPV) and negative predictive value (NPV) were also calculated to analyse the diagnostic accuracy of Mallampati score (MLPT) in sitting and supine position. Results A toal of 22.2% of patients had difficult intubation (CL grade 3) although MLPT of these patients in sitting position anticipated a non-difficult airway (MLPT 1 and 2) and there was no significant correlation between MLPT grade in sitting position with the Cormack-Lehane grade. In comparison to sitting position, MLPT in supine position had significant correlation with the Cormack-Lehane grading and all patients with supine MLPT 1 and 2 (non-difficult airway) had easy intubation (CL grade 1 and 2). ROC analysis also showed that MLPT grade in supine position had superior correlation and better diagnostic accuracy than MLPT in sitting position for assessment of airway as indicated by higher sensitivity and better positive as well as negative predictive values. Conclusion Mallampati test done in supine position has far greater sensitivity and is superior in predicting difficult intubation as compared to MLPT done in conventional sitting position.

Blunt Injury Forearm Debridement Under Ultrasound-Guided Regional Anesthesia for a Marfan Syndrome Patient.

Marfan syndrome is an autosomal dominant connective tissue disorder with anomalies involving the musculoskeletal system, cardiovascular system, skin, eyes, and teeth. Patients with Marfan syndrome are especially prone to cardiovascular complications, which increases the risk multifold under general anesthesia. This is a case of a 37-year-old Marfan syndrome male patient with cardiac manifestations and his anesthesia course during emergency wound debridement.

Combined Spinal-Epidural Anaesthesia for Caesarean Delivery in Takayasu's Arteritis: A Viable Alternative.

Takayasu's arteritis (TA), also known as "pulseless disease", is a nonspecific inflammatory arteritis of large and medium caliber arteries of unknown aetiology with a predilection for young women of childbearing age. Although the evolution of the disease is not affected during pregnancy, it can result in uncontrolled hypertension, multiple organ dysfunction, and stenosis that hinder regional blood flow. Associated pregnancy, therefore, poses an increased risk to the mother and foetus due to the many cardiovascular complications that can occur in the course of the disease, making anaesthesia for caesarean delivery especially challenging to the anaesthesiologist. We report the successful anaesthetic management of a case of TA undergoing caesarean section in view of a previous caesarean delivery. We also engage in a brief review of the related literature.

Success rate of Remdesivir, Convalescent Plasma, and Tocilizumab in moderate to severe Covid-19 pneumonia: our experience in a tertiary care center.

INTRODUCTION: After the first case of Covid-19 was identified in Wuhan City, China, the numbers increased rapidly all over the world putting a huge burden on the entire healthcare system. Managing these cases posed a great challenge to the treating clinicians in the absence of targeted therapy. At this juncture, few modalities got approved as EUA (Emergency use under authorization) drugs namely Remdesivir, Convalescent Plasma (CP), and Tocilizumab (TCZ) to treat this deadly disease. AIM: To analyze the success rates of EUA therapies for Covid-19 pneumonia in our hospital. MATERIALS AND METHODS: This was a prospective observational study conducted from April 2020 to October 2020 in the department of Medicine at Tata Main Hospital, Jamshedpur, Jharkhand. All adults with moderate to severe Covid-19 as per the WHO criteria were enrolled in the study with their informed consent. Patients with estimated glomerular filtration rate <30 mL/min, deranged liver function tests, electrocardiographic abnormalities, and deranged hematological parameters were excluded from the study. Thorough clinical evaluation was done in all cases. Routine investigations together with CRP, LDH, serum Ferritin, D Dimer and IL6, Chest X-Ray, and HRCT thorax were done in all cases. ECG was done in all cases and 2D-ECHO in selected ones. Depending on their clinical and radiological criteria, patients were treated with various modalities approved under EUA with close monitoring of clinical, biochemical, and radiological parameters. Presenting symptoms, clinical findings, co-morbidities, laboratory parameters, and radiological assessment were analyzed, and statistical analysis was done. The survival rate and in-hospital mortality was analyzed. OBSERVATIONS AND RESULTS: We had a total of 448 patients who were included in our study, out of which 326 were males and 122 were females with a male to female ratio of 2.7:1. Their age varied between 16 and 91 years with an average age of 51.4 years with a standard deviation (SD) of +/- 6.4 years. About 255 patients (57%) received only Remdesivir (176 males, 79 females), 139 (105 males, 35 females) patients (31%) received Remdesivir along with two units of CP, and 38 (32 males, 6 females) patients received a combination of Remdesivir, CP, and TCZ. All patients in our study tolerated the drugs well. About 5% of cases who received CP had minor transfusion reactions. One patient had TRALI and three patients had TACO, which was managed aggressively. Asymptomatic transaminitis was seen in 36% patients. The survival rate in patients treated with Remdesivir was 78%, those with Remdesivir and CP was 44%, and those with all three was 13%. The mean length of stay was 14.23 days with a SD of 9.06 days in patients treated with TCZ in comparison to other two modalities, which was 13.88 days with a standard variation of +/- 8.71 days in Remdesivir and 13.88 days with a SD of 8.73 days in patients treated with CP that was stastically significant. CONCLUSIONS: Though the success rate of various drugs under EUA varies in different studies from all over the world, the data to support their use are encouraging. We also observed satisfying results in our study specially with the use of Remdesivir. Therefore, EUA agents should be used early to fight against COVID-19 along with the other measures as per the protocol laid by ICMR and MoHFW.

An anaesthetic quandary: Caesarean section during cardiac failure in a case of peripartum cardiomyopathy complicated by preeclampsia.

Anaesthetic management of cardiac disorders in pregnancy has always been complicated and challenging. A rare but extremely fatal entity, peripartum cardiomyopathy (PPCM) is a life-threatening disease affecting the parturient with mortality rates as high as 35-50%. Developing in late pregnancy or immediately after delivery, this unique disorder endangers not only the mother but the baby as well. We report here a case of a 28-year-old female parturient presenting at 37 weeks of gestation for caesarean delivery with recently diagnosed peripartum cardiomyopathy (ejection fraction of 28%) complicated by severe preeclampsia. She developed cardiac failure just before the induction of anaesthesia. She was successfully resuscitated, operated under general anaesthesia and shifted to the critical care unit for further management.

An Inquiry on Airway Management by McCoy Blade with Elevated Tip and Miller Straight Blade with Paraglossal Technique: Relevance for Difficult Airway Management in Current Infectious Times.

Background: Modifications of curved and straight laryngoscope blades have been used for airway management since a long time. While McCoy blade with an elevated tip is commonly used to intubate patients with anticipated difficult airway, the Miller's straight blade is used for intubations in children and less commonly adults. In this study, we revisit the paraglossal technique of Miller's straight blade as a method to improve laryngeal view especially in difficult intubations. Aim: This study aimed to compare laryngoscopic view and ease of intubation (EOI) using McCoy blade elevated tip and Miller's straight blade paraglossal technique. Materials and Methods: A prospective single-blind study was conducted on 170 patients undergoing elective surgery under general anesthesia. They were randomly allotted to two groups. In Group A, laryngoscopy was performed by Miller's blade paraglossal approach, whereas in Group B, laryngoscopy was performed by McCoy blade with an elevated tip. Laryngeal view was graded using the modified Cormack-Lehane grading, and EOI was graded using EOI score. These were compared with preoperative intubation prediction score. Statistical analysis was done using "Medcalc" version 19.0.3. Numerical and categorical data were analyzed by Student's t-test and Chi-square test, respectively. A P < 0.05 was considered statistically significant. Results: The paraglossal approach with Miller's blade offered better laryngoscopic view as compared with McCoy blade with an elevated tip in normal (54.1% vs. 25.9%) and difficult airway (44.7% vs. 11.8%). Tracheal intubation was easier with McCoy blade with an elevated tip although the success rate of intubation improved with the assistance of a bougie with Miller's straight blade paraglossal approach. Conclusion: The laryngeal view was significantly better with the paraglossal approach of Miller's straight blade even in difficult airway. McCoy blade with an elevated tip was also found to be a useful tool to have in difficult airway, as EOI is significantly higher. The study also highlights the usefulness of adjuncts such as a gum elastic bougie while intubating.

Self-Resolving Mobitz Type II Second-Degree Heart Block (Atypical Wenckebach Block) After Cesarean Section Under Subarachnoid Block: A Case Report.

The majority of the perioperative arrhythmias in patients undergoing cesarean section under spinal anesthesia are benign. We report a case of a 30-year-old full-term parturient with a history of an uneventful previous cesarean section. She had no preexisting comorbidities. She subsequently underwent another emergency cesarean section three years later due to abdominal pain and scar tenderness indicative of impending rupture. Two hours after an uneventful surgery, the patient developed epigastric pain with a prolonged PR interval (280 ms) and intermittent second-degree AV block with two consecutive blocked P waves, which was consistent with Mobitz type II second-degree heart block (atypical Wenckebach block). However, she remained hemodynamically stable throughout. Serial electrocardiogram (ECG) did not demonstrate any evidence of ST-T wave changes, and normal troponin I and echocardiography excluded myocardial ischemia as a potential cause for the arrhythmia. Normal serum electrolytes and the resolution of the sensorimotor block caused by the spinal anesthesia excluded other known causes for such ECG changes. The PR interval gradually decreased to 240 ms on the second postoperative day and normalized to 200 ms on the fifth postoperative day. Such patients, especially those with a wide QRS complex, are susceptible to developing dangerous ventricular arrhythmias that can adversely affect circulatory function. Close vigil is the key to avoiding adverse perioperative outcomes.

Emergent airway management in blunt tracheal trauma: A novel use of the mini-tracheostomy kit.

AIM: To report and discuss a novel way of managing the airway in a difficult case of anterior tracheal wall disruption caused by blunt trauma to the neck. BACKGROUND: Tracheal injury resulting in laceration of the windpipe may present with either one or many of the multitude of problems such as respiratory distress, hoarseness of voice and subcutaneous emphysema. Most often it requires surgical intervention. CASE DESCRIPTION: We hereby present the novel use of a mini-tracheostomy kit as an aid in the cannot-intubate-cannot-ventilate situation of a 30-year-old patient presenting with severe features of blunt tracheal injury. The airway was established critically with the use of the mini-tracheostomy kit in a "cannot-intubate-cannot-ventilate" situation during surgical tracheostomy and a potentially disastrous cardiorespiratory arrest situation was averted. CONCLUSION: Timely presence of airway equipment, adequate preparation, a willingness to innovate and a team approach are of paramount importance in dealing with difficult airway situations that are presented in myriad and complex ways. CLINICAL SIGNIFICANCE: The stylet of mini-tracheostomy kit can be used in emergent airway management especially in clinical situations mimicking ours specifically as a guide for insertion of the standard tracheostomy tube.

Effectiveness of Granisetron in Prevention of Hypotension Following Spinal Anaesthesia in Patients Undergoing Elective Caesarean Section.

BACKGROUND AND AIM: Spinal anesthesia is the most common type of anesthesia administered for caesarean section and it is frequently associated with hypotension. When post-spinal hypotension is accompanied with bradycardia, the condition may become more complicated. Numerous pharmacological agents have therefore been tried for prevention of hypotension and 5HT3 antagonists are the latest in the armamentarium. However, studies have shown conflicting evidence regardings the effectiveness of 5HT3 inhibitors (ondansetron and granisetron) in preventing spinal hypotension. We have tried to address this controversy and also wanted to explore the adverse effects of granisetron on the foetus, if any. MATERIALS AND METHODS: Two hundred patients were included in the study and divided into two groups of 100 patients each. Group S patients received 5ml of 0.9% normal saline while Group G patients received IV granisetron 1mg (diluted to 5ml) 10 minutes prior to administration of spinal anesthesia. Analysis of variance (ANOVA) test was used for comparing the data, Student t-test was applied to compare the difference between the two means and Chi-Square test was used to test significance of difference of proportions. RESULTS: The incidence of hypotension in Group S was 69%, whereas it was 37% in Group G (p<0.001), hence patients of Group S required a significantly higher (p=0.001) amount of mephentermine. Haemodynamic parameters were well maintained throughout the study period in patients of Group G. The neonatal outcome was assessed by Apgar score at 0 minutes, one minute, and five minutes after delivery, and it was comparable between the two study groups. CONCLUSION: Intravenous granisetron 1mg if administered before administering spinal anesthesia can effectively attenuate hypotension in parturients without any adverse effects on the mother and the neonate.

Sensitive assays enable detection of serum IgG antibodies against Clostridium difficile toxin A and toxin B in healthy subjects and patients with Clostridium difficile infection.

BACKGROUND: Pathogenic Clostridium difficile produces two proinflammatory exotoxins, toxin A and toxin B. Low level of serum antitoxin IgG antibodies is a risk factor for the development of primary and recurrent C. difficile infection (CDI). RESULTS: We developed and validated two sensitive, titer-based electrochemiluminescence assays for the detection of serum antibody levels against C. difficile toxins A and B. These assays demonstrated excellent precision. The sensitivity of the assays allowed the detection of antitoxin A and antitoxin B IgG antibodies in all tested serum samples during assay validation. CONCLUSION: The validated titer-based assays enable assessment of antitoxin A and antitoxin B IgG antibodies as potential biomarkers to identify patients with CDI at increased risk for CDI recurrence.

Quantitative determination of human interleukin 22 (IL-22) in serum using Singulex-Erenna® technology.

Interleukin-22 (IL-22) is a key mediator of inflammatory processes associated with diseases such as psoriasis, inflammatory bowel disease and rheumatoid arthritis. The measurement of this cytokine in human plasma may provide insight into safety, pharmacodynamics and efficacy of drugs targeting inflammatory pathways. However, commonly used immunoassays are not sufficiently sensitive to measure baseline concentrations of IL-22. Here we describe the analytical validation of an ultrasensitive assay for the measurement of IL-22 in human serum using the Erenna® system by Singulex (Alameda, CA). The lower limit of quantification (LLOQ) of the Erenna assay estimated at 0.2pg/mL was sensitive enough to measure IL-22 in all human serum samples tested. The assay ranged from 0.2 to 100.0pg/mL and showed good dilution linearity. The inter-assay and intra-assay imprecision were <9% and <7% CV respectively. The accuracy determined by spiked recovery in serum samples was >86%. In addition, the results using Erenna assay correlated well with those using the IL-22 Quantikine immunoassay (R&D Systems, Minneapolis, MN) with a coefficient R(2) of 0.9285. However the Erenna assay showed an improved sensitivity by approximately 2 logs. These results show that this novel assay offers a significant improvement over previous methods for high-sensitive quantitative measurement of IL-22 in human serum samples.