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Background and Aims: The coronavirus disease 2019 (COVID-19) is spreading at an unprecedented speed. Lack of resources to test every patient scheduled for surgery and false negative test results contribute to considerable stress to anesthesiologists, along with health risks to both caregivers and other patients. The study aimed to develop an early warning screening tool to rapidly detect 'highly suspect' among the patients scheduled for surgery. Methods: Review of literature was conducted using terms 'coronavirus' OR 'nCoV 2019' OR 'SARS-CoV-2' OR 'COVID-19' AND 'clinical characteristics' in PUBMED and MedRxiv. Suitable articles were analysed for symptoms and investigations commonly found in COVID-19 patients. Additionally, COVID-19 patient's symptomatology and investigation profiles were obtained through a survey from 20 COVID-19 facilities in India. Based on literature evidence and the survey information, an Early Warning Scoring System was developed. Results: Literature search yielded 3737 publications, of which 195 were considered relevant. Of these 195 studies, those already included in the meta-analyses were not considered for independent assessment. Based on the combined data from meta-analyses and survey, risk factors of COVID-19 disease identified were as follows: history of exposure, fever, cough, myalgias, lymphocytopaenia, elevated C-reactive protein (CRP)/lactate dehydrogenase (LDH) and radiographic infiltrates. Conclusion: Development of this Early Warning Scoring System for preoperative screening of patients may help in identifying 'highly suspect' COVID-19 patients, alerting the physician and other healthcare workers on the need for adequate personal protection and also to implement necessary measures to prevent cross infection and contamination during the perioperative period.

COVID-19 patients presenting for emergency laparotomy require evaluation of surgical illness and viral disease. As these patients are likely to have a wide spectrum of deranged physiology and organ dysfunction, optimization should start preoperatively and continue through intraoperative and postoperative recovery periods along with appropriate antimicrobial cover. The goal should be not to delay damage control surgery in favor of evaluation and optimization. When a COVID-19 positive or suspected patient is to be operated for laparotomy, the situation often demands general anesthesia with invasive monitoring and analgesia complemented by regional anesthesia to minimize postoperative opioid requirements to facilitate early recovery. This particular article addresses the issues related to emergency laparotomy management in relation to COVID-19 patient. Healthcare workers should diligently use effective PPE and practice disinfection to prevent spread. Video-communication is an effective means of evaluation. Information expected from investigations should be weighed against risk of exposure to healthcare workers/laypersons. Simulation and memory aids should be used to familiarize team members with roles and techniques of management while in PPE. Step-wise detailed planning for patient transfer, anesthesia induction, maintenance and emergence, aid in enhancing HCW safety without compromising patient care.

The world is going through the COVID-19 pandemic, which has high virulence and transmission rate. More significant the viral load during exposure, the greater is the likelihood of contracting a severe disease. Healthcare workers (HCWs) involved in airway care of COVID-19 patients are at high risk of getting exposed to large viral loads during aerosol-generating actions such as coughing or sneezing by the patient or during procedures such as bag-mask ventilation, intubation, extubation, and nebulization. This viral load exposure to airway caregivers decreases considerably with the use of an aerosol box during intubation. The safety tent proposed in this article is useful in limiting the viral load that HCWs are exposed to during airway procedures. Its role can be expanded beyond just intubation to protect against all aerosol-generating actions and procedures involving the patient's airway.

Background and Aims: Perioperative fasting guidelines have been published and updated to standardise practices. Hence, Indian Society of Anaesthesiologists decided to conduct a survey to assess the fasting practices and the food habits across India, which would be subsequently used for developing preoperative fasting guidelines for the Indian population. We detail and discuss herewith the content validity of the questionnaire developed for the survey. Methods: Thirty-six questions related to perioperative fasting practices were framed based on the collected evidence and relevance to regional diet and concerns. Subsequently, an information sheet was prepared and sent to 10 experts to grade each question. The responses were tabulated, and item-wise content validity index (I-CVI), scale-wise content validity index (S-CVI) and modified kappa statistic were calculated in Microsoft Excel™ sheet. Results: Seven of the 10 experts completed the assessment and grading as per the instructions provided and submitted a completed proforma. S-CVI for relevance, simplicity, clarity and ambiguity was 0.72, 0.86, 0.72 and 0.72, respectively. S-CVI/average or average congruency percentagewas 0.95, 0.97, 0.95 and 0.95 for relevance, simplicity, clarity and ambiguity, respectively. Question 2 received an I-CVI of 0.71 in terms of clarity and question 23 received an I-CVI of 0.71. They were modified as persuggestions of the experts. Conclusion: We conclude that our questionnaire designed to ascertain the preoperative fasting practices for a surveymet the content validity criteria both by qualitative and quantitative analyses.

Background: Acute respiratory distress syndrome (ARDS) is seen in critically ill patients. Its etiological spectrum in India is expected to be different from that seen in western countries due to the high prevalence of tropical infections. Aim: To study the epidemiological profile of ARDS patients. Setting: A tertiary care hospital in Karnataka, India. Materials and Methods: Retrospective analysis of 150 out of the 169 ARDS patients diagnosed during 2010–2012. Data collected included the clinical features and severity scoring parameters. Results: The mean age of the study population was 42.92 ± 13.91 years. The causes of ARDS included pneumonia (n = 35, 23.3%), scrub typhus (n = 33, 22%), leptospirosis (n = 11, 7.3%), malaria (n = 6, 4%), influenza (H1N1) (n = 10, 6.7%), pulmonary tuberculosis (n = 2, 1.3%), dengue (n = 1, 0.7%), abdominal sepsis (n = 16, 10.7%), skin infection (n = 3, 2%), unknown cause of sepsis (n = 18, 12%), and nonseptic causes (n = 15, 10%). A total of 77 (51.3%) patients survived, 66 (44%) expired, and 7 (4.7%) were discharged against medical advice (AMA). Preexisting comorbidities (46) were present in 13 survivors, 19 nonsurvivors, and four discharged AMA. History of surgery prior to the onset of ARDS was present in one survivor, 13 nonsurvivors, and one discharge AMA. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Sequential Organ Failure Assessment scores in survivors were 9.06 ± 4.3, 49.22 ± 14, and 6.43 ± 2.5 and in nonsurvivors 21.11 ± 7, 86.45 ± 23.5, and 10.6 ± 10, respectively. Conclusion: The most common cause of ARDS in our study was pneumonia, but a large percentage of cases were due to the tropical infections. Preexisting comorbidity, surgery prior to the onset of ARDS, higher severity scores, and organ failure scores were more frequently observed among nonsurvivors than survivors.

From a simple pneumatic device of the early 20 th century, the anaesthesia machine has evolved to incorporate various mechanical, electrical and electronic components to be more appropriately called anaesthesia workstation. Modern machines have overcome many drawbacks associated with the older machines. However, addition of several mechanical, electronic and electric components has contributed to recurrence of some of the older problems such as leak or obstruction attributable to newer gadgets and development of newer problems. No single checklist can satisfactorily test the integrity and safety of all existing anaesthesia machines due to their complex nature as well as variations in design among manufacturers. Human factors have contributed to greater complications than machine faults. Therefore, better understanding of the basics of anaesthesia machine and checking each component of the machine for proper functioning prior to use is essential to minimise these hazards. Clear documentation of regular and appropriate servicing of the anaesthesia machine, its components and their satisfactory functioning following servicing and repair is also equally important. Trace anaesthetic gases polluting the theatre atmosphere can have several adverse effects on the health of theatre personnel. Therefore, safe disposal of these gases away from the workplace with efficiently functioning scavenging system is necessary. Other ways of minimising atmospheric pollution such as gas delivery equipment with negligible leaks, low flow anaesthesia, minimal leak around the airway equipment (facemask, tracheal tube, laryngeal mask airway, etc.) more than 15 air changes/hour and total intravenous anaesthesia should also be considered.

Lightwand-guided intubation is a semi-blind technique that takes advantage of the anterior location of the trachea in relation to the oesophagus. Fibreoptic evaluation of lightwand-guided intubation has revealed a possibility of laryngeal interference and epiglottic distortion. Jaw lift, tongue traction or a combination of both have been used to assist in lightwand-guided intubation. This study fibreoptically evaluates lightwand-guided intubation using jaw lift and combined jaw and tongue traction. Eighty four patients with normal airway undergoing general anaesthesia were studied. This randomised, double blinded, cross over study was done in two phases. First phase - after achieving adequate depth of anaesthesia, a fibrescope was advanced nasally, and lightwand-guided intubation was carried out under direct fibreoptic visualisation with the aid of either jaw lift or combined jaw and tongue traction. Second phase - Extubation followed by reintubation using the other manoeuvre. Interference with laryngeal structures during intubation and position of the epiglottis at the end of intubation were noted. Epiglottic distortion (deviated to one side/infolded into trachea) was observed in 6 patients with jaw lift and 17 patients with combined jaw and tongue traction (P=0.003). Laryngeal interference was significantly higher (P=0.012) with combined manoeuvre (30/78) than with jaw lift alone (9/81). Although lightwand-guided intubation can be performed quickly and easily, interference with laryngeal structures and distortion of the epiglottis can occur. Jaw lift manoeuvre causes less laryngeal interference than combined jaw and tongue traction applied by a single operator.

Double outlet right ventricle (DORV) is a rare congenital heart defect involving the great arteries. In DORV, both aorta and pulmonary artery arise from the right ventricle resulting in admixture of blood. We report a 22-year-old parturient with DORV and severe pulmonary stenosis who underwent caesarean delivery at 36 weeks gestation with low dose combined spinal-epidural anesthesia. This lady was assessed by echocardiogram to have situs inversus, dextrocardia, severe pulmonary artery stenosis (gradient = 146 mm Hg), DORV with subarterial VSD (1 cm). She had 95% room air saturation and her blood investigations were within normal limits. We established a peripheral venous access and radial arterial line for continuous blood pressure monitoring. Combined spinal epidural anesthesia was considered a better option. Epidural catheter was secured at L 2 -L 3 space and fixed after giving test dose 3 mL 2% lignocaine. Subarachnoid block administered at L 3 -L 4 level using 1.2 mL of 0.5% heavy bupivacaine. A sensory block of T 10 was obtained which was supplemented with 4 mL 0.75% ropivacaine to obtain a level of T 6 . Patient tolerated the procedure well. She was shifted to post-operative ICU. Post-operative pain was managed with epidural 0.2% ropivacaine at 4 mL/h. Patient remained hemodynamically stable throughout the procedure and in the postoperative period while she was being followed up for subsequent 48 h.

Dexmedetomidine, an α2 agonist, has demonstrated its effectiveness as a sedative during awake intubation, but its utility in fiberoptic bronchoscopy (FOB) is not clear. We evaluated the effects of midazolam and dexmedetomidine on patient’s response to FOB. The patients received either midazolam, 0.02 mg/kg (group M, n=27), or dexmedetomidine, 1 µg/kg (group D, n=27). A composite score of five different parameters and a numerical rating scale (NRS) for pain intensity and distress were used to assess patient response during FOB. Patients rated the quality of sedation and level of discomfort 24 h after the procedure. Ease of bronchoscopy, rescue medication requirement, and haemodynamic variables were noted. Ideal or acceptable composite score was observed in 15 and 26 patients, respectively, in group M (14.48 ± 3.65) and group D (9.41 ± 3.13), p

A 28-year-old lady with term gestation, pre-eclampsia and a vague history of occasional breathing difficulty, on irregular bronchodilator therapy, was scheduled for category 1 lower segment caesarean section in view of foetal distress. A Cormack-Lehane grade 1 direct laryngoscopic view was obtained following rapid sequence induction. However, it was not possible to insert a 7.0 or 6.0 size styleted cuffed tracheal tube in two attempts. Ventilation with a supraglottic device was inadequate. Airway was secured with a 4.0 size microlaryngeal surgery tube with difficulty. Computed tomography scan of the neck following tracheostomy for failed extubation revealed subglottic stenosis (SGS) with asymmetric arytenoid calcification. This report describes the management of a rare case of unrecognised idiopathic SGS in pregnancy.

A 62-year-old housewife presented to the chest outpatient department with a history of exertional breathlessness of four-month duration. On general physical examination, clubbing of toes was present with sparing of fingers. Chest examination revealed bilateral basal end inspiratory fine crepitations. A diagnosis of idiopathic pulmonary fibrosis was made on the basis of clinical, spirometric, and high-resolution computed tomography findings. Extensive evaluation could not reveal any cause for the differential clubbing. The unusual distribution of clubbing in a clinical condition, such as idiopathic pulmonary fibrosis, where generalized clubbing is expected can lead to a diagnostic confusion. This can lead to a further burden of investigations on the patient as clubbing being a significant finding cannot be ignored.

A 62-year-old male presented to the outpatient department of chest with history of dry cough since two months and swelling on the anterior aspect of neck of 30-year duration. Physical examination revealed a goitre. However, further imaging studies revealed presence of another associated pathology, a Kommerell’s diverticulum in association with a right aortic arch with aberrant left subclavian artery. The enlarged thyroid was not compressing the trachea, and its occurrence in this case could be incidental. The diverticulum was considered as the cause of chronic cough in our case as it was causing tracheal compression, and also there were no other obvious causes which could explain the symptom. Vascular anomalies such as Kommerell’s diverticulum, though uncommon, should be considered in the differential diagnosis of chronic cough particularly when other common causes have been ruled out.

Author(s): Goneppanavar Umesh (corresponding author) [1]; S. Bala Bhaskar [2]; S. S. Harsoor [3]; Pradeep A. Dongare [4]; Rakesh Garg [5]; Sudheesh Kannan [6]; Zulfiqar Ali [7]; Abhijit Nair [8]; [...]

Byline: Goneppanavar. Umesh, Gopal. Gotur, Amrut. Rao, Tim. Joseph Background and Aims: Bag mask ventilation (BMV) allows for oxygenation and ventilation of patients until a definitive airway is secured and [...]

Byline: Goneppanavar. Umesh, C. Tejesh Pulmonary aspiration of gastric contents is a dreaded perioperative complication, accounting for nearly 9% of anaesthesia-related deaths.[1],[2],[3] The Fourth National Audit Project by the Royal [...]

Byline: Goneppanavar. Umesh Airway management is the most important skill that all airway managers (anaesthesiologists, intensivists, emergency physicians, resuscitation team members) require to master. Multiple definitions for difficult airway (DA) [...]

Byline: Goneppanavar. Umesh, Jasvinder. Kaur, Rashmi. Annigeri, K. Thilakchand Sir, The anaesthesia machine is a well-recognised source for leakage of anaesthesia gases.[sup][1] There are several areas in the machine that [...]

Byline: Kaur. Jasvinder, Goneppanavar. Umesh Sir, A 27-month-old boy weighing 12 kg was scheduled for cystoscopy and evaluation. Preoperative evaluation was unremarkable. In the operating room, standard anaesthesia monitoring was [...]

Byline: Goneppanavar. Umesh Ever since Aaron Bunsen Lerner isolated melatonin (N-acetyl-5-methoxytryptamine) from pineal glands of cattle in 1958, the hormone has been found to have several uses in humans. Endogenous [...]

Byline: Goneppanavar. Umesh, John. Karippacheril, Rahul. Magazine With a large output of medical literature coming out every year, it is impossible for readers to read every article. Critical appraisal of [...]

Byline: Goneppanavar. Umesh, Rajesh. Phatke, Manikant. Lodaya Sir, We read the article, “Magnification to avoid medication errors” with interest.[sup][1] However, we believe there is a risk of misplacement or damage [...]

Byline: Goneppanavar. Umesh, K. Sushma, M. Sindhupriya, U. Swarnamba Sir, The standard gum elastic bougie (GEB) which is used mainly for aiding in difficult laryngoscopy and intubation can be used [...]

Byline: Goneppanavar. Umesh, Kaur. Jasvinder Sir, We read with great interest the article written by Kundra and Parida. [sup][1] The article is thought provoking and nicely written. Although we agree [...]