Continuous Positive Airway Pressure (CPAP)-Can this be a boon to tide over ICU crisis in pandemic? A case series.

Introduction: Coronavirus Disease 19 (COVID-19) disease has caused unusual overload of health care systems all over the world. We describe four severe COVID cases managed by non-intensivist. Cases and Outcome: We had four unvaccinated cases with acute onset influenza like illness with signs of respiratory failure. Apart from general and COVID-specific measures, we started Continuous Positive Airway Pressure (CPAP) trial for these patients. All these patients were weaned off CPAP and were discharged once they recovered. Discussion: Limitation of bed numbers in ICU has caused unforeseen stress upon the system to manage sudden increase of severe acute respiratory distress syndrome during COVID pandemics. Studies have shown non-invasive ventilation (NIV) and high frequency nasal cannula (HFNC) have improved patient outcomes. But managing NIV and HFNC is resource intensive in terms of manpower and equipment. We have found that patients with severe COVID disease can be managed safely using CPAP in secondary care with minimal training of non-intensivist healthcare workers in a cost-effective and efficient way of treating severe COVID who are unlikely to worsen. Conclusion: With the imminent third COVID wave looming, it is high time to strengthen our existing primary and secondary health care system by these novel methods to reduce the burden of our tertiary care.

Reduction in post-operative nausea and vomiting (PONV) by preoperative risk stratification and adherence to a standardized anti emetic prophylaxis protocol in the day-care surgical population.

CONTEXT: Postoperative nausea (PON) and postoperative vomiting (POV) are the most undesirable morbidity after anaesthesia. There is paucity of data on PONV from the Indian subcontinent. AIMS: We aim to study the prevalence of PON and POV, associated risk factors and the effect of following standardized risk stratification and prophylaxis protocols in the day care patient population. SETTINGS AND DESIGN: This was a prospective cohort study at a tertiary care teaching institute. METHODS AND MATERIAL: Data from 500 patients undergoing day care surgery over a period of 12 months were analysed. We used the Apfel scoring system for evaluation of risk of post-operative nausea and vomiting (PONV) for each participant. A standard PONV prophylaxis protocol was used intra-operatively. STATISTICAL ANALYSIS USED: Data analysis was done using the Mann-Whitney U test, the Chi-square and Fisher's exact test. RESULTS: The period prevalence of post-operative nausea (PON) and post-operative vomiting (POV) was 2.04% and 2.45%, respectively, in this study. The prevalence of PONV in each risk category was lower than that predicted by the Apfel score due to utilization of a standard anti-emetic prophylactic protocol. We found younger age, previous history of nausea, previous history of vomiting, urological surgeries and alcohol consumption as significant risk factors for postoperative nausea. Longer duration of surgery, previous history of nausea, alcohol consumption and higher BMI were the significant risk factors for postoperative vomiting. CONCLUSIONS: Adherence to preoperative risk stratification and a standard anti-emetic prophylactic protocol can significantly reduce the prevalence of postoperative nausea and vomiting.

Lumbar Erector Spinae Plane Block for Posterior-Superior Iliac Spine Bone Graft Site Pain in Patients Undergoing Occipitocervical and C1-C2 Fusion for Atlantoaxial Dislocation/Odontoid Fracture-A Case Series.

Pain at the autologous bone graft site from the posterior-superior iliac spine (PSIS) is severe enough to affect the postoperative ambulation. It adds to the morbidity of the surgical procedure. Inadequate pain management at the graft site not only affects the postoperative recovery but also can lead to chronic pain. We report the use of ultrasound (US)-guided lumbar erector spinae plane block (ESPB), to deliver effective analgesia for this pain. Patients who underwent occipitocervical fusion (OCF) and C1-C2 fusion using PSIS for atlantoaxial dislocation (AAD)/odontoid fracture from January to March 2020 and who received US-guided lumbar ESPB were retrospectively studied. All the necessary data were collected from the inpatient hospital, anesthesia, and the acute pain service records. A total of six patients received lumbar ESPB, of which one received a single shot injection, and the rest five had a catheter placement for postoperative analgesia. The average volume of intraoperative and postoperative bolus was 27(range: 15-30) and 21 (range: 15-30) mL of 0.2% ropivacaine, respectively. All patients achieved a unilateral sensory blockade ranging from L1 to L3 dermatomes. None of our patients had a numerical rating scale of > 4 on movement at any time point during the first 48 hours except in one, in whom only a single shot bolus was given. No complications related to ESPB were noted. All were ambulated on the second postoperative day except one. The average length of hospital stay was 6 (range: 4-10) days. US-guided lumbar ESPB provides excellent analgesia for PSIS bone graft site pain and promotes early ambulation.

Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN: This is a prospective observational study. SETTING: A level 1 trauma center in California. PARTICIPANTS: From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION: All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS: A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001). CONCLUSION: FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE: The level of evidence was II.

Distribution of virulence determinants among antimicrobial-resistant and antimicrobial-susceptible Escherichia coli implicated in urinary tract infections.

INTRODUCTION: Uropathogenic Escherichia coli (UPEC) rely on the correlation of virulence expression with antimicrobial resistance to persist and cause severe urinary tract infections (UTIs). OBJECTIVES: We assessed the virulence pattern and prevalence among UPEC strains susceptible and resistant to multiple antimicrobial classes. METHODS: A total of 174 non-duplicate UPEC strains from patients with clinically significant UTIs were analysed for susceptibility to aminoglycoside, antifolate, cephalosporin, nitrofuran and quinolone antibiotics for the production of extended-spectrum ß-lactamases and for the presence of six virulence determinants encoding adhesins (afimbrial, Type 1 fimbriae, P and S-fimbriae) and toxins (cytotoxic necrotising factor and haemolysin). RESULTS: Relatively high resistance rates to nalidixic acid, ciprofloxacin, cephalothin and trimethoprim-sulfamethoxazole (82%, 78%, 62% and 59%, respectively) were observed. Fourteen distinct patterns were identified for the virulence determinants such as afaBC, cnfI, fimH, hylA, papEF and sfaDE. The toxin gene, cnfI (75.3%), was the second most prevalent marker to the adhesin, fimH (97.1%). The significant association of sfaDE/hylA (P < 0.01) among antimicrobial resistant and susceptible strains was also observed notwithstanding an overall greater occurrence of virulence factors among the latter. CONCLUSIONS: This study provides a snapshot of UPEC complexity in Jamaica and highlights the significant clonal heterogeneity among strains. Such outcomes emphasise the need for evidence-based strategies in the effective management and control of UTIs.