Search

Background and Aims: Maternal hypotension is a common concern during cesarean sections (CS) with spinal anesthesia and can have adverse consequences for both the mother and fetus. This study aimed to investigate the prophylactic effectiveness of intermittent boluses of phenylephrine and norepinephrine in preventing maternal bradycardia during maintenance of systolic blood pressure (SBP) within 90–100% of baseline. Material and Methods: Two hundred American Society of Anesthesiologists physical status -II parturients scheduled for CS with subarachnoid block (SAB) were randomly assigned to Group A (phenylephrine, 50 µg) or Group B (norepinephrine, 4 µg). The primary goal was to assess the incidence of maternal bradycardia (≤50 bpm) whilst SBP maintenance at 90-100% of baseline. The secondary objectives encompassed total boluses administered, episodes of hypertension (≥120% of baseline), Intraoperative nausea and vomiting (IONV), and neonatal APGAR scores. The time from intrathecal injection to fetal delivery (induction–delivery interval) was also evaluated. Results: Both norepinephrine and phenylephrine groups effectively prevented spinal-induced hypotension, with similar outcomes However, Group A (phenylephrine) experienced a significantly higher incidence of bradycardia (18%) compared to Group B (norepinephrine) with only 5% (P=0.016). Episodes of hypertension, IONV, and neonatal APGAR scores were comparable between the two groups. Conclusion: Intermittent boluses of norepinephrine and phenylephrine demonstrated equivalent efficacy in preventing spinal-induced hypotension during CS. However, norepinephrine exhibited an advantage over phenylephrine by significantly reducing the incidence of bradycardia. These findings support the consideration of norepinephrine as an effective alternative vasopressor for maintaining maternal hemodynamics during CS under SAB.

The subspecialty of obstetric anaesthesiology is different from other subspecialties in anaesthesiology in that, at any point of time, two lives are at stake, making drug errors particularly critical. This narrative review explores the incidence, contributing factors, and preventive strategies for medication errors in Obstetric Anaesthesia. Key contributors of medication errors include distractions, fatigue, look-alike/sound-alike drugs, lack of standardized protocols, poor communication strategies, inadequate training and education. Effective strategies for reducing errors include double-check procedures, bar-coded medication administration systems, implementing “Tall Man lettering for look-alike/sound-alike drugs, structured communication tools, continuous education and training. The review also introduces the mnemonic "SAFE-LABEL CHECK" to encapsulate best practices for minimizing drug errors. Future directions suggest integrating advanced technologies and fostering a multidisciplinary approach to enhance patient safety in obstetric anaesthesia.

Abstract Background Cancer remains an escalating and challenging public health issue. The management, especially palliative care (PC), is disintegrated and out of reach of in need patients. The overall aim of the project is to develop a feasible and scalable Comprehensive Coordinated Community based PC model for Cancer Patients (C3PaC); congruent with socio-cultural, context and unmet needs in north India. Methods A mixed method approach will be used for three-phased pre- and post-intervention study in one of the districts of North India, having a high incidence of cancer. During phase I, validated tools will be used for quantitative assessment of palliative needs among cancer patients and their caregivers. Barriers and challenges for provision of palliative care will be explored using in-depth interviews and focus group discussions among participants and health care workers. The findings of phase I along with inputs from national experts and literature review will provide inputs for the development of the C3PAC model in phase II. During phase III C3PAC model will be deployed over a period of 12 months and its impact assessed. Categorical and continuous variables will be depicted as frequency (percentages) and mean ± SD/median (IQR) respectively. Chi-square test/Fischer test, independent samples Student t-tests and Mann–Whitney U tests will be used for categorical, normally and non-normally distributed continuous variables, respectively. Qualitative data will be analyzed using thematic analysis using Atlas.ti 8 software. Discussion The proposed model is designed to address the unmet palliative care needs, to empower community-based healthcare providers in comprehensive home-based PC and to improve the quality of life of cancer patients and caregivers. This model will provide pragmatic scalable solutions in comparable health systems particularly in low- and lower-middle Income countries. Trial registration The study has been registered with the Clinical Trial Registry-India (CTRI/2023/04/051357).

Background: Right ventricular (RV) dysfunction is an important predictor of both immediate and long-term outcomes in valve surgeries. Levosimendan has proven beneficial in improving RV function. Aims: The objective was to study the effect of the addition of levosimendan to the conventional treatment on RV function in patients with RV dysfunction undergoing mitral valve (MV) surgeries. Setting and Design: Prospective randomized double-blinded controlled study at a tertiary care institution. Materials and Methods: Sixty adult patients aged 15–65 years, with preoperative transthoracic echocardiography (TTE) findings of RV dysfunction posted for elective MV surgery, were randomized into levosimendan (L) group and placebo (P) group. Patients in the L group were administered levosimendan at a rate of 0.1 mcg/kg/min after induction for 24 hrs, whereas patients in the P group were given multivitamin infusion at the same rate. Both the groups received standard inotropic therapy. The hemodynamic and echocardiographic parameters of RV function (RV size, Inferior vena cava (IVC) diameter, RV fractional area change (RVFAC) Tricuspid annular plane systolic excursion (TAPSE), and Systolic Pulmonary Artery Pressure (SPAP) were compared between the groups at 6 hrs, 24 hrs, and 7th day postoperatively. Results: All hemodynamic and echocardiographic parameters of RV function like RV size, IVC diameter, RVFAC, TAPSE, and SPAP improved from baseline to 24 hrs in both groups. Levosimendan caused a significant improvement in RV function compared to the P group at 24 hrs and 7th day postoperatively. Conclusions: The present study concludes that levosimendan is a promising option in patients with RV dysfunction undergoing MV surgeries.

Background: Ilioinguinal and iliohypogastric (IIIH) nerve block for postoperative analgesia after lower-segment cesarean section (LSCS) is stated to have a short duration of action, and prolongation of its effect with adjuvants remains unexplored. We aimed to assess the efficacy of dexamethasone and fentanyl as adjuvants to ropivacaine in ultrasound-guided bilateral IIIH block. Methods: After approval from the Institutional Ethics Committee and informed consent, this prospective randomized double-blind study enrolled 40 American Society of Anesthesiologists II parturients, divided into two groups. Group I (n = 20) received IIIH block with 3 mg/kg of 0.75% ropivacaine and dexamethasone 8 mg whereas Group II (n = 20) received 3 mg/kg of 0.75% ropivacaine and fentanyl 50 μg. The primary outcome studied was the duration of analgesia (as defined by the requirement of first rescue analgesia). The secondary outcomes included total rescue analgesic consumption and the median number of times rescue analgesic requirement in 24 h postoperatively. Student's t-test and Mann–Whitney U-test were applied to compare the analgesic parameters among the groups. Results: Both the groups were comparable for the duration of analgesia (8.15 ± 0.95 vs. 7.55 ± 1.51 h, P = 0.142), the median number of times rescue analgesics required in 24 h (2.5 [2–3] in Group I vs. 3 [2–3] in Group II, P = 0.590), and total tramadol required in 24 h (125 ± 25.6 vs. 130 ± 25.1 mg, P = 0.540). Conclusion: Both dexamethasone and fentanyl as an adjuvant to ropivacaine for IIIH block were found to have a comparable duration of analgesia following LSCS.

Airway and spine involvement in ankylosing spondylitis (AS) impose unique anesthetic challenges. Ankylosis and intervertebral space obliteration in AS make neuraxial anesthesia technically challenging and sometimes impossible. The anatomical variations of impalpable sacral cornu and complete or partially closed sacral hiatus in adults coupled with positioning difficulties, epidural space narrowing as well as an increased predilection for intraosseous or intravascular injection, and cauda equina syndrome complicate caudal anesthesia in AS. Combined ultrasound and fluoroscopic (ultrafluoro) guidance during caudal anesthesia improves accessibility and identifies and avoids any aberrant nonepidural injection. By providing a fluoroanatomical endpoint, i.e., local anesthetic (LA) contrast washout covering the concordant dermatomes, it reduces the amount of LA required and pressure build-up in already compromised epidural space. Ultrafluoro guidance improves accessibility, identifies, and avoids any nonepidural injection, and reduces the amount of LA required during caudal anesthesia in AS.

Background: Ventilator-associated pneumonia (VAP) is a serious nosocomial infection that threatens pediatric patients who have undergone cardiac surgery. The aim of this study is to analyze the bacteriological profile and antibiotic resistance pattern of the organisms grown from pediatric patients diagnosed as VAP after cardiac surgery and also to study the bacteriological and clinical outcomes of the patients. Patients and Methods: This prospective observational study was conducted in a tertiary care teaching institution in children aged younger than 14 years who had undergone cardiac surgery and were diagnosed to have VAP and on mechanical ventilation (MV). The clinical and the bacteriological profile of patients with VAP, the systemic antibiotics used, the resistance pattern to the antibiotics, and, finally, the bacteriological and clinical outcomes were analyzed. Results: Among the 98 patients with VAP, 55% were early onset (4 days of MV) VAP. Among the most common pathogens causing VAP, Klebsiella and Escherichia coli contributed to 18% each of the total VAP. Twenty percent of VAP were polymicrobial in origin. About 63% of organisms were resistant to Augmentin, and 11% of the organisms were multidrug resistant (MDR). Conclusion: This study not only showed the pattern of early and late onset VAP but also revealed the bacteriological profile and the resistance pattern of the local microbial flora causing VAP, guiding us in a more efficient management of VAP in children.

Background: Ventilator-associated pneumonia (VAP) with multidrug-resistant (MDR) gram negative organisms is a common problem in intensive care unit (ICU). Aerosolized antibiotics enhance the efficacy of systemic antibiotics when added as adjuvants. Aim: The primary objective of the study was to compare the clinical and bacteriological outcome of patients with VAP who were administered intravenous (IV) antibiotics alone with those patients who were treated with adjunctive nebulized colistin (NC) along with IV antibiotics. The secondary objective was to study the occurrence of any adverse events during colistin nebulization. Settings and Design: The study was a prospective, randomized, double-blinded controlled study conducted at a tertiary-care teaching institution. Materials and Methods: Ninety-eight children from surgical ICU aged less than 12 years who were diagnosed with VAP due to gram negative bacteria following cardiac surgery were chosen and divided randomly into two groups. The experimental group (NC group) was treated with systemic antibiotics along with NC, whereas the control group (NS group) was administered systemic antibiotics with nebulized normal saline (NS). Clinical and bacteriological outcomes were noted. Statistical analysis was done using SPSS Version 20.0 software. The patient characteristics were compared using independent Student's t test and Chi-square test. Results: There was a statistically significant reduction in the duration of mechanical ventilation, postoperative ICU and hospital stay (P < 0.05) in the NC group compared with the NS group. Conclusion: Aerosolized colistin may be considered as an adjunct to systemic IV antibiotics in pediatric patients with VAP due to gram negative bacteria susceptible to colistin.

Aims and Objectives: The objective of the study was to determine the preconditioning myocardial protective effects of intralipid (IL) in off-pump coronary artery bypass (OPCAB) surgery by measuring highly sensitive troponin T (hsTnT) and cardiac-specific creatine kinase (CK-MB) as markers of myocardial injury. Materials and Methods: Thirty patients, scheduled to undergo elective OPCAB surgery, were randomly assigned to the IL group (n = 15) or control (C) group (n = 15); the IL group received an infusion of 20% IL 2 ml/kg, 30 min prior to revascularization and the control group received an equivalent volume of normal saline. Serum levels of hsTnT and CK-MB were measured before surgery and at 6 h, 24 h, 48 h, and 72 h postoperatively. Also, intraoperative hemodynamic parameters, inotrope use, ventilatory hours, ICU stay, postoperative left ventricular ejection fraction, postoperative lipid profile, renal and hepatic function tests were measured. Results: The hsTnT values at the 24 h, 48 h, and 72 h in IL group were significantly lower as compared with the control group. The decline in plasma levels of CK-MB mirrored the hsTnT levels post revascularization at 24 h and 48 h in the IL group compared with the control group; however, at 72 h, level was comparable in both the groups. None of the treated patients had abnormal lipid metabolism, deranged renal, and hepatic function. Conclusion: The study revealed Intralipid as a safe pharmacological preconditioning agent for OPCAB surgeries which can reduce the postischemic myocardial injury indicated by the reduction in postischemic cardiac enzymes hsTnT and CK-MB.

Aneurysmal subarachnoid hemorrhage (aSAH) necessitates prompt neurosurgical intervention. However, patients with associated dilated cardiomyopathy (DCM) face higher cardiovascular instability due to sympathetic surge, stunned myocardium, and tendency to arrhythmias secondary to aSAH. We report a case of DCM and ischemic cardiac disease with a 30% ejection fraction, who presented to us with a severe headache associated with vomiting. Noncontrast computed tomography revealed hematoma in the right fronto-temporoparietal and blood in all the ventricles. Cerebral angiography showed a saccular aneurysm at the right middle cerebral artery bifurcation, thus requiring cerebral aneurysm clipping surgery. Anesthetic agents for induction and maintenance were selected and titrated to minimize cardiac depression and also avoiding systemic hypotension. A bilateral scalp block was administered to blunt sympathetic response to scalp pin application and scalp incision. Hemodynamic monitoring was done perioperatively using pulse index continuous cardiac output monitoring. The patient made an uneventful recovery from the surgery. This case highlights the importance of preoperative planning, accurate interpretation of hemodynamic measurements, and appropriate therapeutic responses to optimize outcomes in cerebral aneurysm surgery associated with DCM.

This article discusses a case study involving the use of a bronchial blocker during thoracic surgery. The EZ bronchial blocker, a Y-shaped device, is commonly used for one-lung ventilation. However, in this particular case, the diaphragm of the cap mounted on the blocker was missing, leading to difficulty in ventilation. The issue was resolved by replacing the diaphragm and reinserting the bronchial blocker. The article emphasizes the importance of being familiar with different types of bronchial blockers and performing thorough checks before use. [Extracted from the article]