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The coronavirus disease-2019 (COVID-19) pandemic had overwhelmed the healthcare system and forced many patients to be treated at home with oxygen, antibiotics, and steroids, particularly during the second wave. There was increased misuse of antimicrobials in hospitals as well as unguarded self-prescription of these medications among the common people. We are likely to see an increase in the incidence of antimicrobial resistance (AMR), change in the susceptibility pattern of the organisms causing community-acquired infections, and an increase in opportunistic bacterial, tubercular, viral, and fungal infections. How to cite this article: Panda R, Hirolli D, Baidya DK. Aftermath of COVID-19 and Critical Care in India. Indian J Crit Care Med 2021; 25(10):1173-1175., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

How to cite this article: Nath S, Baidya DK. Mucormycosis in COVID-19: Is Zinc a Silent Killer in India? Indian J Crit Care Med 2021;25(9):1079-1080., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Cardiopulmonary resuscitation (CPR) is considered an aerosol-generating procedure. The aim of this study was to identify the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare providers (HCPs) involved in CPR in coronavirus 2019 (COVID-19) patients. An online and offline anonymous survey with a preformed questionnaire was conducted among the HCPs involved in the care of COVID-19 patients. HCPs who developed reverse transcription-polymerase chain reaction-positive confirmed COVID-19 and/or symptomatic influenza-like illness (ILI) within 14 days of their involvement in CPR of a confirmed COVID-19 patient were identified. Activities performed during CPR, the cumulative number of CPR performed, any breach in personal protective equipment (PPE), type of the mask used, use of any pharmacological prophylaxis, and any psychological impact among HCPs were also identified. A total of 393 HCPs participated in the survey; out of them, 197 HCPs participated in CPR at least once (CPR group) and the rest 196 did not (control group). Ten in the control group and five in the CPR group developed confirmed COVID-19 within the next 2 weeks; however, only one of these five had a breach in PPE during CPR. To conclude, participation in CPR does not increase the risk of SARS-CoV-2 infection in HCPs caring for the COVID-19 patients. Ethics approval and consent to participate: The study was approved by the ethics committee of the All India Institute of Medical Sciences, New Delhi, vide letter number: IEC-676/03.07.2020, dated July 4, 2020. How to cite this article: Soni L, Maitra S, Ray BR, Anand RK, Subramaniam R, Baidya DK. Risk of SARS-CoV-2 Infection among Healthcare Providers Involved in Cardiopulmonary Resuscitation in COVID-19 Patients. Indian J Crit Care Med 2021;25(8):920-922., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background and Aims: Optimum timing of laryngeal mask airway (LMA) removal after general anesthesia with isoflurane is debatable. The objective was to investigate the potential benefits of removing LMA ProSeal at ≤0.4 Minimum alveolar concentration (MAC) isoflurane over awake and "deep plane" extubation after short duration laparoscopic gynecological surgery., Material and Methods: In this prospective randomized trial 90 adult female patients undergoing elective laparoscopic surgery under general anesthesia using LMA ProSeal™ as airway device were included. At the end of surgery, LMA ProSeal™ was removed when the patient was awake, could open mouth following verbal command (Group A); at MAC ≤0.4 (Group B); or at MAC of 0.6 (Group C). Adverse airway events like nausea, vomiting, airway obstruction, coughing, bucking, laryngospasm were noted. Statistical analyses were done by SPSS statistical software (IBM SPSS Statistics for Mac OS X, Version 21.0. IBM Corp, Armonk, NY)., Results: Baseline demographic characteristics were comparable in all three groups. Coughing or bucking at the time of LMA removal was higher in group A ( P = 0.004). Snoring and airway obstruction after LMA removal was significantly higher in group C compared to group A and group B ( P = 0.002 and P = 0.011, respectively). There was significant change in mean arterial pressure and heart rate between before and after LMA removal on group A ( P = 0.008 and P < 0.001, respectively) but not in other groups., Conclusion: MAC ≤0.4 can be considered optimum depth of anesthesia for removal of LMA Proseal in adult patients undergoing isoflurane anesthesia., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.)

Introduction: Although various preventive strategies have been advocated, delirium is common in critically ill patients and is associated with increased morbidity, mortality, and long-term adverse effects. The efficacy of a novel delirium prevention bundle in mechanically ventilated critically ill patients was investigated in this study., Methods: In this randomized controlled trial, 50 mechanically ventilated adult patients in a tertiary care medical-surgical intensive care unit (ICU) were randomized to receive either delirium prevention bundle protocol or standard of care protocol. Delirium was assessed daily using the Confusion Assessment Method for the ICU (CAM-ICU) score by an independent investigator up to 28 days or death or discharge. The primary outcome was the incidence of new-onset delirium. Secondary outcomes were duration of mechanical ventilation, ICU length of stay (ICU-LOS), hospital LOS, and other adverse events., Results: There was a 20% reduction in the incidence of delirium in the intervention group (36 vs 56%; p = 0.156). The 28-day mortality (28 vs 24%; p = 0.747), duration of mechanical ventilation (9 vs 12 days; p = 0.281), ICU-LOS (11 vs 12 days; p = 0.221), and hospital LOS (16 vs 20 days; p = 0.062) were similar between the groups., Conclusion: Implementation of delirium prevention bundle does not reduce the incidence of delirium compared to standard of care protocol in mechanically ventilated critically ill patients., How to Cite This Article: Malik AK, Baidya DK, Anand RK, Subramaniam R. A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial. Indian J Crit Care Med 2021;25(7):754-760., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions., Methods: Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmH 2 O was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally., Results: Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO 2 >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups., Conclusion: Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Vitamin-D is an immune-modulator which might be linked to disease severity by SARS-CoV-2., Methods: Meta-analysis of RCTs and quasi-experimental studies, evaluating the role of vitamin-D supplementation in COVID patients was done., Results: Total 5 studies (3 RCTs and 2 Quasi-experimental) including n = 467 patients were included. Vitamin D didn't reduce mortality (RR 0.55, 95%CI 0.22 to 1.39, p = 0.21), ICU admission rates (RR 0.20, 95% CI 0.01-4.26, p = 0.3) and need for invasive ventilation (RR 0.24, 95% CI 0.01-7.89, p = 0.42)., Conclusion: No significant difference with vitamin-D supplementation on major health related outcomes in COVID-19. Well-designed RCTs are required addressing this topic., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Study Design: Retrospective, comparative., Objective: The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care., Summary of Background Data: Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes., Methods: Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals., Results: A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months)., Conclusion: Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Data are lacking on the role of cellular components of hematological system as biomarkers for prognosis of sepsis. We planned to identify if these parameters measured at admission to ICU and at 72 hours can be useful as prognostic marker in septic critically ill patients., Materials and Methods: In this prospective observational study, 130 adult patients with sepsis were recruited. Various hematological study parameters (total, differential, and absolute leukocyte count, platelet count, platelet distribution width, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio) were noted at day 1 and day 3 of admission. Primary outcome was 28-day mortality, and secondary outcomes were duration of mechanical ventilation, vasopressor requirement, ICU length of stay, and requirement of renal replacement therapy. The variables were compared between two groups and using binary regression model and were evaluated as prognostic markers for 28-day mortality., Results: Data from n = 129 were analyzed. At day-28, n = 58 (44.96%) patients survived. Baseline and demographic parameters were comparable between survivors and nonsurvivors. Admission Sequential Organ Failure Assessment score was more in nonsurvivors than survivors [8 (6-8) vs 6 (4-8); p = 0.002]. In nonsurvivors, monocyte, lymphocyte, basophil, eosinophil, and platelet count were significantly less at day 1 and lymphocyte, eosinophil, basophil and platelet count were significantly less at day 3. NLR and PLR at day 3 were significantly more in nonsurvivors. On logistic regression analysis, age, thrombocytopenia on day 1, and low eosinophil count on day 3 predicted 28-day mortality ( p = 0.006, p = 0.02, and p = 0.04, respectively)., Conclusion: Thrombocytopenia on day 1 and eosinopenia on day 3 may predict 28-day mortality in sepsis., How to Cite This Article: Sinha H, Maitra S, Anand RK, Aggarwal R, Rewari V, Subramaniam R, et al . Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis. Indian J Crit Care Med 2021;25(6):660-667., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background and Aims: Accurate measurement of intraocular pressure (IOP) under anaesthesia is essential for diagnosis and further management of pediatric glaucoma patients. However, depth of anaesthesia and use of airway device like laryngeal mask airway (LMA) or endotracheal tube can influence IOP values measured. We planned this study to compare change of IOP with facemask or LMA. Change of IOP at varying depth of anaesthesia was also assessed., Material and Methods: After Institutional ethical clearance and informed parental consent, 89 children of glaucoma aged 0-12 years were included in this prospective randomized controlled trial. The children were randomized to facemask (Group M) and LMA (Group L). Sevoflurane was the sole general anaesthetic used in both the groups and IOP were recorded after induction, at BIS 40-60, after LMA insertion (Group L), at BIS 60-80 and BIS more than 80., Results: The IOP values did not differ significantly between the groups at BIS 40-60 and at BIS 60-80. Moreover, pre and post LMA insertion IOP values were also comparable in Gr L (p = 0.11). However, significant increase in IOP values were observed with increasing BIS values within each group. The mean IOP in Group M at BIS 40-60 was 13.41 ± 4.04 as compared to 14.18 ± 3.64 at BIS 60-80 (p = 0.003). There was a similar pattern observed in Group L, where mean IOP at BIS 40-60 & BIS 60-80 was 14.13 ± 4.90 and 15.52 ± 4.57 respectively (p < 0.001)., Conclusion: Either facemask or classic LMA can be safely used as per anaesthesiologist's preference without any significant effect on IOP. BIS monitoring may be used during IOP measurement in paediatric glaucoma suspects for accurate assessment of IOP., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.)

Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods : After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18-65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders." Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 ( p = 0.016), 0.440 ( p = 0.052), and 0.044 ( p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. How to cite this article: Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, et al . Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310-316. CTRI/Trial Reg No: www.ctri.nic.in, CTRI/2017/11/010434., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Purpose: This study aimed to compare the analgesic efficacy of wound infiltration with ropivacaine alone or with adjuvants clonidine or dexamethasone for postoperative pain in temporomandibular joint ankylosis (TMJA) surgery., Materials and Methods: The investigators implemented a randomized controlled trial with 3 parallel groups, among the patients of bilateral TMJA visiting the maxillofacial surgery unit between March 12, 2015 and February 5, 2017. At the completion of surgery, wound infiltration was done with 0.25% of ropivacaine (R group), 0.25% of ropivacaine with 0.5 mcg/kg of clonidine (RC group), 0.25% of ropivacaine with 0.1 mg/kg of dexamethasone (RD group), and 0.2 mL/kg of drug volume on each side. The primary outcome variables were total opioid consumption (fentanyl in micrograms/kilogram) and visual analog scale for pain at rest and movement for 24 hours after surgery. The secondary outcome variables were time (minutes) to first rescue analgesic requirement and patient satisfaction scores. The patients, surgeons, and anesthesiologists collecting the data were blinded to the group allocation. Continuous and qualitative data were summarized using mean (standard deviation) and frequency distribution, respectively., Results: About 45 patients were randomized into 3 equal groups. Mean age of the sample was 17.6 ± 8.04 years (males = 24 [53%]; females = 21 [47%]). Surgery for TMJA included gap arthroplasty (n = 17), interpositional arthroplasty (n = 24), and total TMJ replacement (n = 4). Total fentanyl (micrograms) consumption during 24 hours was comparable between all the 3 groups and statistically not significant (P = .40). The pain scores (visual analog scale at rest and movement) were comparable at all time points. No significant difference was noted for time to first rescue analgesic requirement (P = .31). Patient satisfaction was higher in RC group as compared with R group (P = .009). No adverse effects were noted in any group., Conclusions: Within the confines of the sample size and the absence of power calculation, the study implies that wound infiltration with ropivacaine was as efficacious as when mixed with adjuvants, either clonidine or dexamethasone, for control of postoperative pain for 24 hours., (Copyright © 2020. Published by Elsevier Inc.)

Competing Interests: There are no conflicts of interest.

How to cite this article: Anand RK, Baidya DK, Maitra S, Ray BR. A Proposal for Dedicated "Prone Team" and "Prone Bundle of Care" in COVID-19 ICU. Indian J Crit Care Med 2021;25(3):349-350., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

How to cite this article: Rai N, Baidya DK. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic: Is Sequela the Bigger Threat? Indian J Crit Care Med 2021;25(2):245-246., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: Coronavirus disease 2019 (COVID-19) is a type of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 pneumonia has characteristic radiological features. Recent evidence indicates usefulness of chest X-ray and lung ultrasound (LUS) in detecting COVID-19 pneumonia., Materials and Methods: In this prospective observational study, chest X-ray and LUS features of 50 adults with COVID-19 pneumonia at the time of presentation were described., Results: Chest X-ray findings were present in 96% of patients, whereas all patients have ultrasound finding. Proportion (95% CI) of patients having bilateral opacities in chest X-ray was 96% (86.5-98.9%), ground glass opacity 74% (60.5-84.1%), and consolidation 50% (36.7-63.4%). In LUS, shred sign and thickened pleura was present in all patients recruited in this study. Air bronchogram was present in at least one area in 80% of all patients and B-lines score of more than 2 was present in at least one lung area in 84% patients. Number of lung areas with "shred sign" were higher in hypoxemic ( p = 0.005) and tachypneic ( p = 0.006) patients and pleura line abnormalities were present in more lung areas in hypoxemic patients ( p = 0.03)., Conclusion: According to our study, LUS is a useful tool not only in diagnosing, but it also correlates with requirement of respiratory support in COVID-19 patients., How to Cite This Article: Behera S, Maitra S, Anand RK, Baidya DK, Subramaniam R, Kayina CA, et al. Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study. Indian J Crit Care Med 2021;25(1):85-87., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

How to cite this article: Kayina CA, Maitra S, Anand RK, Ray BR, Baidya DK, Subramaniam R. SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients. Indian J Crit Care Med 2020;24(11):1141-1142., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.)

How to cite this article: Nair PR, Maitra S, Ray BR, Anand RK, Baidya DK, Subramaniam R. Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients. Indian J Crit Care Med 2020;24(11):1143-1144., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.)

Competing Interests: There are no conflicts of interest.

Background & Objectives: In this study we describe the epidemiological data, comorbidities, clinical symptoms, severity of illness and early outcome of patients with coronavirus disease 2019 (COVID-19) from a tertiary care teaching hospital in New Delhi, India., Methods: In this preliminary analysis of a prospective observational study, all adult patients admitted to the screening intensive care unit (ICU) of the institute who fulfilled the WHO case definition of COVID-19 and confirmed to have SARS-CoV-2 infection by reverse transcription-polymerase chain reaction were included. Demographics, clinical data and 24 h outcome were assessed., Results: The preliminary analysis of 235 patients revealed that the mean age was 50.7±15.1 yr and 68.1 per cent were male. Fever (68.1%), cough (59.6%) and shortness of breath (71.9%) were the most common presenting symptoms. Hypertension (28.1%) and diabetes mellitus (23.3%) were the most common associated comorbid illnesses. Patients with mild, moderate, severe and critical illness were 18.3, 32.3, 31.1 and 18.3 per cent, respectively, at the time of ICU admission. The proportions (95% confidence interval) of patients requiring any form of oxygen therapy, oxygen therapy by high-flow nasal cannula and invasive mechanical ventilation were 77, 21.7 and 25.5 per cent, respectively, within 24 h of hospital admission. The 24 h ICU mortality was 8.5 per cent, and non-survivors had higher respiratory rate (P <0.01, n=198) and lower baseline oxyhaemoglobin saturation (P <0.001, n=198) at presentation and higher baseline serum lactate (P <0.01, n=122), total leucocyte count (P <0.001, n=186), absolute neutrophil count (P <0.001, n=132), prothrombin time (P <0.05, n=54) and INR (P <0.05, n=54) compared to survivors., Interpretation & Conclusions: Nearly half of the patients presented with severe and critical disease and required high-flow nasal oxygen or invasive mechanical ventilation at admission. Severity of the presenting respiratory illness, haematological parameters and lactate rather than age or presence of comorbidity predicted early death within 24 h., Competing Interests: None

Competing Interests: There are no conflicts of interest.

Background and Aims: Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures., Methods: The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software., Results: Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement ( P = 0.01) and postoperative fentanyl requirement until 24 h ( P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment ( P = 0.000)., Conclusion: ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Anaesthesia.)

Introduction: Pelvi-ureteric junction obstruction (PUJO) is one of the most common conditions presenting to a pediatric urologist. As laparoscopic or robotic-assisted pyeloplasty, either transperitoneal or retroperitoneal, involves intracorporeal suturing skills and has a long learning curve, they have not gained popularity among beginners in laparoscopy., Objective: We conducted a study to assess the results of a single-port, retroperitoneoscopic approach to renal access, i.e. lumboscopic-assisted pyeloplasty (LAP), by single surgeon at our institute., Materials and Methods: A retrospective review of all children who underwent LAP from July 2013 to March 2018 was conducted. Patients who presented with PUJO and required surgical treatment were included. A single-port lumboscopy using coaxial telescope was performed in prone position in all patients. The renal pelvis was dissected and retrieved through the port site followed by extracorporeal hand-sewn pyeloplasty over a double-J stent or a nephrostent. The operative time, postoperative pain, surgical complications, duration of hospital stay, follow-up, and cosmesis at 6 months postsurgery were evaluated., Results: A total of 96 children were included (72 males and 24 females), with the age at operation ranging from 3 months to 10 years (mean = 4.9 years). All patients had an uneventful postoperative recovery. Two patients had a superficial wound infection, and one patient was converted to open approach due to excessive bleeding. The average operating time was 80 ± 22.5 min, the median duration of hospital stay was 3 days, and the average scar length at 3 months was 15.6 ± 0.4 mm. Follow-up renogram (diethylenetriamine pentaacetic acid) showed satisfactory postpyeloplasty drainage pattern in 93 children while three showed obstructive drainage curves., Conclusion: LAP can be performed safely with minimal retroperitoneal dissection, excellent cosmetic results, and minimal postoperative pain in children with PUJO. It has a shorter learning curve as compared to laparoscopic pyeloplasty as it involves time tested extracorporeal hand-sewn anastomosis., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Indian Association of Pediatric Surgeons.)

Purpose: Carotid artery corrected flow time (cFT) derived from Doppler USG is a known predictor of volume responsiveness. However, it can't be obtained continuously, and is operator dependent. In this prospective study, correlation between Doppler derived carotid artery cFT and pressure transducer derived radial artery cFT was evaluated in adult patients undergoing surgery under general anaesthesia., Methods: Doppler derived carotid artery cFT were obtained from n = 51 adult patients at n = 125 time points. Simultaneously, pressure transducer waveforms were saved at the time of measurement of carotid artery cFT. Later, images were analyzed by an image processing computer software; both pulse pressure variation and cFT were estimated from pressure transducer waveform., Results: Radial artery flow times measured by two independent observers, were significantly correlated (r 2  = 0.99, p < 0.00001). Bland-Altman analysis found limits of agreement - 8.3 to 6.3 ms [mean difference (95% CI) - 0.98 (- 1.63, - 0.32)]. Doppler derived carotid artery cFT & pressure transducer derived radial artery cFT were also significantly correlated [r 2  = 0.78, p < 0.0001]. However, radial artery cFT was significantly higher than carotid artery cFT [p < 0.0001, paired sample t test]. Radial artery cFT > 404.4 ms had an sensitivity and specificity of 87.34% and 85% respectively with a grey zone was between 393.7 and 417 ms to predict PPV ≥ 12%., Conclusion: Pressure transducer derived radial artery cFT correlated with Doppler derived carotid artery cFT and may be a reasonable predictor of volume responsiveness. Further studies are required to confirm its role in various clinical scenario for prediction of volume responsiveness.

Objectives: Hypotension is common after induction of general anesthesia, and intraoperative hypotension is associated with postoperative end-organ injury such as acute kidney injury and myocardial ischemia. This study was designed to determine the utility of the carotid corrected flow time (cFT) and carotid artery peak blood flow velocity variation (ðV peak ) for prediction of hypotension after induction of general anesthesia., Methods: Adult patients (n = 112) undergoing any elective surgery under general anesthesia who fasted for at least 6 to 8 hours were recruited in this prospective observational study. The common carotid artery cFT and ðV peak were measured with ultrasound 10 minutes before induction of general anesthesia. After that, general anesthesia with propofol was used, and hemodynamic data were collected until 3 minutes after induction of anesthesia., Results: The carotid cFT was significantly correlated with percentages of the fall in the systolic blood pressure at 2 minutes (P < .0001) and 3 minutes (P < .0001) and percentages of the fall in the mean arterial pressure at 1 minute (P = .0006), 2 minutes (P < .0001), and 3 minutes (P < .0001). The cFT was a predictor of hypotension after induction of general anesthesia, with an area under the receiver operating characteristic curve of 0.91. The best cutoff value obtained from this study was 330.2 milliseconds or less, which predicted postinduction hypotension with sensitivity and specificity of 85.7% and 96.8%, respectively. The ðV peak was an inferior predictor of postinduction hypotension, with an area under the receiver operating characteristic curve of 0.68. The optimum cutoff value was 18.8%, with sensitivity and specificity of 61.9% and 67.4%., Conclusions: The cFT measured in the common carotid artery is a reasonable predictor of hypotension after induction of general anesthesia in American Society of Anesthesiologists physical status I and II patients. Further studies are required to identify its role in high-risk patients such as older groups and patients with cardiovascular diseases and also to identify interobserver and intraobserver variability of cFT and ðV peak measurements., (© 2019 by the American Institute of Ultrasound in Medicine.)

Objective: Outpatient hysteroscopy is often accompanied by pain and discomfort along with frequent occurrence of bradycardia and hypotension. This study aimed to observe if intravenous low-dose ketamine reduces the pain scores along with lowering the incidence of bradycardia and hypotension during hysteroscopy., Methods: This prospective, randomised, double-blind trial was conducted in operating rooms in a tertiary care hospital. In this study, we enrolled 72 patients with American Society of Anesthesiologists status I to II undergoing hysteroscopy. We randomised patients into two groups, and both groups received paracervical block. The control group received intravenous pentazocine and promethazine along with saline infusion. The ketamine group received ketamine infusion (0.75 mg kg -1 bolus followed by infusion at the rate of 10 mcg kg -1 min -1 ). We analysed visual analogue scale (VAS), rescue analgesic consumption, hemodynamic parameters, lowest recorded heart rate, blood pressure, level of sedation, patient's comfort, surgeon's satisfaction and nursing staff's satisfaction., Results: Analysis of the data revealed that the pain scores were similar in both the groups (p=0.493, p<0.001). Rescue analgesic was required by 47% patients in control group, compared to only 5.6% patients in ketamine group. Episodes of bradycardia and hypotension were more pronounced in the control group than in the ketamine group [77.4±10.9 vs. 78.4±5.5; 67.6±8 vs. 70.1±6 respectively] (p<0.001). Patient comfort and surgeon's satisfaction were higher in the ketamine group, but nursing satisfaction was higher in the control group. Disorientation was present in 75% patients in the ketamine group as compared to none in the control group., Conclusion: We concluded that low-dose ketamine in day-care hysteroscopy is an effective and safe agent., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (© Copyright 2020 by Turkish Anaesthesiology and Intensive Care Society.)

Background: Comparison between various approaches of ultrasound (USG)-guided internal jugular vein cannulation, that is, short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach, is sparse. In this network meta-analysis of randomized controlled trials, all three approaches were evaluated to identify the best technique for USG-guided internal jugular vein cannulation., Methods: Randomized controlled trials comparing short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach in any combination (i.e. comparison of any two or all three) for USG-guided internal jugular vein cannulation were included in this meta-analysis. Bayesian network meta-analysis was conducted with a non-informative prior effect size and heterogeneity, and all results were reported as posterior median odds ratio with 95% credible interval., Results: Data of 658 patients from five randomized controlled trials were included in this meta-analysis. No difference was obtained in first attempt success rate of cannulation in three approaches (posterior median odds ratio between long-axis and short-axis view, oblique-axis and short-axis view, and long-axis and oblique-axis view were 0.67 (0.20, 2.08), 0.92 (0.09, 4.790), and 1.3420 (0.1680, 6.7820), respectively). No difference was seen in the incidence of carotid artery puncture and overall success rate of cannulation., Conclusion: All three commonly used approaches for USG-guided internal jugular vein cannulation, that is, short axis, long axis, and oblique axis, are comparable in terms of clinical utility and safety. There is insufficient evidence to recommend one approach over another for this purpose.

Objective: This trial investigated the post operative analgesic efficacy of oarl etoricoxib 90 mg and 120 mg and a placebo in mandibular fracture pain model., Methods: A total of 63 adult patients with mandibular fractures who were scheduled to undergo maxillofacial surgery were randomly allocated to receive etoricoxib 90 mg, etoricoxib 120 mg and a placebo 1 hour before the surgery. Patients were followed-up till 24 hours after the surgery. Duration of analgesia, intra-operative and post-operative analgesic requirement, pain score, post-operative patient satisfaction and adverse effects were measured., Results: The baseline demographic parameters were similar in all the groups. Duration of analgesia was longer in both the E120 (6.00±0.816 hours) and E90 (4.37±1.008 hours) groups (p<0.05) as compared to the placebo group (2.60±0.821 hours). Mean difference of duration of analgesia between E120 and E90 was 1.62 (95% confidence interval: 0.234-3.484; p>0.05). Post-operative pain intensity was significantly lower in both the E120 and E90 groups as compared to the C group. Both the etoricoxib groups required less intra-operative (p=0.002) and post-operative (p=0.001) analgesic supplementation as compared to the placebo group. The patient satisfaction score and rate of occurrence of significant adverse effects were similar among all the three groups., Conclusion: Etoricoxib 90 mg is equally efficacious to etoricoxib120 mg with a similar side effect profile in a severely acute setting., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (© Copyright 2020 by Turkish Anaesthesiology and Intensive Care Society.)

Background: Serial lactate measurement is found to predict mortality in septic shock. Majority of patients with perforation peritonitis for emergency laparotomy are in sepsis and mortality rate is substantial. However, lactate dynamics has not been studied in this patient population., Methods: After institutional ethics clearance and informed written consent, 113 patients with suspected or proven perforation peritonitis presenting for emergency laparotomy were recruited in this prospective observational trial. Baseline Mannheim peritonitis index (MPI), SOFA and APACHE II score were calculated. Lactate values were obtained at baseline, immediate and 24-h postoperative period. Primary outcome was 28-day mortality., Results: Mortality was 15.04% at 28 days. Age, SOFA, qSOFA, APACHE, preoperative lactate, MPI and site of perforation were significantly different between survivors and non-survivors. Arterial lactate values at preoperative (cut off 2.75 mmol/L), immediate postoperative (cut off 2.8 mmol/L) and 24 h-postoperative period (cut off 2.45 mmol/L) independently predicted mortality at day 28. Combination of MPI and 24-h lactate value was best predictor of mortality with AUC 0.99., Conclusion: Preoperative, immediate postoperative and 24-h postoperative lactate value independently predict 28-day mortality in perforation peritonitis patients undergoing emergency laparotomy. Combination of MPI and 24-h lactate value is the most accurate predictor of mortality., Trial Registration: Clinical Trial Registry of India - CTRI/2018/01/011103., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2019.)

Background: Postspinal anesthesia hypotension (PSH) in pregnant women is common and may lead to poor maternal and fetal outcome. Fluid loading in pregnant women before spinal anesthesia to prevent hypotension is of limited ability. We hypothesized that those women who are hypovolemic before spinal anesthesia may be at risk of PSH and inferior vena cava collapsibility index (IVCCI) will be able to identify hypovolemic parturients., Methods: In this prospective observational study, n = 45 women undergoing elective lower segment cesarean section with singleton pregnancy were recruited and IVCCI in left lateral tilt (with wedge) and supine position (without wedge) were noted by M-mode ultrasound (USG) before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted till 15 min after spinal anesthesia., Results: USG measurements were obtained in 40 patients and 23 of 40 patients (57.5%) had at least one episode of hypotension. Area under the ROC curve of IVCCI with wedge to predict PSH was 0.46 (95% CI 0.27, 0.64) and best cut-of value was 25.64 with a sensitivity and specificity of 60.9% and 35.5%, respectively. Area under the ROC curve of IVCCI without wedge to predict PSH was 0.38 (95% CI 0.19, 0.56) and best cut-of value was 20.4 with a sensitivity and specificity of 69.6% and 23.5%, respectively., Conclusion: We conclude that IVCCI is not a predictor of PSH in pregnant women undergoing elective cesarean section., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Saudi Journal of Anesthesia.)

Background and Aims: Administration of fentanyl before induction of anaesthesia with propofol should facilitate smooth induction, with a reduction in induction dose of propofol and its side effects. This study was designed to examine the effect of varying intervals between fentanyl and propofol administration on the dose of propofol required for induction of anaesthesia., Methods: After institutional ethical clearance, 129 American Society of Anesthesiologists physical status I--II patients, aged 18--65 years, undergoing elective surgery under general anaesthesia were randomised into three groups. Fentanyl 2 mcg/kg was administered immediately prior to, 3 and 5 min before induction with propofol in Groups 1, 2, and 3, respectively. Requirement of propofol induction dose and haemodynamic parameters was recorded. Statistical analysis was performed using software SPSS (SPSS Inc., Chicago, Illinois, USA)., Results: Total dose of propofol required for induction was highest in Groups 1 and lowest Group 3 (Group 1 vs. 2 vs. 3: 86.28 ± 21.12 vs. 71.67 ± 21.68 vs. 59.98 ± 20.35 mg, P < 0.00001). Dose of propofol required per kg body weight was significantly higher in Group 1 (1.41 ± 0.34 mg/kg) compared to both Group 2 (1.14 ± 0.38 mg/kg) and Group 3 (0.97 ± 0.32 mg/kg) ( P < 0.00001). Incidence of hypotension during induction was significantly lower in Group 3 (14%) and Group 2 (17.1%) than in Group 1 (35.6%; P = 0.03)., Conclusion: Administering fentanyl 5 min prior to propofol causes marked reduction in the dose requirement of the latter along with a significantly decreased incidence of hypotension during induction., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Indian Journal of Anaesthesia.)

Purpose: Safety and feasibility of distal radial artery cannulation at the anatomic snuffbox in the perioperative settings in adult patients have been assessed in this study., Methods: Adult patients undergoing elective surgery requiring arterial cannulation were recruited in this retrospective cohort study., Results: Data of 55 patients have been reviewed here; among which in 21 patients, arterial puncture was performed ultrasound guidance and in 34 patients puncture was guided by the pulsation of the distal radial artery at the anatomical snuffbox. First attempt success rate of distal radial arterial cannulation was 76.3% (42 of 55 patients) and it was similar between ultrasound guided (USG) and palpation technique ( P = 0.53, Chi-square test). Overall, cannulation success rate was 87.3% (48 of 55 patients) and it was also similar between USG and palpation technique ( P = 0.79, Chi-square test)., Conclusion: Distal radial artery cannulation is technically feasible in patients undergoing elective surgery. However, further randomized controlled trials are required to establish its clinical utility and safety profile in comparison to conventional radial artery cannulation., Competing Interests: There are no conflicts of interest.

Objectives: The aim of the study was to compare time to intubation and glottic visualization between Macintosh, McCoy, and Glidescope video laryngoscope (GVL) in morbidly obese patients., Methodology: Forty-five American Society of Anesthesiologists I-III morbidly obese patients were randomized into three groups of 15 each and time to intubation, Cormack-Lehane grading, and Intubation Difficulty Score (IDS) were compared., Results: GVL took more time to intubate (TTI) compared to Macintosh and McCoy laryngoscope ( P = 0.0001). Overall IDS were similar between the groups., Conclusion: To conclude, GVL takes longer TTI with no added advantage in IDS and hemodynamic response to intubation in morbidly obese patients. McCoy is only as effective as Macintosh and hence Macintosh laryngoscope should be laryngoscope of choice due to its widespread availability and familiarity., Competing Interests: There are no conflicts of interest.

Study Objectives: Direct laryngoscopy is the most commonly used modality for endotracheal intubation in the emergency department. Video laryngoscopy may improve glottic view during laryngoscopy and intubation success rate in such patients. This meta-analysis has been designed to compare clinical efficacy of video laryngoscopy with direct laryngoscopy for endotracheal intubation in the emergency department., Design: Meta-analysis of randomized controlled trial., Setting: Randomized controlled trials comparing video laryngoscopy and direct laryngoscopy for endotracheal intubation in adult patients in emergency department. PubMed (1946 to 20th October 2017) and The Cochrane Library databases (CENTRAL) were searched for potentially eligible trials on 20th October 2017., Patients: Adult patients presenting in the emergency department., Interventions: Video laryngoscopy & direct laryngoscopy for intubation in emergency department., Measurement: Primary outcome was 'first intubation success rate' and secondary outcomes were overall intubation success rate, in-hospital mortality and oesophageal intubation rate., Main Results: Data of 1250 patients from 5 randomized controlled trials have been included in this study. Video laryngoscopy offers no advantage over direct laryngoscopy in terms of first intubation success rate (odds ratio 1.28, 95% CI 0.70, 2.36; p = 0.42), overall intubation success rate (OR 1.26, 95% CI 0.53, 3.01; p = 0.6) or in-hospital mortality (OR 1.25, 95% CI 0.8, 1.95; p = 0.32). However, oesophageal intubation rate is lower with the use of video laryngoscopy (OR 0.09, 95% CI 0.01, 0.7; p = 0.02)., Conclusion: Use of video laryngoscopy for emergency endotracheal intubation in adult patients is associated with reduced oesophageal intubation over direct laryngoscopy. However, no benefit was found in terms of overall intubation success., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Objective: Possible advantages and risks associated with ultrasound guided radial artery cannulation in-comparison to digital palpation guided method in adult patients are not fully known. We have compared ultrasound guided radial artery cannulation with digital palpation technique in this meta-analysis., Design: Meta-analysis of randomized controlled trials., Setting: Trials conducted in operating room, emergency department, cardiac catheterization laboratory., Patients: PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) were searched (from 1946 to 20th November 2017) to identify prospective randomized controlled trials in adult patients., Intervention: Two-dimensional ultrasound guided radial artery catheterization versus digital palpation guided radial artery cannulation., Measurements: Overall cannulation success rate, first attempt success rate, time to cannulation and mean number of attempts to successful cannulation. Odds ratio (OR) and standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI) were calculated for categorical and continuous variables respectively., Results: Data of 1895 patients from 10 studies have been included in this meta- analysis. Overall cannulation success rate was similar between ultrasound guided technique and digital palpation [OR (95% CI) 2.01 (1.00, 4.06); p = 0.05]. Ultrasound guided radial artery cannulation is associated with higher first attempt success rate of radial artery cannulation in comparison to digital palpation [OR (95% CI) 2.76 (186, 4.10); p < 0.001]. No difference was seen in time to cannulate [SMD (95% CI) -0.31 (-0.65, 0.04); p = 0.30] and mean number of attempt [MD (95% CI) -0.65 (-1.32, 0.02); p = 0.06] between USG guided technique with palpation technique., Conclusion: Radial artery cannulation by ultrasound guidance may increase the first attempt success rate but not the overall cannulation success when compared to digital palpation technique. However, results of this meta-analysis should be interpreted with caution due presence of heterogeneity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background and Aims: Increasing the cross-sectional area (CSA) of the internal jugular vein (IJV) improves the success rate of cannulation and decreases complications. Application of positive end-expiratory pressure (PEEP) may increase the CSA of IJV beyond that achieved in Trendelenburg position. However, the optimum PEEP to achieve maximal increase in CSA of IJV and the effect of PEEP on IJV and CA relationship is not known., Methods: In this prospective, blinded, randomised controlled study, 120 anesthetised paralysed patients of the American Society of Anesthesiologists physical Status I-II were placed in 20° Trendelenburg position. Patients were randomised into four groups as follows: PEEP of 0, 5, 10 and 15 cmH 2 O. CSA, anteroposterior (AP) diameter and transverse diameter (Td) of IJV and overlapping of IJV with CA were assessed using two-dimensional ultrasound. Statistical analysis was performed in SPSS version 21.0 software using Chi-square/Fisher's exact test (categorical data) and analysis of variance (continuous data) tests and P < 0.05 was considered statistically significant., Results: There was significant increase in AP diameter, CSA and Td with the application of PEEP 10-15 cmH 2 O. Increase in CSA up to 25% with PEEP 10 and 44% with PEEP 15 was noted. There was a significant decrease in the overlapping of the internal CA with an increase in PEEP. It ranged from 21% at P0 to 17% P15., Conclusion: Application of PEEP 10-15 cmH 2 O in Trendelenburg position significantly increased CSA and AP diameter of IJV and decreased CA overlap of IJV in anesthetised paralysed patients., Competing Interests: There are no conflicts of interest.

Background: Third molar extraction is associated with considerable pain and discomfort, which is mostly managed with oral analgesic medication. We assessed the analgesic effect of benzydamine hydrochloride, a topical analgesic oral rinse, for controlling postoperative pain following third molar extraction., Methods: A randomized controlled trial was conducted in 40 patients divided into two groups, for extraction of fully erupted third molar. Groups A received benzydamine hydrochloride mouthwash and group B received normal saline gargle with oral ibuprofen and paracetamol. Oral ibuprofen and paracetamol was the rescue analgesic drug in group A. Patients were evaluated on the 3 rd and 7 th post-operative days (POD) for pain using the visual analogue score (VAS), trismus, total number of analgesics consumed, and satisfaction level of patients., Results: The VAS in groups A and B on POD3 and POD7 was 4.55 ± 2.54 and 3.95 ± 1.8, and 1.2 ± 1.64 and 0.95 ± 1.14, respectively and was statistically insignificant. The number of analgesics consumed in groups A and B on POD3 (5.25 ± 2.22 and 6.05 ± 2.43) was not statistically different from that consumed on POD7 (9.15 ± 5.93 and 10.65 ± 6.46). The p values for trismus on POD3 and POD7 were 0.609 and 0.490, respectively and those for patient satisfaction level on POD3 and POD7 were 0.283 and 0.217, respectively., Conclusions: Benzydamine hydrochloride oral rinses do not significantly reduce intake of oral analgesics and are inadequate for pain relief following mandibular third molar extraction., Competing Interests: DECLARATION OF INTERESTS: The authors declare that there are no conflicts of interest in this study.

Background and Aims: Effect of serum 25-hydroxy vitamin D (25[OH] D) levels on the recovery of critically ill mechanically ventilated patients is unclear. Hence, this study assessed 25(OH)D levels of critically ill patients on mechanical ventilation at the time of admission to the Intensive Care Unit (ICU) and its relationship with clinical outcome., Methods: In this prospective observational pilot study, forty adult patients receiving mechanical ventilation in the ICU were included. Serum 25(OH)D was assessed within 24 h of admission. Primary outcome was 30-day mortality and secondary outcomes were days on mechanical ventilation, ICU-length of stay (ICU-LOS), days to reach spontaneous breathing trial (SBT), requirement of advanced care modality and complications., Results: Seventy-five percent patients had low serum 25(OH)D (65% deficient and 10% insufficient). Between patients with low and normal vitamin D, there was no significant difference in 30-day mortality (10% vs. 16.7%; P = 0.81), days on mechanical ventilation (16.2 ± 8.9 vs. 19.9 ± 8.4; P = 0.23), ICU-length of stay (18.7 ± 8.5 vs. 23.3 ± 11.4; P = 0.28), days to reach SBT (11.5 (0-20) vs. 21 (8-30); P = 0.78), complications developed during ICU stay ( P = 0.60) and need for advanced care modalities ( P = 0.72)., Conclusion: Low Vitamin D level at admission did not affect 30-day mortality of critically ill patients on mechanical ventilation., Competing Interests: There are no conflicts of interest.

Objectives: Despite of advancement in intensive care medicine, sepsis and septic shock carry a high mortality. Levosimendan, an inodilator, may be promising for septic shock patients with myocardial dysfunction; however, firm evidence is lacking. In this meta- analysis of randomized controlled trials, levosimendan has been compared with dobutamine in adult patients with sepsis and septic shock., Design: Meta-analysis of randomized controlled trial., Setting: Intensive-care unit., Participants: Adult septic shock patients., Intervention: Adult septic shock patients received dobutamine or levosimendan., Main Outcome Measure: Mortality at longest follow-up, blood lactate level, cardiac index and noradrenaline requirement., Results: Data from 7 randomized trials have been included in this meta-analysis. Levosimendan has no benefit in terms of mortality at longest follow up in comparison to dobutamine (Odds ratio 0.77, 95% CI 0.45, 132; p=0.34) and length of ICU stay (MD -4.7days, 95% CI -10.3, 0.9days, p=0.10). Patients received levosimendan had less blood lactate level (standardized mean difference -0.95; 95% CI -1.64, -0.27; p=0.006) and higher cardiac index (mean difference 0.44; 95% CI 0.17, 0.71; p=0.001). Noradrenaline requirements are similar in both the groups., Conclusion: There is no evidence that levosimendan is superior to dobutamine in adult patients with sepsis and septic shock. Further large randomized trials are necessary in this area., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Sternotomy for cardiac surgeries causes significant postoperative pain and when not properly managed may cause significant morbidity. As neuropathic pain is a significant component here, gabapentin and pregabalin may be effective in these patients and may reduce postoperative opioid consumption. The purpose of this systematic review was to find out efficacy of gabapentin and pregabalin in acute postoperative pain after cardiac surgery., Methods: Published prospective human randomized clinical trials, which compared preoperative and/or postoperative gabapentin/pregabalin with placebo or no treatment for postoperative pain management after cardiac surgery has been included in this review., Results: Four RCTs each for gabapentin and pregabalin have been included in this systematic review. Three gabapentin and two pregabalin studies reported decrease in opioid consumption in cardiac surgical patients while one gabapentin and two pregabalin studies did not. Three RCTs each for gabapentin and pregabalin reported lower pain scores both during activity and rest. The drugs are not associated with any significant complications., Conclusion: Despite lower pain scores in the postoperative period, there is insufficient evidence to recommend routine use of gabapentin and pregabalin to reduce opioid consumption in the cardiac surgical patients., (Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background and Aims: Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients., Material and Methods: Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study., Results: Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95 % CI 0.46-1.08, p = 0.11) length of post-operative hospital stay (SMD -0.14; 95 % CI -0.28, 0.00; p = 0.05) and length of ICU stay (SMD -0.12; 95 % CI -0.28, 0.04; p = 0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95 % CI 0.43, 0.75; p < 0.0001). Abdominal complications (p = 0.008), wound infection (p = 0.002) and postoperative hypotension (p = 0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p < 0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure., Conclusion: GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.

Introduction: 5-Hydroxytryptamine type 3 (5-HT3) receptor antagonists are the most commonly used drugs for postoperative nausea vomiting (PONV) prophylaxis. Dexamethasone is another antiemetic with proven efficacy in reducing PONV. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the combination of dexamethasone and 5-HT3 antagonist versus a 5-HT3 antagonist alone as prophylaxis of PONV in laparoscopic surgical patients., Methods: PubMed, PubMed Central, and CENTRAL databases were searched to identify those randomized trials that compared a 5-HT3 antagonist with the 5-HT3 antagonist and dexamethasone combination for PONV prophylaxis after laparoscopic surgeries., Results: Data from 17 RCTs that evaluated 1402 patients were included. Results from our meta-analysis show that the combination of dexamethasone and a 5-HT3 receptor antagonist is more effective in preventing PONV than the 5-HT3 antagonist alone (odds ratio 0.38, 95% confidence interval [CI] 0.27-0.54; number needed to treat = 6.6), with no statistical heterogeneity (I = 0) among studies. The need for rescue antiemetic is also decreased in patients receiving the combination (odds ratio 0.21, 99% CI 0.10-0.46; number needed to treat = 6), although data are insufficient to detect any significant difference in incidence of adverse effects. In addition, patients in the combination group complained of less pain after 24 hours (Weighted Mean Difference -0.67, 99% CI -1.27 to -0.08)., Conclusion: Combination of a 5-HT3 receptor antagonist and dexamethasone is significantly more effective than 5-HT3 antagonist alone in preventing PONV after laparoscopic surgeries, with possible improvement in postoperative analgesia.

Purpose: The role of high-flow nasal oxygen (HFNO) therapy in adult patients with acute hypoxemic respiratory failure is controversial., Methods: This meta-analysis of prospective randomized controlled trials (RCTs) has been designed to compare HFNO with noninvasive ventilation (NIV) and conventional oxygen therapy in such patients., Results: Initial database searching revealed 336 RCTs, of which 7 were included in this meta-analysis. Five RCTs compared HFNO with standard oxygen therapy, one compared HFNO with NIV, and one compared all three. HFNO did not decrease the requirement of higher respiratory support compared with control group. HFNO was associated with improved respiratory rate and dyspnea score, and better comfort in 3 RCTs, whereas other studies did not find any difference., Conclusion: High-flow nasal oxygen does not offer any benefit over NIV or conventional oxygen therapy in terms of requirement of higher respiratory support., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Cardiac arrest is associated with very high mortality and causes neurological dysfunction in the survivors. Therapeutic hypothermia is one of the recommended modality in the postarrest management. However, recent findings question its benefit in postarrest management. This meta-analysis has been conceptualized to quantify clinical benefit of therapeutic hypothermia in post-cardiac arrest patients., Methods: Prospective, randomized, and quasi-randomized controlled trials comparing the efficacy of therapeutic hypothermia in post-cardiac arrest adult population with a post-cardiac arrest management protocol that does not include therapeutic hypothermia were included in this meta-analysis. Two authors independently searched PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration for potentially eligible trials., Results: Data of 1399 patients from 6 controlled trials have been included in this systematic review and meta-analysis. Therapeutic hypothermia does not provide any benefit in favorable neurological outcome (P=.06; odds ratio, 1.80; 95% confidence interval [CI], 0.97-3.35; n=1384), in survival at hospital discharge (P=.58; odds ratio, 1.16; 95% CI, 0.69-1.96; n=1399), and in long-term survival (P=.36; odds ratio, 1.32; 95% CI, 0.73-2.39; n=1292). Therapeutic hypothermia also increases incidence of pneumonia (P=.02; odds ratio, 1.30; 95% CI, 1.04-1.64; n=1204; number needed to harm, 15)., Conclusion: Therapeutic hypothermia in the post-cardiac arrest management protocol does not provide any benefit in favorable neurological outcome, survival to hospital discharge, and long term survival. Incidence of pneumonia may be increased with the use of therapeutic hypothermia., (Copyright © 2016 Elsevier Inc. All rights reserved.)