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Background and Aims: Postoperative nausea and vomiting (PONV) is a common and distressing complication in all types of surgeries involving general anaesthesia. To establish evidence for best clinical practices, this meta-analysis compares the efficacy and safety of palonosetron and ondansetron in preventing PONV in patients undergoing non-laparoscopic surgeries. Methods: A PRISMA-guided systematic review and meta-analysis was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library to identify comparative studies that reported the efficacy (nausea and vomiting) at postoperative time points, namely T1 (0–2 hours), T2 (0–6 hours), T3 (12–24 hours), T4 (24–48 hours), and T5 (24–72 hours), as well as safety (number of incidence of adverse effects). A meta-analysis of the efficacy and safety groups was performed using a random-effects model. Results: Nineteen randomised controlled trials were included. Pooled risk ratio (RR) revealed that patients receiving palonosetron were significantly less likely to develop nausea [0–2 h, RR = 0.82 (95% confidence interval (CI): 0.50, 1.34), P = 0.317, I2 = 15.3%], [0–6 h, RR = 0.76 (95% CI: 0.44, 1.29), P = 0.137, I2 = 45.7%], [12–24 h, RR = 0.39 (95%CI: 0.16, 0.96), P = 0.088, I2 = 54.2%], [24–48 h, RR = 0.44 (95% CI: 0.20, 0.96), P = 0.598, I2 = 0%], [24–72 h, RR 0.22 (95% CI: 0.08, 0.57), P = 0.119, I2 = 53.0%] and vomiting [0–2 h, RR = 0.59 (95% CI: 0.29, 1.23), P = 0.868, I2 = 0%], [0–6 h, RR = 1.42 (95% CI: 0.74, 2.72), P = 0.790, I2 = 0%], [12–24 h, RR = 0.14 (95% CI: 0.04, 0.51), P = 0.749, I2 = 0.0%], [24–48 h, RR = 0.24 (95%CI: 0.09, 0.62), P = 0.561, I2 = 0%], [24–72 h, RR = 0.11 (95% CI: 0.02, 0.58), P = 0.859, I2 = 0%]. The safety profiles of palonosetron and ondansetron were comparable [headache: RR = 0.82 (95%CI: 0.65, 1.04), P = 0.940, I2 = 0%], [drowsiness: RR = 0.96 (95%CI: 0.54, 1.71), P = 0.870, I2 = 0%], [constipation: RR=1.20 (95%CI: 0.52, 2.79), P = 0.650, I2 = 0%], [dizziness: RR = 0.60 (95%CI: 0.44, 0.83), P = 0.644, I2 = 0%]. Conclusion: Palonosetron and ondansetron exhibited comparable efficacy in the early hours (0–6 h). Palonosetron showed superior efficacy beyond 6 hours, providing sustained PONV prophylaxis in patients undergoing various surgeries, excluding laparoscopic procedures. [ABSTRACT FROM AUTHOR]

Objectives: Conflicting studies have resulted in several systematic reviews and meta-analyses on the relationship between COVID-19 and body mass index (BMI). Methods: This systematic review of systematic reviews followed an umbrella review design, and preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines; Medical literature analysis and retrieval system online (MEDLINE) and SCOPUS databases were searched for systematic reviews on the topic. A predefined screening and selection procedure was done for the retrieved results based on the population, intervention/interest, comparator, outcome, study (PICOS) framework. Results: The search strategy yielded 6334 citations. With the predefined selection and screening process, 23 systematic reviews were retrieved for inclusion in the present study. Twenty-three (n = 23) systematic reviews met the inclusion criteria. As expected, there was overlap across the reviews in the included primary studies. Available evidence suggests that Class III obesity (morbid obesity) is strongly associated with increased mortality risk in patients with Covid-19. It is difficult to draw a firm conclusion about Class I and Class II obesity due to conflicting outcomes of metanalyses. Increased obesity was consistently associated with increased risk of invasive mechanical ventilation (IMV) in all the reviews with low to moderate heterogeneity. Conclusions: Available evidence suggests that Class III obesity (morbid obesity) is strongly associated with increased mortality risk in patients with Covid-19. Increased BMI is positively associated with the risk of IMV and the severity of COVID- care. [ABSTRACT FROM AUTHOR]

The practice of emergency medicine has reached its cross roads. Emergency physicians (EPs) are managing many more time-dependent conditions, initiating complex treatments in the emergency department (ED), handling ethical and end of life care discussions upfront, and even performing procedures which used to be done only in critical care settings, in the resuscitation room. EPs manage a wide spectrum of patients, 24 h a day, which reflects the community and society they practice in. Besides the medical and "technical" issues to handle, they have to learn how to resolve confounding elements which their patients can present with. These may include social, financial, cultural, ethical, relationship, and even employment matters. EPs cannot overlook these, in order to provide holistic care. More and more emphasis is also now given to the social determinants of health. We, from the emergency medicine fraternity, are proposing a unique "BRAVE model," as a mnemonic to assist in the provision of point of care, adaptive leadership at the bedside in the ED. This represents another useful tool for use in the current climate of the ED, where patients have higher expectations, need more patient-centric resolution and handling of their issues, looming against the background of a more complex society and world. [ABSTRACT FROM AUTHOR]

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) remains common with distressingly high mortality. Over time, risk scorings systems have been developed to predict it and preoperative low estimated glomerular filtration rate (eGFR) has been regarded as one of the predicting risk factors.Objectives: The present study is aimed at assessing the relation of different ranges of preoperative eGFR with an incidence of CSA-AKI defined by the AKI network (AKIN) criteria.Materials and Methods: Files of 134 patients with eGFR of >40 cc/min/1.73 m2 body surface area (BSA) who underwent cardiac surgeries on cardiopulmonary bypass were screened for data collection. Occurrences of CSA-AKI were evaluated as per the AKIN criteria over the course of 3 postoperative days. The relationships of different ranges of preoperative eGFR with CSA-AKI were analyzed by appropriate statistical tests using Instat software and P < 0.05 was considered statistically significant.Results: A total of 60 males and 74 females with a mean + standard deviation (SD) age of 37.98 ± 12.50 years and mean + SD preoperative eGFR of 70.20 ± 20.89 cc/min/1.73 m2 were analyzed in this study. About 49.25% of patients suffered from CSA-AKI by the 3rd postoperative day. The crude risk of CSA-AKI in patients with eGFR 40-60 cc/min/1.73 m2 was not higher (odds ratio 0.29) as compared to patients in patients with eGFR >100 cc/min/1.73 m2. The CSA-AKI trend with different eGFR was also statistically insignificant (P > 0.05).Conclusion: In patients with preoperative eGFR >40 cc/min/1.73 m2 BSA, a lower preoperative eGFR (40-60 cc/min/1.73 m2) does not predict higher incidence of CSA-AKI as defined by AKIN criteria as compared to higher preoperative eGFR (>100 cc/min/1.73 m2). Lower height is independently associated with higher incidence of CSA-AKI in such patients. [ABSTRACT FROM AUTHOR]

Owing to COVID-19 pandemic, wearing personal protective equipment (PPE) and N95 mask inside an operation theatre has become a common practice. Subjective symptoms of suffocation, headache, dizziness, and lack of concentration while on PPE may at times become significant enough requiring oxygen therapy, removal of mask, or even doffing of PPE, which may increase the risk of being infected and at the same time compromising patient care. The reason behind such subjective symptoms may be multifactorial. We report here a 52-years-old anesthetist with a high body mass index, wearing PPE for a prolonged duration inside an operation theatre during a high-risk surgery encountered a similar episode. Being the lone anesthetist, he decided to oxygenate himself in an innovative way, thus, avoiding doffing and any undesirable event. With pandemic expanding rapidly such scenarios may be encountered often, identifying factors predicting such events and finding methods of oxygenation while wearing PPE may be extremely beneficial. [ABSTRACT FROM AUTHOR]

Background and Aim: Nalbuphine as an adjuvant intrathecally can produce significant analgesia with minimal side effects. However, no research has been done with isobaric ropivacaine. We, therefore, in this prospective, randomised double-blind study tried to find the optimal dose of intrathecal nalbuphine with isobaric 0.75% ropivacaine for elective lower limb surgeries. Materials and Methods: One hundred American Society of Anaesthesiologists I and II patients undergoing elective lower limb surgery were divided into four groups randomly: groups A, B, C and D, who received 0.5 mL normal saline or 0.4, 0.8 and 1.6 mg nalbuphine made up to 0.5 mL normal saline added to 22.5 mg (total volume 3.5 mL) isobaric 0.75% ropivacaine, respectively. The onset of sensory and motor block, two-segment regression time, duration of sensory and motor block, Visual Analogue Scale (VAS) and the incidence of adverse effects were compared between the groups. Results: The onset of both sensory and motor blockade was faster with addition of 0.4, 0.8 and 1.6 mg of nalbuphine when compared with ropivacaine alone; however, it was not statistically significant (P > 0.05). Two-segment regression time and duration of analgesia and motor blockade were highest with 1.6 mg of nalbuphine followed by 0.8, 0.4 and plain 0.75% ropivacaine (P < 0.05). The duration of sensory blockade in all four groups was slightly more than the duration of motor blockade. VAS readings were comparable in all nalbuphine groups when compared with ropivacaine group. Haemodynamic variability among the four groups was comparable. Incidence of adverse effects was highest in the 1.6-mg group when compared with others, although it was statistically insignificant (P > 0.05). Conclusion: Nalbuphine can be a good alternative to other opioids as an adjuvant intrathecally to prolong postoperative analgesia with a minimal side effect profile. Addition of nalbuphine to isobaric 0.75% ropivacaine gives the added advantage of significant analgesia with early motor recovery. We infer from our study that when compared with 1.6 mg of nalbuphine, both 0.4 and 0.8 mg nalbuphine are equally good as adjuvants to isobaric 0.75% ropivacaine in elective lower limb surgeries with prolonged analgesia, a reliable block with equal efficacy but with lesser side effects. [ABSTRACT FROM AUTHOR]

Background and Aims: Minimum alveolar concentration (MAC) monitoring is an integral part of modern-day anaesthesia. Both MAC and MAC-awake are age dependant, and age of the patient needs to be entered in the monitor. This study was aimed to assess the practice of patient birth year entry in the anaesthesia monitor and its impact on MAC monitoring. Methods: Sixty volatile anaesthetic-based general anaesthetics (GAs) were observed silently in two tertiary care teaching hospitals with regard to 'birth year' entry in the patient monitor. The impact on MAC for non-entry of age was assessed. The observed MAC reading and the MAC corrected for age (MACage) of the patients were noted. Paired t-test was used to compare the differences in observed MAC and MACage values. P <0.05 was significant. Results: Sixty GAs of patients aged between 10 and 68 years were observed; 96.67% anaesthetics were conducted without entering 'birth year'. Thirty-four patients (mean age 35.14 ± 15.38 years) were further assessed for impact of non-entry of age. The observed MAC was similar to MACage in patients aged 40 ± 5 years (36-45 years group). Nearly 79.41% of the observed MACs were incorrect; 55.88% patients were potentially underdosed whereas 23.53% were overdosed. Conclusion: Omitting patient age entry in the monitor results in erroneous MAC values, exposing patients <40 years to underdosing and older patients to overdose. [ABSTRACT FROM AUTHOR]

Background and Aims: Pre-operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence-based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre-operative investigations and referral practices and compare it with the standard guidelines. Methods: The present observational study was carried out during 2014-2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre-anaesthetic check-up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA). Results: Seventy-five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 (SD ±1.64) days loss. Anaesthesiologist-ordered testing was more focused than surgeons. Conclusion: More than two-third of pre-operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre-operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost. [ABSTRACT FROM AUTHOR]

Background: Basic life support (BLS) is an integral part of emergency medical care. Studies have shown poor knowledge of it among health care providers who are usually taught BLS by lecture-based teachings in classes. Objectives: This study is designed to assess the effectiveness of class lecture versus workshop-based teaching of BLS on acquiring the practice skills on mannequin. Methods: After ethical approval and informed consent from the participants, the present study was conducted among the health care providers. Participants were grouped in lecture-based class teaching and workshop-based teaching. They were then asked to practice BLS on mannequin (Resusci Anne with QCPR) and evaluated as per performance parameters based on American Heart Association BLS. Statistical analyses are done by Fisher's exact t-test using GraphPad INSTAT software and P < 0.05 is taken as significant. Results: There were 55 participants in lecture-based teaching and 50 in workshop-based teaching group. There is no statistical difference in recognition of arrest, checking pulse, and starting chest compression (P > 0.05). Though more than 83% of lecture-based teaching group has started chest compression as compared 96% of workshop group; only 49% of the participants of lecture-based group performed quality chest compression as compared to 82% of other group (P = 0.0005). The workshop group also performed better bag mask ventilation and defibrillation (P < 0.0001). Conclusion: Workshop-based BLS teaching is more effective and lecture-based class teaching better is replaced in medical education curriculum. [ABSTRACT FROM AUTHOR]

The article presents the case study of a 30-year-old man with a pointed iron rod penetrating below his xiphisternum and had fractured rib and right humerus. The patient's physical condition is discussed who underwent surgery immediately as his extended focused assessment by sonography for trauma revealed that the rod penetrated the liver with hemoperitonium and left hemothorax. The patient recovered after almost two weeks of being hospitalized.