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The high mortality associated with the thrombotic events in hospitalized COVID-19 patients resulted in the usage of anticoagulants in varying doses. Whether high-dose anticoagulants have led to better outcomes or higher incidence of clinically significant bleeding events is debatable. Thus, this study was conducted to find the incidence of clinically significant bleeding events in moderate-to-severe COVID-19 ARDS (acute respiratory distress syndrome) patients on therapeutic anticoagulation and their outcomes.In this retrospective, single-centre study of 155 critically ill COVID-19 patients, the incidence of clinically significant bleeding was observed. Multivariate regression models were used to evaluate the association between anticoagulant regimen, coagulation and inflammatory markers with the incidence of bleeding and thrombotic events.The incidence of clinically relevant non-major bleeding was 33.54 per cent (26.17-41.46%) and major bleeding was 9.03 per cent (5.02-14.69%). The anticoagulation intensity at baseline had a high odds of major bleeding when enoxaparin and dual antiplatelet therapy were used together [adjusted odds ratio OR of 434.09 (3.81-49502.95), P0.05]. At admission, bleeders had a poorer PaOThe incidence of bleeding in critically ill COVID-19 patients on therapeutic anticoagulation may increase with the severity of the disease as well as with concurrent use of dual antiplatelets. Major bleeding may also contribute to higher mortality.

Background and objectives Inadvertent perioperative hypothermia is expected in the elderly during central neuraxial anesthesia. We aimed to compare the incidence of intraoperative hypothermia (36-degree celsius) between preoperative forced-air warming for 30 minutes and non-warming groups. Also, we compared the time to develop hypothermia, perioperative shivering, duration of intraoperative active warming, metabolic acidosis, surgical site infections, coagulation derangements, and post-anesthesia care unit (PACU) stay. Material and methodology A total of 100 American Society of Anesthesiologists (ASA) I-III (Age60 years) patients scheduled to undergo femur fracture surgeries under central neuraxial anesthesia were enrolled in this single-blinded prospective randomized study. They were randomly allocated into Group A (active forced-air warming for 30 minutes in the preoperative period) and Group B (without forced-air warming). Then, patients were transferred to the operation theatre, where central neuraxial anesthesia was administered for surgery. An infrared tympanic membrane thermometer measured the core body temperature during the different study points. Results The intraoperative hypothermia incidences were 26.0% and 68.0% in groups A and B, respectively. The mean time for developing hypothermia was found to be 143.08 ± 26.26 min and 25.88 ± 9.25 min in groups A and B, respectively. The mean duration of intraoperative active warming was observed to be 15.6 minutes and 103.6 minutes in groups A and B, respectively. The shivering and surgical site infection (SSI) grades were lower in group A. Conclusion A preoperative forced-air warming strategy for 30 minutes helps in reducing the incidence of intraoperative hypothermia and shivering in elderly patients undergoing femur fracture surgeries under central neuraxial anesthesia.

Introduction: Use of rocuronium has been associated with withdrawal movements of injected arm during its administration. Our study is to compare the effectiveness of palonosetron vs. lignocaine pretreatment with venous occlusion on reducing withdrawal movements associated with rocuronium injection. Materials and Methods: This prospective randomized double blind trial includes 150 patients aged between 18 and 65 years undergoing elective day-care surgeries. Patients were randomly divided into 3 groups of 50 patients each with assistance from computer generated random number table. Group P received palonosetron 075mg, Group L received Lignocaine 30 mg and Group S received Normal saline as pretreatment. The degree of withdrawal of limb was graded on four-point scale. Haemodynamic changes namely HR and MAP following administration of study drugs and complications following administration of the study drugs like urticaria, wheal and rash were also monitored. Results: Overall incidence of rocuronium induced withdrawal movements was significantly more in-group S (84%) than other study groups (p Conclusion: Study demonstrated that palonosetron pretreatment and venous occlusion has reduced rocuronium induced withdrawal movements more effectively than lignocaine. Keywords: Palanosetron, Rocuronium, Withdrawal movements, Lignocaine.

Context: Trauma-induced coagulopathy (TIC) is life-threatening in head injury patients, and there is a lack of Indian data on its incidence and outcome. Aims: In this study, incidence and outcome related to coagulopathy were assessed in patients with moderate-to-severe isolated traumatic brain injury (iTBI). Settings and Design: A prospective observational study carried out in patients admitted within 24 h of injury. Materials and Methods: One hundred patients with moderate-to-severe iTBI were included. Samples for coagulation tests (prothrombin time [PT], PT index [PTI], international normalization ratio [INR], activated partial thromboplastin time, and platelet count) were collected at 5 points of time for 72 h. TIC was diagnosed if any three readings were abnormal during this period. Patients were also followed up posthospital discharge using the Glasgow Outcome Score (GOS) at 1 and 3 months. Statistical Analysis: Data were analyzed using SPSS ver. 21. Logistic regression analysis was employed to determine individual coagulation test as best predictors for mortality. P < 0.05 was considered statistically significant. Results: The incidence of TIC was found to be 62%; it was 63.75% in severe head injury and 55% in moderate head injury patients. Deranged INR at the time of hospital admission (odds ratio [OR] 4.38) and PTI at 24 h (OR 3.913) are highly predictive of mortality. There was no significant difference in GOS score at 1 and 3 months. Conclusions: The incidence of TIC in our study was 62% among iTBI patients. It contributes to increased mortality at 1 and 3 months. However, the neurological outcome was not different in between the groups.

Background and objectives Recent randomized controlled trials (RCTs) have indicated potential therapeutic benefits with high-dose dexamethasone (HDD) or tocilizumab (TCZ) plus standard care in moderate to severe coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome (ARDS). No study has compared these two against each other. We aimed to compare the efficacy and safety of HDD against TCZ in moderate to severe COVID-ARDS. Methods Patients admitted with moderate to severe COVID-19 ARDS with clinical worsening within 48 hours of standard care were randomly assigned to receive either HDD or TCZ plus standard care. The primary outcome was ventilator-free days (VFDs) at 28 days. The main secondary outcomes were 28-day all-cause mortality and the incidence of adverse events. Our initial plan was to perform an interim analysis of the first 42 patients. Results VFDs were significantly lower in the HDD arm (median difference: 28 days; 95% confidence interval (CI): 19.35-36.65; Cohen’s d = 1.14;p < 0.001). We stopped the trial at the first interim analysis due to high 28-day mortality in the HDD arm (relative risk (RR) of death: 6.5; p = 0.007; NNT (harm) = 1.91). The incidence of secondary infections was also significantly high in the HDD arm (RR: 5.5; p = 0.015; NNT (harm) = 2.33). Conclusions In our study population, HDD was associated with a very high rate of mortality and adverse events. We would not recommend HDD to mitigate the cytokine storm in moderate to severe COVID-19 ARDS. TCZ appears to be a much better and safer alternative.

Background Survivors of COVID-19 pneumonia may have residual lung injury and poor physical and mental health even after discharge. We hypothesized that COVID-19 severe acute respiratory distress syndrome (ARDS) patients needing mechanical ventilation may be at a greater risk of deterioration in pulmonary function, mental health, and quality of life (QOL). This study analyses the differences in pulmonary function, mental health, and QOL after recovery, in patients having received non-invasive oxygen therapy versus invasive mechanical ventilation during ICU stay. Methods Patients aged >18 years, who had completed 3 months post ICU discharge, with moderate to severe COVID-19 ARDS, were consecutively enrolled from May 1 to July 31, 2021. Patients were allocated into Group A - having required high flow nasal cannula (HFNC)/non-invasive ventilation (NIV) and Group B - having received invasive mechanical ventilation. Pulmonary function tests, 6-minute walk test (6-MWT), and health-related quality of life were compared. Results Of the 145 eligible patients, 31 were lost to follow-up and 21 died. Seventy-four patients were allocated into Groups A (57 patients) and B (17 patients). In Group A, abnormal forced expiratory volume in first second (FEV1), forced vital capacity (FVC), forced expiratory flow in mid-half of FVC (FEF25-75), and peak expiratory flow rate (PEFR) values were obtained in 27 (47.37%), 43 (75.44%), 11 (19.3%), and 25 (43.86%) patients, and in Group B, in 13 (76.47%), 17 (100%), 1 (5.88%), and 8 (47%) patients, respectively. No patient had abnormal FEV1/FVC. All Group B patients had a restrictive pattern in spirometry as compared to 77% in Group A. Group B had a lower arterial partial pressure of oxygen (PaO2) (p=0.0019), % predicted FVC (p

Traditionally, fluid administration during kidney transplant surgery is guided by central venous pressure (CVP) despite its limited reliability as a parameter for assessing intravascular fluid volume, particularly in patients with cardiovascular diseases. The recommended goals at graft reperfusion are a mean arterial pressure of 90 mm Hg and a CVP of 12-14 mm Hg. This approach may increase the risk of significant adverse effects due to volume overload. Perioperative fluid therapy guided by dynamic indices of fluid responsiveness has been shown to optimize intravascular volume and prevent complications associated with overzealous administration of fluids in major abdominal surgeries. We hypothesized that pulse pressure variation (PPV)-guided fluid administration would result in better optimization of intravascular fluid volume compared with a CVP-guided strategy during kidney transplant surgery.In this single-centre randomized double blinded trial, 77 end-stage renal disease patients, who underwent kidney transplant surgery under general anesthesia with epidural analgesia, were randomized to receive either CVP-guided (n = 35) or PPV-guided (n = 35) fluid therapy using predefined hemodynamic endpoints. The primary outcome was the total volume of intraoperative fluids administered. Secondary outcomes were intraoperative hemodynamic changes, serum lactate levels, serum creatinine, need for dialysis within the first week, creatinine elimination ratio, and incidence of immediate and delayed graft dysfunction.Results were analyzed for 70 patients. Eighty percent of the patients underwent living-related donor allograft kidney transplant. Operative variables related to donor characteristics, duration of surgery, graft cold ischemia time, and blood loss were comparable in both groups. The mean (standard deviation) volume of intravenous fluids administered intraoperatively was 1,346 (337) mL in the PPV-guided group vs 1,901 (379) mL in the CVP-guided group (difference in means, 556 mL; 95% confidence interval, 385 to 727; P = 0.001). There were no significant differences in secondary outcomes between the two groups.Pulse pressure variation -guided fluid administration significantly decreased the total volume of crystalloids compared with CVP-guided fluid therapy during the intraoperative period in patients who underwent kidney transplant surgery. Nevertheless, our study was underpowered to detect differences in secondary outcomes.www.ctri.nic.in (CTRI/2018/01/011638); registered 31 January 2018.RéSUMé: CONTEXTE: Traditionnellement, l’administration liquidienne pendant une chirurgie de transplantation rénale est guidée par la pression veineuse centrale (PVC) et ce, malgré sa fiabilité limitée en tant que paramètre d’évaluation du volume liquidien intravasculaire, en particulier chez les patients atteints de maladies cardiovasculaires. Les objectifs recommandés lors de la reperfusion du greffon sont une tension artérielle moyenne de 90 mmHg et une PVC de 12–14 mmHg. Cette approche pourrait augmenter le risque d’effets indésirables importants dus à une surcharge volémique. Il a été démontré que la thérapie liquidienne périopératoire guidée par des indices dynamiques de réponse au remplissage optimisait le volume intravasculaire et prévenait les complications associées à l’administration liquidienne exagérée lors de chirurgie abdominale majeure. Nous avons émis l’hypothèse qu’une administration liquidienne guidée par la variation de pression différentielle (VPD et delta PP) entraînerait une meilleure optimisation du volume liquidien intravasculaire par rapport à une stratégie guidée par la PVC pendant une chirurgie de transplantation rénale. MéTHODE: Dans cette étude randomisée monocentrique à double insu, 77 patients atteints d’insuffisance rénale terminale, qui ont bénéficié d’une greffe rénale sous anesthésie générale avec analgésie péridurale, ont été randomisés à recevoir une administration liquidienne guidée soit par la PVC (n = 35) ou par la VPD (n = 35) en utilisant des critères hémodynamiques prédéfinis. Le critère d’évaluation principal était le volume total de liquides peropératoires administrés. Les critères secondaires comprenaient les variations hémodynamiques peropératoires, les taux sériques de lactate, la créatininémie, le besoin de dialyse au cours de la première semaine, le taux d’élimination de la créatinine et l’incidence de dysfonctionnement immédiat et retardé du greffon. RéSULTATS: Les résultats ont été analysés pour 70 patients. Quatre-vingts pour cent des patients ont subi une allogreffe de rein provenant d’un donneur vivant apparenté. Les variables opératoires liées aux caractéristiques du donneur, la durée de la chirurgie, le temps d’ischémie froide du greffon et les pertes sanguines étaient comparables dans les deux groupes. Le volume moyen (écart type) de liquides intraveineux administrés en peropératoire était de 1346 (337) mL dans le groupe guidé par VPD vs 1901 (379) mL dans le groupe guidé par PVC (différence de moyennes, 556 mL; intervalle de confiance à 95 %, 385 à 727; P = 0,001). Aucune différence intergroupe significative n’a été observée dans les critères d’évaluation secondaires. CONCLUSION: L’administration liquidienne guidée par la variation de pression différentielle a significativement diminué le volume total de cristalloïdes par rapport à la thérapie liquidienne guidée par la PVC pendant la période peropératoire chez les patients ayant bénéficié d’une greffe de rein. Néanmoins, notre étude ne disposait pas de la puissance suffisante pour détecter les différences dans les critères d’évaluation secondaires. ENREGISTREMENT DE L’éTUDE: www.ctri.nic.in (CTRI/2018/01/011638); enregistré le 31 janvier 2018.

Background & Aims: A procoagulant state with pulmonary micro-thrombosis has been described in COVID-19, which contributes to pathophysiology of respiratory failure along with diffuse alveolar damage. Cytokine storm and systemic inflammation in COVID-19 generates endogenous heparinoids from the endothelium which leads to secondary organ failures. We prospectively studied the dynamic association of the coagulation abnormalities with respiratory failure and mortality in patients with COVID-19. Methods: We did a prospective observational study in adults aged between 18-80 years with COVID 19 pneumonia requiring intensive care (ICU) admissions in a tertiary care hospital in North India. All patients received standard medical therapy based on best available evidence. Patients were categorized based on the oxygen support therapy into low flow, high flow and invasive ventilation groups. In patients considered to be at risk of thromboembolic or bleeding phenomena, paired coagulation tests were performed at days 1 and 3 with, Sonoclot ® (glass beaded and heparinase-treated). All patients were consecutively followed for inflammatory markers, ventilator requirements and survival. Activated clotting time (ACT) 75 units were used as the cut-off for hypercoagulable state. The heparin like effect (HLE) was considered by a correction of ≥ 40 s in hACT (heparinized treated ACT). The trial is registered with ClinicalTrials.gov (NCT04668404). Results: A total of 2324 patients with COVID-19 were screened from August 2020 to November 2020. Two hundred and fifteen patients requiring ICU admission were assessed and 74 patients with a median age of 54(42-67) years were enrolled. A procoagulant profile was seen in 45.5%, 32.4% and 20.7% in low-flow, high-flow, and invasive ventilation. Paired Sonoclot ® assays in 33 patients demonstrated HLE in 17 (51.5%) and 20 (62.5%) at days 1 and 3 respectively. In multivariate analysis, the presence of HLE (HR 1.02; CI 1.08-1.6; p 131 s, clot rate 96.7 mg/l at admission predicted mortality. Conclusions: HLE contributes to hypocoagulable effect, need for invasive ventilation and mortality in patients with COVID-19. Trial Registration: The trial is registered with ClinicalTrials.gov (NCT04668404). Funding Statement: None Declaration of Interests: None Ethics Approval Statement: Ethical clearance was obtained from the Institutional Review Board (PGI/IEC/2020/000997 dated 24 August 2020)

We would like to add to the study, Understanding the physiological effects of wearing enhanced personal protective equipment while providing patient care by Bulson and Shawl from the November/December 2019 issue of Journal of Emergency Management.

COVID-19 pandemic is an emerging, rapidly evolving public health emergency where a nation's health-care system can face a marked surge in demand for intensive care unit (ICU) beds and organ support. In regions with insufficient medical resources, it may further aggravate the existing shortage, limiting an ICU's ability to provide the normal standard of care. It can present ethically or legally demanding questions about how to prioritize the allocation of life-saving medical resources. In developing countries like India, still many hospitals are challenged by competing priorities and remain underprepared. In the wake of COVID-19 pandemic, to guide the intensive care disaster planners in regions with low resources and to ensure ICU readiness, this review shares our experience and strategies for preparing ICU with existing and alternative resources, focusing on space, equipment, and health-care workers' safety and training.

Trans-nasal endoscopic surgery (TNES) is a helpful diagnostic and therapeutic modality in otorhinolaryngology surgeries and requires controlled hypotension for better visualization of the surgical field. Recent literature shows evidence of intravenous Lignocaine infusion to produce the controlled hypotension. The study aims to assess and compare the effects of Lignocaine (LIG) and Dexmedetomidine (DEX) infusion with respect to surgical field quality. 101 Consenting adult patients undergoing elective TNES were double-blinded, randomly allocated in one of the two groups and received either DEX infusion of 0.5ug/kg/hr (n = 51) or LIG infusion of 1.5 mg/kg/h (n = 50) after a loading dose. Surgical field score (SVF) as the primary outcome and secondary outcomes such as variations in hemodynamic parameters, the requirement for rescue agents and total blood loss were recorded. Both the groups were comparable with respect to patient demographics, total duration of anesthesia and surgery. SVF scores were significantly better in the LIG group during the first 105 min of the surgery (p

Introduction and Aims: Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. Materials and Methods: This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. Results: We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS

Rectal foreign bodies are not uncommon and often pose a serious challenge to surgeons. In majority, the objects are inserted by self in children, psychiatric patients and for sexual gratification in adults. Various rectal foreign bodies have been reported. Deodorant aerosol spray can in the rectum has not been reported previously. Danger of aerosol dispenser can is the risk of fire and explosion. Especially during any surgical procedures to remove the foreign body using cautery or any energy devices. We report of a rare foreign body of deodorant aerosol spray can in the rectum in a young male patient, which was removed under general anaesthesia.

Background: Nitrous oxide has been used during surgical anesthesia for many years. However, information about occupational exposure and related risks due to N2O exposure to the health care personnel in India are still poorly understood. Here, we measured the residual N2O levels during the working time of operation theatre room air in our tertiary care hospital. Material and Methods: The air samples were collected from different anesthesia exposure zones on different days for quantitative analysis of available N2O in the room air in respective areas. Nitrous oxide concentrations in the ambient air were also measured to compare outdoor and indoor levels. Observations and Results: Nitrous oxide mixing ratios were found to be 65.61 ± 0.05 ppm, 281.63 ± 0.43 ppm, and 165.42 ± 0.42 ppm in elective surgical theatres of the hospital on three different days whereas in emergency operation theatres of the same hospital levels of N2O were 166.75 ± 0.07 ppm, 510.19 ± 0.30 ppm and 2443.92 ± 0.64 ppm during same period. In elective pediatric surgical theatres levels of N2O were found to be 1132.55 ± 0.70 ppm and 362.21 ± 0.13 ppm on two days of reading respectively. Outdoor levels of N2O in contrast found 0.32 ± 0.01 ppm and was lower by a factor of 1000. Conclusion: We observed the very high ambient concentration of N2O in the surgical theatre's environment (up to 2443 ppm) and recovery areas (up to 50 ppm). It was 5 to 50 times higher ambient concentration of N2O than REL in OT area and 200-7000 times higher ambient concentration of N2O than outdoor ambient air in all surgical theaters other than CTVS OTs.

Unfractionated heparin is a widely used drug to prevent deep vein thrombosis and pulmonary emboli in patients at risk. With the advent of newer anticoagulants having lesser side effects, its use has diminished but not out of service. Here, we report a case of deep venous thrombosis, in a patient on prophylactic dose of heparin, which was later found to be a manifestation of heparin-induced thrombocytopenia (HIT). Thrombosis in the presence of heparin prophylaxis should be considered as HIT rather than a failure of anticoagulation.

We would like to share a novel modification of the existing stethoscope that is widely used and is an indispensable part of patient care. In the era of the ongoing pandemic, the existing stethoscope has a lot of limitations to its use, and we would like to further contribute to the same by elaborating on the limitations and offering a novel solution to the same in a resource-limited setting. First, it is practically impossible to use to the conventional stethoscope in a …

Background The most frequent complication of nasotracheal intubation (NTI) is epistaxis. Epinephrine nasal gauze packing has been used conventionally as a pre-treatment for reducing epistaxis, but it carries a disadvantage of pain and anxiety in patients. However, xylometazoline drops are easier to administer and more convenient for patients. We aimed at comparing the effectiveness of xylometazoline drops and epinephrine merocele packing in reducing bleeding and postoperative complications in our population. Methods Our study enrolled 120 patients in a double-blind randomized controlled trial. We randomly allocated ASA1 or 2 adult patients into 2 groups: Group X and Group E. Group X received 0.1% xylometazoline nasal drops, and epinephrine (1:10,000) merocele nasal packing was used in Group E. The primary outcome was the incidence of bleeding during NTI; the severity of bleeding, navigability, bleeding during extubation, and postoperative complications were secondary outcomes. We used IBM SPSS and Minitab software for statistical analysis, and P < 0.05 was considered statistically significant. Results We analyzed the data of 110 patients: 55 in Group X and 55 in Group E. The two groups did not have different bleeding incidence (56.4% vs 60.0%; P = 0.70); however, the incidence of severe bleeding was less with xylometazoline than with epinephrine (3.63% vs 14.54%; P < 0.05). We also observed less bleeding during extubation (38.2% vs 68.5%; P < 0.05) with xylometazoline. Other secondary outcomes were akin to both groups. Conclusion The incidence of severe and post-extubation bleeding was significantly less with xylometazoline. Hence, it may be an effective alternative for reducing the incidence and severity of epistaxis during NTI.

Cerebral venous thrombosis is a rare cerebrovascular disease and causes 0.5% of all strokes. Headache is one of the usual symptoms along with nausea, vomiting and seizures which are lesser common. Focal neurological deficits may also occur. Both genetic and acquired conditions may predispose to cerebral venous thrombosis. Management of a caesarean section in this situation poses significant anaesthetic challenges in view of anticoagulation, haemodynamic stability, and neurological outcomes. We present a case of a 30 year old lady who was primigravida associated with cerebral venous thrombosis posted for caesarean section.

Context: Although international guidelines have been developed for emergency tracheal intubation (ETI), there is little evidence of their applicability in developing countries. Aims: The aim of this study was done to evaluate the different methods of ETI that are practiced among anesthetist and anesthesia trainees in India outside operating room (OR)/intensive care unit (ICU) settings. Settings and Design: This was prospective observational audit did among anesthesia personals managing ETI outside OR and ICU. Materials and Methods: The study was conducted through an online survey using electronic media. Certified anesthetists and anesthesia trainees were sent a questionnaire where they were asked to complete and submit it online. Results: Out of 145 respondents, 52% were certified anesthetists. Availability of equipment, technical staff, and visual monitors was a big constraint. About 28% of the participants do not examine the airway before ETI, 61% of participants invariably do not perform rapid sequence induction and intubation, and 89% of the participants have only the bougie at their disposal with the availability of videolaryngoscope (10%) and Fibreoptic bronchoscopy (FOB) (6%) being scarce. About 12% of the respondents use capnography for ETI confirmation. Only 48% of the participants accompany the patient during shifting. Conclusions: Our survey has reported wide disparity during ETI with poor compliance to the international guidelines.