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Introduction: It has been extensively highlighted that SARS-CoV-2 affects the RAS (renin-angiotensin system) and the angiotensinconverting enzyme-2 receptors play the most important role in the presentation of the COVID-19 disease 2-5 The ACE2 is type I membrane protein expressed on endothelial cells in the kidney, heart, gastrointestinal tract, blood vessels, and, importantly, lung AT2 alveolar epithelial cells, which are particularly prone to SARS-CoV-2 infection As SARS-CoV-2 is a new coronavirus, and its cardiovascular complications and the underlying pathology is still emerging However, it is accepted that the virus affects the total vasculature in the human body and this infection becomes a highly accelerated process for the target organ damage In the case of acute cardiological manifestation, it is termed as Acute COVID-19 Cardiovascular Syndrome (ACovCS) by the American Heart Association's white paper 6 European Society of Cardiology (ESC) has published a detailed review paper 7 on the involvement of various cardiovascular target organs in COVID-19 disease This review clearly establishes a close two-way relationship between COVID-19 disease and all cardiovascular diseases (CVD) The prognosis is even worse in patients with preexisting cardiovascular system involvement Cardiovascular involvement in COVID-19 is seen as a key manifestation The best way to assess endothelial dysfunction is an assessment of its clinical manifestation, i e , an increase in arterial stiffness There have been multiple in vitro and in vivo studies that have shown that the vascular endothelium is an important factor in setting the vascular tone and endothelial dysfunction leads to arterial stiffness 8 Arterial stiffness and enhanced wave reflections are markers of cardiovascular disease and independent predictors of cardiovascular risk 9-12 Stiffening of the large arteries and enhanced wave reflections lead to increased left ventricular (LV) afterload, disturbed coronary perfusion, and mechanical fatigue of the arterial wall 13 The relationship between systemic inflammation and arterial stiffness is well established in the literature 14 The cause-and-effect relationship that acute systemic inflammation leads to deterioration of large-artery stiffness Findings in study15 on induced inflammation have shown that an acute inflammation caused a temporary increase in central blood pressure and arterial stiffness in terms of pulse wave velocity This implies the increased risk of cardiovascular events associated with acute systemic inflammation in the COVID-19 COVID-19 diseaserelated worldwide research and proposed mechanisms pointed to pathophysiological involvement of endothelial dysfunction and arterial wall compromise However, there was no empirical evidence of the functional compromise of arterial walls Hence, a study was urgently needed to study an increase in arterial stiffness in COVID-19 patients due to systemic inflammation to stratify the risk and mitigate further cardiovascular damage with guided therapeutic treatment based on the severity of arterial stiffness This pressing need is justified by a comprehensive review article16 published after the present study was envisaged We hope that the findings from our study will fulfill the need to a large extent Objectives: Primary objective: To study if the measurement of arterial stiffness using pulse wave velocity in mild-moderate and a severe group of COVID-19 patients can stratify cardiovascular risk Secondary objective: To determine if initial measurements and subsequent changes in arterial stiffness can project the future course of the COVID-19 patient and hence predict the grade of clinical management a confirmed COVID-19 patient would require Materials and methods: The present prospective nonrandomized observational study {titled - “To study the relationship of COVID-19 severity with arterial stiffness: A prospective cross-sectional study” (“COSEVAST study”)} was conducted in the COVID-19 ICU, medical ICU, and various wards of dedicated COVID hospital at AIIMS, Patna, Bihar, India The study protocol, informed consents, and other trial-related documents received the written approval of the Institutional Ethics Committee (IEC No AIIMS/Pat/IEC/2020/595) The study design was registered with the Clinical Trials Registry of India (CTRI No CTRI/2020/10/028489) All COVID-19 patients were subject to RT-PCR test and had a confirmed infection of the SARS-CoV-2 virus Participants, after understanding the study protocol and procedures, gave their written informed consent for the study The exclusion criteria were known history of any of these diseases - diabetes mellitus (DM), hypertension (HTN), CAD, stroke, neuropathy, PAD, nephropathy, MI, pregnancy, peripheral edema or inflammation, cardiac arrhythmia, and any preexisting cardiovascular disorder Patient categorization: The selected patients after fulfilling the inclusion criteria were grouped into three categories - mild, moderate, and severe category based on the latest NIH Guidelines 27 as follows: •Mild category: Individuals with mild signs and symptoms like fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell but who do not have shortness of breath, dyspnea, or abnormal chest imaging •Moderate category: Individuals who show evidence of lower respiratory disease during clinical assessment or imaging and who have a saturation of oxygen (SpO2) ≥ 94% on room air at sea level •Severe category: Individuals who have a saturation of oxygen (SpO2) 30 breaths/minute, PaO2/FiO2

Trypsin, a pancreatic serine protease, due to its narrow specificity and selectivity, has been tremendously used in food technology, proteome analysis, modulating soy protein allergenicity, antihypertensive peptide production, as well as, a biomarker in diseases such as pancreatitis, cystic fibrosis

Oxygen supplementation is required for approximately 14% of the patients diagnosed of having COVID-19 infection. Despite the use of conventional oxygen therapy, 5% among these require treatment in the intensive care unit (ICU). Here, we are describing a situation in which oxygen therapy was delivered to the patients by making an assembly of oxygen tubing, three-way stopcock, and high-flow nasal cannula (HFNC) present in the hospital setting following the malfunction of air blender of HFNC machine (Fig. 1). This assembly might be useful as rescue oxygen therapy during a malfunction of HFNC machine and in resource-limited settings where HFNC machine is not available. The mechanisms of action could be (1) washout of anatomic dead space due to medium oxygen flow, (2) improved gas mixing in large airways, and (3) increased oxygen concentration inside the conducting airway. How to cite this article: Kumar A, Kumar A, Kumar N, Kumar A, Singh V, Kumar S, et al. Repackaging of Malfunctioning High-flow Nasal Cannula as a Rescue Oxygen Therapy: An Innovation amid COVID-19 Crisis. Indian J Crit Care Med 2021;25(8):948–949.

Objectives: Diagnostics is the first step for the treatment and eradication of infectious microbial diseases. Due to ever evolving pathogens and emerging new diseases, there is an urgent need to identify suitable diagnostic techniques for better management of each disease. The success rate of specific diagnostic technique in any population depends on various factors including type of the microbial pathogen, availability of resources, technical expertise, disease severity and degree of epidemic of disease in the area. One of the important tasks of the policy makers is to identify and implement suitable diagnostic techniques for specific regions based on their specific requirements. In this review we have discussed various techniques available in the literature and their suitability for the target population based on above mentioned criteria. Methods: Diagnostic techniques evaluation of well documented representative microbial diseases; Tuberculosis (bacterial), Malaria (parasitic) and HIV (viral) were included in the study. Identification and collection of information and data was performed focusing on the diagnostic techniques used from the scientific publications from Pubmed, Science Access, Scopus, EMBASE and several regional databases. WHO and CDC database for Tuberculosis, Malaria and HIV were also included. These techniques were compared with respect to the financial resource availability, expertise and management, functional capacity, pathogen virulence and degree of epidemic in the population. Results and Conclusion: In case of Tuberculosis, ELISA and colorimetric techniques are successful in rural and urban communities with 80% – 90% sensitivity. Genotyping and SNP analysis are useful in drug resistant strains. Parasitic disease Malaria also follows the same trend with diagnostic techniques like RDTs being common in both population with fast results and around 90% sensitivity. STD disease like HIV however shows slight different trends due to urgent need of interference in rural epidemics of the disease. Rapid and sensitive immunotechniques like dipsticks and agglutination with almost 100% sensitivity are used in both rural and urban areas. For the confirmation further tests are done like protein Western and NAAT. Advance techniques could be the option for higher epidemic area, drug resistance and disease research, while rapid techniques would be suitable for low income areas and POC facilities. Therefore, suitability of the diagnostic techniques for better management depends not only on the financial resources and assessment skills of a community but sometimes on the disease itself. We have further discussed the technological improvements for specific settings (rural/urban) based on the past research for better management of diseases, which could be implemented for the understanding of understudied and newly emerging diseases.

How to cite this article Kumar A, Kumar A, Kumar A, Sinha C, Kumar N, Singh PK. Acute Exacerbation of Cough as a Precipitating Cause of Hypoxia in COVID-19 Patients. Indian J Crit Care Med 2021;25(11):1324–1325.

Background: Studies have reported that dental procedures may serve as a portal of entry for bacteria into the blood circulation, commonly termed as bacteremia which may inhabitate the heart and joints subjected to repair and replacement by prosthesis and may lead to complications in immunocompromised patients. Dental procedure may play a pivotal role in the development of infective endocarditis and infection around the prosthetic joint. Antibiotic use is suggested for all dental procedures requiring gingival manipulation or of the periapical region of teeth or mucosal incision in these patients. Objective: The present study has been conducted to inspect the antibiotic prescribing practices of general dentists among 250 dental practitioners. Methods: The study was conducted on 250 dental surgeons practicing in the urban Indian population of various parts of the country. A validated questionnaire was developed by a multidisciplinary dental and medical team and was circulated on the subject of the basic knowledge and awareness about antibiotic prophylaxis in susceptible patients. The data from the participants were collected, collated, and statistically analyzed. Results: The present study comprised 250 dental surgeons; 178 out of 250 were male, whereas 72 were female. Antibiotic prophylaxis guidelines were followed by 169 practitioners (67.60%), whereas 81 (32.40%) dentists did not follow any guidelines. Out of 169, 67 followed the American Academy of Orthopaedic Surgeons (AAOS) guidelines (39.64%), 58 followed American Heart Association (AHA) guidelines (34.30%), whereas 44 followed general physician's guidelines (26.03%). On screening the underlying conditions for which antibiotic cover was prescribed, it was shown that majority of the dental surgeons did the same for patients with cardiac valve repair or replacement (230; 92%), followed by infective endocarditis (212; 84.80%); organ transplant (212; 84.405); diabetes (189; 75.60%); prosthetic joint replacement (150; 60%); and congenital heart defect (110; 44%). Conclusion: Patients should then be trained to perform meticulous oral hygiene and advised to schedule regular dental checkups to maintain optimal dental health. Dentists should use antibiotic prophylaxis in only conditions associated with a valid scientific basis and should follow the standard protocols recommended by the American Dental Association, AHA, or AAOS.

Objective: The phenomenal popularity of social networking sites has been used globally by medical professionals to boost professional associations and scientific developments. They have tremendous potential to forge professional liaisons, generate employment,upgrading skills and publicizing scientific achievements. We highlight the role of social networking mediums in influencing teaching, training and research in anaesthesiology. Background: The growth of social networking sites have been prompted by the limitations of previous facilities in terms of ease of data and interface sharing and the amalgamation of audio visual aids on common platforms in the newer facilities. Review: Contemporary social networking sites like Facebook, Twitter, Tumblr,Linkedn etc and their respective features based on anaesthesiology training or practice have been discussed. A host of advantages which these sites confer are also discussed. Likewise the potential pitfalls and drawbacks of these facilities have also been addressed. Conclusion: Social networking sites have immense potential for development of training and research in Anaesthesiology. However responsible and cautious utilization is advocated.

Large posterior mediastinal masses may lead threatening complications such as critical tracheobronchial compression. Airway management in these individuals is a challenge and being a lower airway obstruction; rescue strategies are limited. We encountered one such case of a large esophageal mucocele causing extrinsic tracheobronchial compression. We have described the anesthetic management of this case using awake fiber-optic assessment followed by intubation. Close communication with the surgical team, meticulous planning of airway management, and early drainage of the mucocele are the cornerstones of management in such patients.

Background: N-acetyl cysteine, a mucolytic agent, demonstrates free radical scavenging and anti-inflammatory properties, and prevents endothelial dysfunction by inhibition of NF-KB and formation of no adducts. This has a potential role to tackle cytokine storms, endothelial dysfunction and prothrombotic state observed in COVID-19 manifestations like ARDS and Multi organ dysfunction.Methods: Institution based descriptive cross sectional study, 164 patients from laboratory confirmed RT PCR positive COVID-19 patients, in the study period from 27th May 2020 to 10th August 2020, were assessed, in medical college Kolkata, a dedicated COVID-19 care facility.Results: It was observed that moderate-severe patients who received N-acetyl cysteine along with standard therapy had average hospital stay duration of 12 days, higher rate of discharge, average duration of oxygen therapy of 8 days, less number of deaths and reduced transfer to critical care facilities.Conclusions: N-acetyl cysteine can be considered as an adjunctive therapy with standard protocol driven care, due to its beneficial anti-inflammatory and free radical scavenging properties.

Objective Identification of risk factors that might be responsible for postoperative hypoxaemia, in view of changing profile of surgical patients and better but more complex perioperative care nowadays. Methods We conducted a prospective observational study that included patients aged 18-65 years, who underwent elective surgery and required general anaesthesia. Oxygen saturation was monitored before the induction in operating room and continued 72 hours post-surgery. Patients were maintained on room air if SpO2 remained >94%. If SpO2 was between 90% and 94%, then patients were provided oxygen therapy via face mask (flow rate at 5-6 litre min-1). If SpO2 was between 89%-85% despite oxygen therapy with face mask, the Bilevel Positive Airway Pressure (BiPAP) was applied. If SpO2 was 90% on BiPAP, then patient was intubated, and ventilatory support was provided. Results Out of 452 patients, 61 developed SpO2 ≤94% requiring oxygen therapy (13.5%). Oxygen therapy by face mask was required in 51 patients, BiPAP in 8 and ventilatory support with endotracheal intubation in 2. Age, body mass index (BMI), smoking status, presence of preoperative respiratory disease, SPO2 (on room air) at baseline and immediately after the transfer to the post-anaesthesia care unit (PACU) were independently associated with postoperative oxygen therapy. Conclusion The risk of postoperative hypoxaemia was highest in patients aged 51-65 years, BMI higher than 30, current and former smokers, pre-existing respiratory disease, chronic obstructive pulmonary disease, patients with 96% oxygen saturation or less at baseline or after shifting to PACU. The type of surgical incision, duration of surgery and dose of opioids administered were not independent risk factors.

Extubation after general anesthetic procedures is often accompanied by transient undesirable responses such as hypertension, tachycardia, coughing, bucking, and raised intracranial and intraocular pressures. In neurosurgical procedures, they need to be stringently controlled to prevent the rise in cerebral blood flow, increase in intracranial pressure, and intracranial bleeding. Intravenous (IV) lignocaine (1-1.5 mg/kg) administration is one such method to blunt extubation responses. We describe a case where IV lignocaine was administered within the recommended doses to inhibit the extubation response, but the same resulted in generalized convulsions because of the clinical and physiological status of the patient at that point of time. Intravenous lignocaine administered to obtund extubation responses can itself manifest in toxic reactions depending on the preexisting clinical and physiological state of the patients. Thus, extreme caution and vigilance is to be maintained whenever IV local anesthetics are used for such purposes.

The existence of neural connection between the limbic system (hypothalamus, hippocampus, amygdala, and other adjacent areas) and the autonomic nervous system has been postulated to trigger severe hemodynamic responses. The hemodynamic consequences of stimulation of amygdala or hippocampus have been sporadically reported in animal studies and adult patients. However, the effect of this stimulation in pediatric patients is scarce. We present our experience of three cases of sympatholysis during intraoperative manipulation of amygdalohippocampus and review the pertinent literature.

Hyperglycaemia following surgical and anaesthetic stress is a well-established entity which might have undesirable clinical consequences in known diabetics. We encountered a rare event where an undiagnosed diabetic patient developed ketoacidosis in the immediate post-operative period which was her initial presenting symptom of deranged glucoregulation. Presumably, the stress induced by surgery and anaesthesia lead to the genesis of this event. We discuss the management of this case. In addition, we highlight the importance of glycosylated haemoglobin as a subject of future research in identifying such “at risk” patients and for stratifying the risk of hyperglycaemic complications in perioperative settings.

Background: The low-dose ropivacaine provides differential spinal block to reduce adverse hemodynamic effects in elderly patients. Addition of intrathecal fentanyl with ropivacaine may enhance analgesia and early postoperative mobility. The present study was performed to evaluate the efficacy of intrathecal ropivacaine alone and in combination with fentanyl in transurethral resection operation. Methods: Sixty male patients aged >50 years of ASA I-III scheduled for elective transurethral resection were included in a prospective, randomized, double-blinded study and they were divided in two groups of 30 each. Group A (n = 30) received intrathecal injection of ropivacaine 2 ml (0.75%) and Group B (n = 30) ropivacaine 1.8 ml (0.75%) with fentanyl 10 μg. The characteristics of onset and regression of sensory and motor blockade, hemodynamic stability, and side effects were observed. Student's t test (for parametric data) and Mann-Whitney U test (for non-parametric data) were used for statistical analyses. Results: There were no significant differences between the two groups for patient demographic data, intraoperative hemodynamic parameters, side effects, and satisfaction to patients and surgeon. The highest level of sensory block was at T10 in group A and T9 in group B (P = 0.001). Duration of motor block was longer in group B being 210.51 ± 61.25 min than in group A being 286.25 ± 55.65 min (P < 0.001). Conclusion: The addition of fentanyl to ropivacaine may offer the advantage of shorter duration of complete motor block, hemodynamic stability, and without any increase in the frequency of major side effects.

Background: Presently, there is no gold-standard regenerative material for the treatment of periodontal intrabony defects. The use of bone grafts in combination with guided tissue regeneration membrane is a predictable treatment option but is expensive. Platelet concentrates are increasingly being used due to their ease of use and cost-effectiveness. Aims: The objective of the present study is to compare clinically and also by Cone Beam Computed Tomography (CBCT), the effect of platelet-rich fibrin combined with synthetic beta-tricalcium phosphate to synthetic beta-tricalcium phosphate alone in the treatment of periodontal intrabony defects. Materials and Methods: 10 patients possessing 2 almost identical interproximal intrabony defects in either side of mandible were selected and the defects were further divided into 2 groups randomly: Control Group A (Beta-tricalcium phosphate placed) and Test Group B (Beta-tricalcium phosphate with platelet-rich fibrin placed). Regeneration of soft tissue and hard tissue (using CBCT) were evaluated after 6 months from baseline in both groups. Statistical Analysis Used: The intragroup and intergroup comparisons were done using Paired and student t-test. Results: Intragroup showed significant improvement in both soft tissue and hard tissue parameters. Mean of all parameters was better in the test group; however, the intergroup difference was not statistically significant. Conclusions: Within the limitations of the present study, the use of beta-tricalcium phosphate bone graft combined with platelet-rich fibrin and beta-tricalcium phosphate bone graft alone are both equally effective for the treatment of periodontal intrabony defects.

Intra Aortic Balloon Pump (IABP) is conventionally used to support coronary perfusion and weaning from cardiopulmonary bypass. IABP in situ has its own share of complications. We present a case where a patient on IABP support who had reduced peripheral pulsations of the ipsilateral limb and was initially misdiagnosed as IABP catheter associated thromboembolism. A negative embolectomy ruled out the same. Further looking for the cause of reduction of ipsilateral pulses it was found that the tight compressive bandage at saphenous vein conduit harvesting site had led to development of compartment syndrome (CS).

Topical capsaicin and eutectic mixture of local anesthetics (EMLA) have been found to be equally effective in minimizing the pain of venipuncture. After the injection of capsaicin, both tertiary amine local anesthetics and their quaternary ammonium derivatives can elicit a prolonged and predominantly sensory/nociceptor selective block. We hypothesized that the combined application of capsaicin and ELMA will be more effective than their individual effect, and lower concentrations of individual drugs in this mixture may also be associated with reduced side effects.One hundred twenty patients were randomized into 4 equal groups. The control group received plain lubricant cream; the EMLA group received EMLA cream; the capsaicin group received Myolaxin ointment (containing oleoresin capsaicin equivalent to capsaicin 0.075% w/w, methylsalicylate IP 20% w/w, menthol IP 10% w/w, camphor USP 5% w/w, and eucalyptus oil IP 5% w/w); and the EMLA + capsaicin group received EMLA cream and Myolaxin ointment mixed in equal amounts. An anesthesiologist applied the cream to a 10-cm(2) area (site of venous cannulation) on the dorsum of the nondominant hand of the patient 1 hour before venipuncture and covered the area with an occlusive transparent dressing. Venipuncture was performed with an 18-gauge cannula after removing the dressing. Venipuncture pain was graded by the patient on a 0 to 10 visual analog scale, where 0 means no pain and 10 means worst imaginable pain. P values (after correction for multiple comparisons) of0.05 were considered significant.The incidence of no pain on venous cannulation (primary end point) was 0% in the control group (0/30). The incidence of no pain were significantly higher in the EMLA group (32%, 9/28, 95% corrected confidence interval for the difference 12%-57%, P = 0.0025), capsaicin group (30%, 9/30, 10%-53%, P = 0.0031), and EMLA + capsaicin groups (47%, 14/30, 25%-69%, P0.0001). Severity of venipuncture pain as assessed by visual analog scale median (interquartile range) was lower in the EMLA + capsaicin group 1 (2) compared with other groups 3 (1), 1.5 (3), and 1.5 (3) for control, EMLA, and capsaicin, respectively (P0.001, P = 0.04, and P = 0.04, respectively).We observed that the combination of capsaicin and EMLA in a low concentration is as effective in managing venous cannulation as when applied as an individual drug alone. Larger studies with varying concentration of capsaicin and EMLA are recommended to more fully evaluate the potential advantages.

Background: Succinylcholine is used for rapid-sequence induction of anesthesia. Fasciculations and myalgia are adverse effects. The pretreatment modalities prevent or minimize its adverse effects. Aims: The present study is designed to evaluate the efficacy of gabapentin on the incidence of fasciculation and succinylcholine-induced myalgia. Settings and Design: The study was conducted at a tertiary care teaching hospital in a randomized, double-blinded, placebo-controlled manner. Materials and Methods: Patients of both genders undergoing laparoscopic cholecystectomy were randomly assigned to two groups. Patients in Group I (Gabapentin group) received 600 mg of gabapentin orally 2 h prior to surgery and patients in Group II (placebo group) received matching placebo. Anesthesia was induced with fentanyl 3 μg/kg, thiopentone 3-5 mg/kg and succinylcholine 1.5 mg/kg. All patients were observed and graded for fasciculations by a blinded observer and patients were intubated. Anesthesia was maintained with oxygen in air, sevoflurane and intermittent vecuronium bromide. After completion of surgery, neuromuscular blockade was reversed. A blinded observer recorded myalgia grade at 24 h. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief. Statistical analysis: Demographic data, fasciculation grade, fentanyl consumption, and myalgia grade were compared using student t test and test of proportions. Results: The study included 76 American Society of Anesthesiologists' Grade I or II patients of either gender undergoing laparoscopic cholecystectomy. But only 70 patients completed the study. Results demonstrated that the prophylactic use of gabapentin significantly decreases the incidence and the severity of myalgia (20/35 vs. 11/35) (P

Preinduction i.v. fentanyl bolus is associated with coughing in 28-65% of patients. Fentanyl-induced coughing (FIC) is not always benign and can be remarkably troublesome at the most critical moment of induction of anaesthesia when airway reflex is lost. We postulated that the huffing manoeuvre, a forced expiration against open glottis, just before i.v. fentanyl, may suppress this undesirable spasmodic cough.Three hundred patients of ASA I and II, aged 18-60 yr, undergoing elective surgical procedures were randomly allocated into two groups consisting of 150 patients. Both groups received i.v. fentanyl (2.5 microg kg(-1)). Group 1 patients breathed normally whereas Group 2 patients were asked to perform huffing manoeuvre just before the fentanyl injection. The incidence of cough was recorded for 1 min before the induction of anaesthesia, and graded as mild (1-2 cough), moderate (3-5 cough), and severe (5 cough). The incidence of FIC was analysed with Fisher's exact test and severity was analysed with the Mann-Whitney U-test. A P-value of0.05 was considered significant.The incidence of cough was 32% in the control group and 4% in the huffing manoeuvre group (P0.00). In the control group, 12% of FIC cases were moderate to severe in nature whereas no patient suffered severe coughing in the huffing manoeuvre group (P=0.049).A huffing manoeuvre performed just before i.v. fentanyl (2.5 microg kg(-1)) significantly reduces the incidence and severity of FIC in the majority of the patients.

Cardiopulmonary bypass (CPB) provides a unique circumstance to study the effects of drugs on the systemic vasculature. Thus, this study was designed to evaluate the effects of sodium bicarbonate on the systemic circulation during CPB in humans.Randomized, double-blind study.Tertiary care university hospital.Patients presenting for coronary artery bypass graft surgery with CPB.In this double-blind study, 22 consecutive adult patients of both sexes undergoing cardiac surgery were randomized into 2 groups. After establishing CPB and cardioplegia, patients in group 1 (n = 11) received saline (0.9%) (1.2 mL/kg), and group 2 received sodium bicarbonate (SB) (7%) (1.2 mL/kg). The blood level in the cardiotomy reservoir, pump flow, and mean arterial pressure were measured for 25 minutes.The SB-treated patients (group 2) showed significantly greater (p0.05) decreases in cardiotomy reservoir blood volume (336 +/- 186 mL) than the saline-treated (140 +/- 97 mL) patients. The mean arterial pressure in group 2 patients significantly (p0.05) increased (from 49 +/- 11.9 to 65 +/- 5.3 mmHg) more than in the saline group (from 50 +/- 6.8 to 57 +/- 9.2 mmHg) after 20 minutes. The decrease in reservoir volume significantly (p0.05) and inversely correlated (r = -0.61) with the acidotic state of the patients before SB.This study found a biphasic response to SB on the systemic circulation during CPB. Early dilation of venous capacitance vessels occurred followed by arteriolar constriction over the 20-minute study interval.

We evaluated the efficacy of topical Myolaxin (capsaican ointment, Geno, Mumbai) ointment over EMLA (eutectic mixture of lignocaine, prilocaine; Neon, Goa) cream for attenuating venous cannulation pain in this prospective, randomised, double blind study. Sixty adult patients undergoing elective laparoscopic cholecystectomy were randomly assigned into two equal groups. Group I (EMLA) received EMLA cream, whereas Group II (Myolaxin) received Myolaxin ointment. For both groups the cream was applied at the venous cannulation site (dorsum of the non-dominant hand) one hour prior to venous cannulation and was covered with an occlusive dressing. Following venous cannulation patients were asked if they felt pain during venous cannulation. If the answer was yes, they were asked to rate the severity of venous cannulation pain using a Visual Analogue Scale (VAS) of O-10. The incidence of venous cannulation pain was similar between groups: in the EMLA group 65% (18/28) compared to 67% (20/30) in the Myolaxin group (P=0.19). The severity of pain (median VAS with inter quartile range) was also similar between the groups: in the EMLA group 1.5 (3) compared to 1.5 (2) in the Myolaxin group (P=0.46). As the topical application of Myolaxin ointment is cheaper than EMLA and has similar efficacy, it may be a suitable alternative for reducing the incidence and severity of venous cannulation pain.

Pain following craniotomy has frequently been neglected because of the notion that postcraniotomy patients do not experience severe pain. However a gradual change in this outlook is observed because of increased sensitivity of neuroanaesthesiologists and neurosurgeons toward acute postcraniotomy pain. Multiple modalities exist for treating this variety of pain each with its own share of advantages and disadvantages. However, individually none of these modalities has been proclaimed as the best and applicable universally. A considerable amount of dispute remains to ascertain the appropriate therapeutic regimen for treating postcraniotomy pain in spite of numerous trials using different drugs and their combinations. This review aims to highlight the genesis, characteristics, and different strategies that are undertaken for management of acute postcraniotomy pain. Chronic postcraniotomy pain which can be debilitating sequelae is also discussed concisely.

We investigated the effects of pre-incision and post-incision administration of gabapentin on postoperative pain and fentanyl consumption associated with open donor nephrectomy.Sixty ASA I subjects were randomly allocated into three groups to receive gabapentin 600 mg two hours before surgery and placebo after surgical incision (pre-incision group), placebo two hours before surgery and gabapentin 600 mg after surgical incision (post-incision group), or placebo two hours before surgery and after surgical incision (placebo group). After surgery, pain was assessed using a visual analogue scale (VAS), (1-10 cm) at time points 0, 6, 12, 18, and 24 hr. Subjects received patient-controlled-analgesia (fentanyl 1.0 microg x kg(-1) subject activated dose). Total fentanyl consumption in each group was recorded.Subjects of pre-incision and post-incision groups had lower VAS scores at all time points (3.1 +/- 1.8, 2.9 +/- 1.3, 2.8 +/- 1.3, 2.5 +/- 0.9, 2.5 +/- 1.5 and 3.6 +/- 1.1, 3.0 +/- 1.2, 3.2 +/- 1.1, 2.9 +/- 1.0, 2.6 +/- 2.2) compared to placebo group (6.6 +/- 1.3, 5.0 +/- 1.0, 4.4 +/- 0.7, 4.2 +/- 0.8, 3.9 +/- 1.0). They also used less fentanyl (563.3 microg +/- 252.8 and 624.0 microg +/- 210.5 respectively) compared to placebo (924.7 microg +/- 417.5), (P0.05). No difference in total fentanyl consumption and pain scores at any time points were observed between pre- and post-incision groups.Pre-incision administration of 600 mg gabapentin has no added benefit over post-incision administration in terms of pain scores and fentanyl consumption in subjects undergoing open donor nephrectomy.

Summary A number of percutaneous dilational tracheostomy devices are now available for clinical use. Recently, a new percutaneous dilational tracheostomy device, the ‘T-Dagger™’ (Criticure Invasives, India), has been introduced for rapid bedside percutaneous tracheostomy. In a prospective preliminary study, we have performed percutaneous dilational tracheostomy (PDT) using the T-Dagger™ in 20 adult ventilated patients in order to evaluate the safety and efficacy of the new device. The T-Dagger™ facilitated bedside PDT in about 3 min with no untoward incidents. There was no significant bleeding, pneumothorax, pneumomediastinum, tracheal wall injuries or difficulty in ventilation in any of the patients. We conclude that the T-Dagger™ shows early promise in bedside percutaneous dilational tracheostomy. However, controlled studies are required in a larger patient population before it can be recommended for routine use.

We evaluated the optimal preemptive dose of gabapentin for postoperative pain relief after single-level lumbar diskectomy and its effect on fentanyl consumption during the initial 24 hours in a randomized, double-blinded, placebo-controlled study in 100 patients with American Society of Anesthesiologists physical status I and II. Patients were divided into five groups to receive placebo or gabapentin 300, 600, 900, or 1200 mg 2 hours before surgery. After surgery, patients were transferred to the postanesthesia care unit (PACU). A blinded anesthesiologist recorded the pain scores at time points of 6, 12, 18, and 24 hours in the PACU on a Visual Analog Scale (VAS; 0-10 cm) at rest. Patients received patient-controlled analgesia (fentanyl 1.0 mug/kg on each demand with lockout interval of 10 minutes); total fentanyl consumption during initial 24 hours was recorded. Data were entered into the statistical software package SPSS 9.0 for analysis (one-way analysis of variance and Student-Newman-Keuls test). Patients who received gabapentin 300 mg had significantly lower VAS score at all time points. They consumed less fentanyl (patients who received placebo processed 1217.5 +/- 182.0 versus 987.5 +/- 129.6 mug; P < 0.05). Patients who received gabapentin 600, 900, and 1200 mg had lower VAS scores at all time points than patients who received gabapentin 300 mg (P < 0.05). Increasing the dose of gabapentin from 600 to 1200 mg did not decrease the VAS score, nor did the increasing dose of gabapentin significantly decrease fentanyl consumption (702.5, 635, and 626.5 microg). Thus, gabapentin 600 mg is the optimal dose for postoperative pain relief following lumbar diskectomy.

The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal, epidural, IV, or IM routes. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation. In this prospective, randomized, double-blind study, we investigated the effect of epidural bupivacaine on the dose requirement of propofol (as evaluated by using the bispectral index [BIS]), fentanyl, and vecuronium for general anesthesia. This study consisted of 30 adults, ASA physical status I and II, undergoing Whipple's pancreaticoduodenectomy for periampullary carcinoma lasting >4 h. An epidural catheter was placed between T9-10. Depending on the group allocation, 10 mL of the study drug was administered as a bolus followed by an infusion at 6 mL/h via the epidural catheter. Patients were divided into 2 groups of 15 each. Patients in the control group received epidural normal saline whereas those in the bupivacaine group received epidural bupivacaine 0.1%. Induction of anesthesia was performed with IV fentanyl 2 mug/kg and propofol titrated to achieve BIS between 40-50. Endotracheal intubation was facilitated by the IV administration of vecuronium 0.1 mg/kg and patient's lungs were ventilated with 66% nitrous oxide in oxygen. After intubation, infusion of propofol 1% was titrated to maintain BIS between 40-50. Inadequate analgesia was defined as an increase in systolic blood pressure and/or heart rate by >20% of baseline values in response to surgical stimulus and was treated with bolus fentanyl 0.5 mug/kg. Neuromuscular monitoring was used to assess the need for additional doses of vecuronium. Data were analyzed by using the Student's t-test and P

We investigated whether the preemptive use of gabapentin, a structural analogue of gamma amino butyric acid could reduce postoperative pain and fentanyl consumption in patients after single-level lumbar discoidectomy. Fifty-six ASA I and II patients were randomly allocated into two equal groups to receive either gabapentin 300 mg or placebo two hours before surgery. After surgery, the pain was assessed on a visual analogue scale (VAS) at intervals of 0–6, 6–12, 12–18, and 18–24 hr at rest. Total fentanyl consumption in the first 24 hr after surgery was also recorded. Fentanyl 2 μg·kg−1 intravenously was used to treat postoperative pain on patients’ demand. Patients in the gabapentin group had significantly lower VAS scores at all time intervals of 0–6, 6–12, 12–18,and 18–24 hr than those in the placebo group (3.5 ± 2.3, 3.2 ± 2.1, 1.8 ± 1.7, 1.2 ± 1.3 vs 6.1 ± 1.7, 4.4 ± 1.2, 3.3 ± 1.1, 2.1 ± 1.2; P < 0.05). The total fentanyl consumed after surgery in the first 24 hr in the gabapentin group (233.5 ± 141.9, mean + SD) was significantly less than in the placebo group (359.6 ± 104.1 ; P < 0.05). Preemptive gabapentin 300 mg po significantly decreases the severity of pain postoperatively in patients who undergo single-level lumbar discoidectomy.

Purpose To evaluate the comparative preemptive effects of gabapentin and tramadol on postoperative pain and fentanyl requirement in laparoscopic cholecystectomy.

UNLABELLED Propofol causes pain on IV injection in 28%-90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. We compared the efficacy of pretreatment with thiopental 0.25 mg/kg and 0.5 mg/kg and lidocaine 40 mg after venous occlusion for prevention of propofol-induced pain. One-hundred-twenty-four adult patients, ASA physical status I-II, undergoing elective surgery were randomly assigned into 4 groups of 31 each. Group I received normal saline, group II received lidocaine 2% (40 mg), and groups III and IV received thiopental 0.25 mg/kg and 0.5 mg/kg, respectively. All pretreatment drugs were made in 2 mL and were accompanied by manual venous occlusion for 1 min. Propofol was administered after release of venous occlusion. Pain was assessed with a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain at the time of propofol injection. Twenty-four patients (77%) complained of pain in the group pretreated with normal saline as compared with 12 (39%), 10 (32%), and 1 (3%) in the groups pretreated with lidocaine 40 mg, thiopental 0.25 mg/kg, and thiopental 0.5 mg/kg, respectively (P < 0.05). Thiopental 0.5 mg/kg was the most effective treatment. We therefore suggest routine pretreatment with thiopental 0.5 mg/kg along with venous occlusion for 1 min for prevention of pain associated with propofol injection. IMPLICATIONS Pain associated with IV injection of propofol is seen in 28%-90% patients. Pretreatment with thiopental 0.25 mg/kg and 0.5 mg/kg after manual venous occlusion for 1 min effectively attenuated pain associated with propofol injection. Thiopental 0.5 mg/kg was the most effective in prevention of propofol pain and can be used routinely.

Summary Craniopagus conjoined twins are rare, and the chance that an anesthesiologist might face the challenge of providing anesthesia for this condition is very rare. The incidence of conjoined twins ranges from 1 : 50 000 to 1 : 200 000 births. We describe the anesthetic management of a pair of premature craniopagus conjoined twins posted for emergency surgery prior to their separation.

Splint application avoids unwanted movement of limbs and kinking of intravenous catheters in infants, allowing free flow of intravenous fluids. However, if placed in contact with dependent surfaces during prone surgeries, they have the propensity to cause inadvertent pressure injuries. This occurs due to the weight of the limb and continuous friction and is augmented by a rise in the local temperature and perspiration. We wish to share our experience of such an unintentional injury caused by a paediatric intravenous splint.

UNLABELLED Pain syndromes of Guillain-Barre are neuropathic as well as nociceptive in origin. We aimed to evaluate the therapeutic efficacy of gabapentin in relieving the bimodal nature of pain in Guillain-Barre syndrome in a randomized, double-blinded, placebo-controlled, crossover study in 18 patients admitted to the intensive care unit for ventilatory support. Patients were assigned to receive either gabapentin (15 mg. kg(-1). d(-1) in 3 divided doses) or matching placebo as initial medication for 7 days. After a 2-day washout period, those who previously received gabapentin received placebo, and those previously receiving placebo received gabapentin as in the initial phase. Fentanyl 2 micro g/kg was used as a rescue analgesic on patient demand or when the pain score was >5 on a numeric rating scale of 0-10. The numeric rating score, sedation score, consumption of fentanyl, and adverse effects were noted, and these observed variables were compared. The numeric pain score decreased from 7.22 +/- 0.83 to 2.33 +/- 1.67 on the second day after initiation of gabapentin therapy and remained low during the period of gabapentin therapy (2.06 +/- 0.63) (P < 0.001). There was a significant decrease in the need for fentanyl from Day 1 to Day 7 during the gabapentin therapy period (211.11 +/- 21.39 to 65.53 +/- 16.17 [ micro g]) in comparison to the placebo therapy period (319.44 +/- 25.08 to 316.67 +/- 24.25 [ micro g]) (P < 0.001). IMPLICATIONS Gabapentin, an antiepileptic drug, has been used effectively for different types of pain management. This study demonstrates that gabapentin has minimal side effects and is an alternative to opioids and nonsteroidal antiinflammatory drugs for management of the bimodal nature of pain of Guillain-Barre Syndrome patients.

Background Ventriculitis also referred as ependymitis or ventricular empyema is a known complication of pyogenic meningitis. Despite high incidence of tubercular meningitis in developing countries, there are hardly any reports of tubercular ventriculitis. Methods Five patients (four males and one female) of tubercular ventriculitis were retrospectively identified from December 2007 to August 2013. Their clinical features, cranial MRI characteristics, treatment offered, and outcome were reviewed. Results The median age of 5 patients was 29 years (range 15 to 64 years). Two patients had preceding pulmonary/pleural tuberculosis and one had Pott's spine. One patient had multi-drug resistant tuberculosis. All five patients had papilledema, four had seizures, two had hemiparesis, and two had vision loss. On cranial MRI all patients showed contrast enhancement of ependymal wall of lateral/fourth ventricle with restricted diffusion and hydrocephalus; three showed intra-ventricular septations with sequestered ventricles, and two had ventricular sludge. Magnetization transfer (MT) images were available in only two patients. Both showed hyperintense epedymal wall on MT images. Four patients required ventriculo-peritoneal shunt and two underwent temporal lobectomy. Two patients with sequestered temporal lobe had acute deterioration in consciousness with signs of impending herniation and required urgent surgical intervention. Four patients recovered on anti-tubercular treatment over 18 months; one receiving secondary line ATT for residual brain abscess. Conclusion Tubercular ventriculitis is a rare complication of tubercular meningitis. MRI feature of sequestered ventricles/intraventricular septations and hyperintense ependymal wall on MT images could suggest tubercular etiology. Symptomatic hydrocephalus may require CSF diversion in most patients.

BACKGROUND: Venous cannulation is often performed without any analgesia, even though pain experienced during this procedure is at times very distressing. Various pharmacological and nonpharmacological measures have been tried with variable results to minimize venous cannulation pain. We designed the present study to evaluate the efficacy of a flash of light on attenuating venous cannulation pain. METHODS: Ninety adults (15-60 yr), ASA physical status I and II, of either sex, undergoing elective laparoscopic cholecystectomy, were included in this prospective and randomized study. Patients were divided into three groups of 30 each. Group I (control); Group II (distraction): photographed without a flash of light; and Group III (flash): photographed with a flash of light just before venous cannulation of a vein on the dorsum of the nondominant hand. Immediately after the photograph, venous cannulation was performed using an 18-gauge cannula. RESULTS: Two patients from each group could not be cannulated on their first attempt and were therefore dropped from subsequent analysis. The incidence of venous cannulation pain in the flash group was lower, i.e., 50% (14 of 28) when compared to 100% (28 of 28) observed in the other two study groups (P < 0.01). Severity of venous cannulation pain as assessed by the Visual Analog Scale scores (between 0 and 100; where 0 = no pain and 100 = worst imaginable pain) presented as median (interquartile range) were reduced in the flash [10(20)] and distraction [20(10)] groups compared with the control group [40(20)] (P < 0.01). The severity of venous cannulation pain was also reduced in the flash group compared with the distraction group (P < 0.01). CONCLUSION: We conclude that a flash of light before venous cannulation is a safe, effective, and easy-to-use method for minimizing venous cannulation pain.

IV lidocaine is effective in suppressing the cough reflex of tracheal intubation, extubation, bronchography, bronchoscopy, and laryngoscopy. We investigated this effect of lidocaine on fentanyl-induced cough in 502 patients of ASA physical status I and II scheduled for elective surgery. The patients were assigned to 2 equal groups to receive either lidocaine 1.5 mg/kg or placebo (0.9% saline) over 5 s 1 min before the administration of fentanyl 3 mug/kg in a randomized and double-blind fashion. Coughs were classified as coughing and graded as mild (1-2), moderate (3-4), or severe (5 or more). The results of the study suggest that IV lidocaine 1.5 mg/kg, when administered 1 min before fentanyl, is significantly effective in suppressing fentanyl-induced cough compared to placebo (0.9% saline) (218 versus 165 patients) (P0.002) but without affecting the severity of cough (P0.05).

Context: Catheter-related bladder discomfort (CRBD) is the most distressing symptom in patients due to intraoperative urinary catheterization. Amikacin significantly inhibits detrusor contraction evoked by prejunctional stimulation. Aims: The aim of this study is to evaluate the efficacy of amikacin in prevention of CRBD in patients undergoing percutaneous nephrolithotomy. Settings and Design: Study areas were operation theater and postanesthesia care unit of the Department of Anesthesiology, SGPGIMS, Lucknow. Subjects and Methods: One hundred adult patients of either sex were randomly assigned into two groups of fifty each. Patients in control group received normal saline whereas patients in amikacin group received amikacin 10 mg/kg just before induction. Grading of CRBD was done as none, mild, moderate, and severe by a blinded observer at 0, 1, 6, 12, and 24 h after surgery. Statistical Analysis Used: Data were analyzed using Student's t-test and Chi-square test among groups. Incidence of CRBD was compared with Chi-square test whereas severity was analyzed by the test of proportions (Z-test). Visual analog score was compared using Mann–Whitney U-test for surgical site pain. Results: Incidence of CRBD in control group was 66% as compared to 44% observed in amikacin group (P < 0.05). During intergroup comparison at different time points, incidence of CRBD was reduced at 1 and 6 h in the amikacin group (P < 0.05). Significant reduction in the severity of CRBD (moderate) was also observed at 1 h in the amikacin group (P < 0.05). At rest of the time points, there was no significant difference. Conclusions: Amikacin can significantly reduce the incidence and severity of CRBD in the first few hours after surgery.

Valsalva maneuver is associated with diverse physiological changes. These changes are used in various diagnostic and therapeutic clinical settings. Valsalva maneuver is also employed during various phases of neurosurgical procedures to achieve specific targets and confirm intraoperative findings. In this article, we attempt to describe the various clinical applications of the Valsalva maneuver within the realms of clinical neurosurgery. The associated complications of this act have also been discussed.

Pressure injuries are an accepted complication of prone positioning during the neurosurgical procedures. Horseshoe headrest are intended to reduce the incidence and severity of such injuries by allowing limited areas of contact between the skin of dependent areas of contact and the supporting surfaces. We report a case where a patient positioned prone over a horseshoe headrest developed inadvertent unilateral facial pressure injuries following a 6-h long craniovertebral junction (CVJ) surgery. We attempt to highlight this complication, analyze its causation, and briefly review the existing literature related to similar reported injuries.

Background & objectives: There is paucity of studies on the quality of anticoagulation in neurological patients from India. This study evaluates the quality of oral anticoagulation therapy in neurology patients. Methods: Consecutive patients attending a tertiary care neurology service in north India who were prescribed oral anticoagulant (OAC), were included. Their international normalized ratio (INR) values were prospectively monitored and the earlier INR values of the patients who were already on OAC were retrospectively analyzed. The patients with multi-organ dysfunction, pregnancy and those below 18 yr of age were excluded. The therapeutic INR range was defined as per standard recommendations. The level of anticoagulation, factors interfering with OAC and complications were noted. Results: The results were based on 77 patients with median age 40 yr. Fifty one patients received OAC for secondary stroke prevention, 23 for cerebral venous sinus thrombosis (CVST) and three for deep vein thrombosis (DVT). A total 167.9 person-years of follow up was done with a median of 1.2 (0.3-9.3) years. of the 1287 INR reports, 505 (39.3%) reports were in the therapeutic range, 496 (38.5%) were below and 282 (21.91%) were above the therapeutic level. Stable INR was obtained in 33 (42.86%) patients only. INR level was improved by dose adjustment in 20 (26%), drug modification in two (2.6%), and dietary adjustment in six (7.8%) patients. Three patients were sensitive and five were resistant to OAC. Complications were noted in 28 instances; thromboembolic in 16 and haemorrhagic stroke in 12. The overall complication rate was 16.7 per 100 person-years. Interpretation & conclusions: It may be concluded that stable therapeutic INR is difficult to maintain in neurological patients. Optimal modification of diet, drug and dose of oral anticoagulant may help in stabilization of INR.

Providing anesthesia to children undergoing MRI is challenging. Adequate premedication, administered noninvasively, would make the process smoother. In this study, we compare the efficacy of intranasal dexmedetomidine (DXM) with the intranasal administration of ketamine for procedural sedation in children undergoing MRI. We studied 150 children, between 1 and 10 years of age, divided randomly into three groups (DXM, K, and S). For blinding, every child received the intranasal drugs twice; syringe S1, 60 min before, and syringe S2, 30 min before intravenous (IV) cannulation. For children in group DXM, S1 contained DXM (1 μg/kg) and S2 was plain saline. Children in group K received saline in S1 and ketamine (5 mg/kg) in S2 whereas children in group S received saline in both S1 and S2. The child’s response to drug administration, ease of IV cannulation, the satisfaction of the anesthesiologist and child’s parents with the premedication, and the total propofol dose required for the satisfactory conduct of the procedure were compared. We also compared the time to awakening and discharge of the child as well as the occurrence of any side effects with these drugs. Both DXM and ketamine were equally effective as premedication in these patients. Most of the children accepted the intranasal drugs with minimal discomfort; 90.4 % of the anesthesiologists in the DXM group and 82.7 % in the ketamine group were satisfied with the conditions for IV cannulation whereas only 21.3 % were satisfied in the saline group. The total dose of propofol used was less in the study groups. Furthermore, children in group DXM and group K had earlier awakening and discharge than those in group S. DXM and ketamine were equally effective, by the intranasal route, as premedication in children undergoing MRI.