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Artificial intelligence is an ever-growing modality revolutionizing the field of medical science. It utilizes various computational models and algorithms and helps out in different sectors of healthcare. Here, in this scoping review, we are trying to evaluate the use of Artificial intelligence (AI) in the field of pediatric anesthesia, specifically in the more challenging domain, the pediatric airway. Different components within the domain of AI include machine learning, neural networks, deep learning, robotics, and computer vision. Electronic databases like Google Scholar, Cochrane databases, and Pubmed were searched. Different studies had heterogeneity of age groups, so all studies with children under 18 years of age were included and assessed. The use of AI was reviewed in the preoperative, intraoperative, and postoperative domains of pediatric anesthesia. The applicability of AI needs to be supplemented by clinical judgment for the final anticipation in various fields of medicine.

Background: In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). Methods: After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. Results: From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. Conclusion: Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

The physiological transformations accompanying pregnancy, compounded by the implications of obesity, pose intricate challenges for anaesthesiologists attending to obese parturients. Obesity makes it harder to successfully provide epidural analgesia to a parturient. This narrative review explains the most recent data on the safety and complications of providing labour epidural analgesia in obese expectant mothers. We have emphasised the evidence-based approaches that are the most effective for obese pregnant mothers receiving labour epidural analgesia.

This case report presents a rare case of a mechanical ventilation leak that was initially missed by clinicians in a patient with a myxoedema coma. Despite all efforts to investigate the causes of the leak, including a bedside lung ultrasound and chest radiograph, the leak persisted. It was eventually discovered that the rhythmic inflation and deflation of the polythene covering the closed suction system was causing the leak. The closed suction system was replaced with a new one, and the tidal volume was restored, resulting in the resolution of the leak alarm. The volume leak alarm and low volume alarm are important indicators of potential problems during mechanical ventilation, and close suction system malfunction is a potential cause of volume leak that should be considered in mechanically ventilated patients. Regular monitoring and appropriate management of these alarms and potential causes can help prevent complications and optimize patient care.

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Background: Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. Methods: One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. Results: Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p = 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p = 0.615). Conclusions: Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Abstract Background The aim of this study is to understand the attitude and knowledge of medical undergraduates and interns for basic life support (BLS) measures. We also correlated the need for frequent orientation courses beginning at an earlier stage of the medical curriculum. This cross-sectional study was done based on the questionnaire relating to attitude and knowledge for BLS. The participants were 7th and 9th-semester medical undergraduates and the interns of a tertiary care center. Results A total of 213 participants completed the questionnaire. The majority of them were interns (40.37%). Maximum (94.1%) of the participants opined that the entire medical and nursing fraternity should be exposed to simulation-based training on BLS. Most (80.3%) of them were aware of recent American Heart Association guidelines 2020, and 96.7% knew the correct meaning of cardiopulmonary resuscitation, but they did not know the subsequent steps in BLS according to the guidelines. Conclusions We conclude that awareness of BLS lacked in students of medical school despite regular orientation programs. We recommend the need for frequent orientation courses for BLS and initiate them at the elementary level of education.

Pheochromocytoma in children is an exceptionally uncommon cause of hypertension in this age group. These tumors pose a significant threat of adverse cardiovascular events during the perioperative phase. In this article, we describe three cases of pediatric pheochromocytoma to shed light on the difficulties associated with administering anesthesia to patients with this condition. The foundations for successful perioperative outcomes include preoperative blood pressure control, extensive intraoperative hemodynamic evaluation, and appropriate coordination with surgeons.

Summary: Background: Carbapenem-resistant Enterobacterales (CRE) are a global health problem with a growing prevalence. India has a high prevalence of CRE. CRE infections are difficult to treat, and are associated with significant morbidity and mortality. Colonisation is generally a prerequisite for infection and the prevention of CRE colonisation is key to the prevention of CRE infection. Objectives: To determine the prevalence of CRE colonisation and subsequent infections in an adult intensive care unit (ICU) in India. Methods: We conducted a prospective observational study in which perirectal swabs were obtained along with relevant clinical details of consenting adult patients upon ICU admission between January 2019 and August 2020. Rectal screening was performed using MacConkey agar plates with ertapenem disks and further identification was performed using conventional microbiological techniques. Ertapenem minimum inhibitory concentration (MIC) was determined using an epsillometer (E) test. The modified carbapenem inactivation (mCIM) test and EDTA carbapenem inactivation test (eCIM) were performed to confirm carbapenem resistance using the Clinical Laboratory Standards Institute (CLSI) 2020 guidelines. Results: 192 ICU patients were screened for CRE. 37 patients were found to be colonised with CRE. Klebsiella pneumoniae (N=25; 67.6%) was the most frequent CRE isolate, followed by Escherichia coli (N=11; 29.7%) and one Enterobacter species (N=1; 2.7%). 89.2% (33/37) patients developed CRE infection. Pneumonia was the most common CRE infection identified in 12/33 (36.4%) patients.during the hospital stay. The median duration of hospital stay was longer (17 days) for CRE colonised compared to CRE non-colonised patients (9 days) (P

The current opioid epidemic has had a massive impact on the critical care sector. This is due to an increase in the number of acute opioid overdose-related admissions and the number of opioid-dependent and opioid-tolerant patients admitted to intensive care units (ICUs). This review discusses the challenges that intensive care physicians face when caring for patients suffering from opioid-related disorders and analyses existing solutions. Preference for non-opioid analgesics, treatment of acute pain in the ICUs to avoid chronic pain syndrome, and education of patients and caregivers are critical to preventing this pandemic.

Mucormycosis has become an ever-growing threat to human health, particularly after the COVID-19 pandemic. As the number of cases of mucormycosis increased, it put a burden on anesthesiologists. Here we describe the etiopathogenesis, clinical presentation, and anesthesia management of patients suffering from mucormycosis.

Tracheostomy is a standard surgical procedure that is used in critically ill patients who require sustained mechanical ventilation. In this article, we review the outcomes of coronavirus disease 2019 (COVID-19) patients who underwent tracheostomy. We searched for relevant articles on PubMed, Scopus, and Google Scholar, up to April 20, 2021. This meta- analysis examines ventilation liberation, decannulation, and hospital mortality rates in COVID-19 patients who have undergone tracheostomy. Two investigators evaluated the articles, and the differences of opinion were settled by consensus with a third author. A total of 4366 patients were included in 47 related articles for this meta-analysis. After data pooling, the proportions of ventilation liberation, decannulation and mortality were found to be 48% (95% CI: 31–64), 42% (95% CI: 17–69) and 18% (95% CI: 9–28) respectively. The Luis Furuya-Kanamori (LFK) index values for ventilation liberation, decannulation and mortality were 4.28, 1.32 and 0.69. No transmission of the disease attributable to participating in tracheostomy procedures was reported in most of the included articles.

Abstract Background Bloodstream infections (BSIs) are an emerging cause of significant morbidity and mortality in severe Coronavirus disease 2019 (COVID-19). We aimed to assess the prevalence, clinical profile and outcome of BSIs in critically ill COVID-19 patients. Methods This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age > 18 years) with reverse-transcription polymerase chain reaction (RT-PCR) confirmed COVID-19 admitted in the intensive care unit (ICU) were included. Hospital electronic records were searched for demographic data, time of bloodstream infection since admission, clinical profile, antimicrobial resistance pattern and clinical outcome of all patients who developed BSIs. Results Out of 750 patients admitted in COVID ICU, 8.5% developed secondary BSIs. All severe COVID-19 patients who developed BSIs succumbed to illness. A significant proportion of BSIs were Gram-negative pathogens (53/64, 82.8%). Acinetobacter baumannii was the commonest isolate, followed by Klebsiella pneumoniae (32.8% and 21.9%, respectively). Multidrug-resistance organisms (MDRO) were found in 57.8% of the cases. The majority of MDRO belonged to K. pneumoniae and Enterococcus groups. The proportion of Gram-negative bacteria resistant to carbapenems was 47.2% (25/53). On multivariate analysis, raised total leukocyte counts, mechanical ventilation and presence of comorbidities were significantly associated with the incidence of BSIs. Conclusion We found a significant prevalence of Acinetobacter baumannii in COVID-19 associated BSIs. The presence of comorbidities raised leukocyte counts and mechanical ventilation should alarm clinicians for possible BSIs. The timely initiation of empirical antibiotics and rapid de-escalation is vital to improve the outcome. At the same time, strict compliance of infection control practices should be accomplished to reduce the occurrence of MDRO.

Peripheral intravenous placement can be difficult in children. Vein finder devices are vascular access devices that delineate veins lying in the subcutaneous tissues to identify potential venipuncture sites. In this narrative review, we highlight the currently available literature on this device to analyse the hope that this device has to offer vs. the unnecessary hype. The search of the databases (Cochrane Library, Google Scholar, and PubMed) was limited to studies on the paediatric population and in English language between 2011 and 2019. Twenty-three relevant articles were found. Most of the articles did not demonstrate a major impact of these modalities in the general paediatric population. However, they may be beneficial in children with difficult intravenous access. Appro­priate simulator mannequins should be utilised to train healthcare providers in using these vein finder devices.

Background: In March 2020, the Indian Council of Medical Research (ICMR) issued guidelines that all patients presenting with severe acute respiratory infections (SARI) should be investigated for coronavirus disease 2019 (COVID-19). Following the same protocol, in our institute, all patients with SARI were transferred to the COVID-19 suspect intensive care unit (ICU) and investigated for COVID-19. Methods: This study was planned to examine the demographical, clinical features, and outcomes of the first 500 suspected patients of COVID-19 with SARI admitted in the COVID-19 suspect ICU at a tertiary care center. Between March 7 and July 20, 2020, 500 patients were admitted to the COVID-19 suspect ICU. We analyzed the demographical, clinical features, and outcomes between COVID-19 positive and negative SARI cases. The records of all the patients were reviewed until July 31, 2020. Results: Of the 500 suspected patients admitted to the hospital, 88 patients showed positive results for COVID-19 by reverse transcription-polymerase chain reaction (RT-PCR) of the nasopharyngeal swabs. The mean age in the positive group was higher (55.31 ± 16.16 years) than in the negative group (40.46 ± 17.49 years) (P < 0.001). Forty-seven (53.4%) of these patients in the COVID-19 positive group and 217 (52.7%) from the negative group suffered from previously known comorbidities. The common symptoms included fever, cough, sore throat, and dyspnea. Eighty-five (20.6%) patients died in the COVID-19 negative group, and 30 (34.1%) died in the COVID-19 positive group (P = 0.006). Deaths among the COVID-19 positive group had a significantly higher age than deaths in the COVID-19 negative group (P < 0.001). Among the patients who died with positive COVID-19 status had substantially higher neutrophilia and lymphopenia (P < 0.001). X-ray chest abnormalities were almost three times more likely in COVID-19 deaths (P < 0.001). Conclusion: In the present article, 17.6% of SARI were due to COVID-19 infection with significantly higher mortality (34.1%) in COVID-19 positive patients with SARI. Although all patients presenting as SARI have considerable mortality rates, the COVID-19-associated SARI cases thus had an almost one-third risk of mortality.

Objective: COVID-19 has emerged as a multi-system disease with the potential for endocrine dysfunction. We aimed to study the hormonal profile of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India. Design: A hospital-based clinical study of endocrine profile of COVID-19 patients conducted from 15th May to 30th June 2020 after ethical approval. Measurements: Fasting blood samples for free thyroxine (T4), free tri-iodothyronine (T3), thyroid stimulating Hormone (TSH), serum prolactin; basal and 1 h post-intramuscular adrenocorticotropic hormone (ACTH) stimulated cortisol, interleukin-6 (IL-6), and high sensitivity C-reactive protein (hsCRP) were collected within 24 h of admission after written informed consent. All hormones and IL-6 were analyzed by chemiluminescent immunoassay. hsCRP was measured by immune-turbidimetric assay. Results: Of 235 patients studied, 14% had severe disease and 5.5% died. Adrenal insufficiency was present in 14%, most of whom had mild disease. A robust adrenal response was observed in those with severe disease. Basal and post-ACTH serum cortisol were significantly increased in severe disease or those who died compared to those who were mild or asymptomatic. Basal and post-ACTH serum cortisol showed a significant positive correlation with hsCRP but not with IL-6. Low T3 and low T4 syndrome were documented in 25% and 5%, respectively. Serum TSH and FT3 levels declined significantly from asymptomatic to severe category. Hyperprolactinemia was found in 21 patients. hsCRP showed a rising trend with disease severity while IL-6 did not. Conclusions: Endocrine dysfunction in the form of adrenal insufficiency, low T3, and low TSH syndrome and hyperprolactinemia were common COVID-19 hospitalized patients.

Through this manuscript, we would like to share our experience with building a COVID hospital, allocating duties, planning and managing supplies during COVID-19 pandemic. This manuscript is prepared by the Doctors of various specialties with vast experience involved in actual planning of the infrastructure and resources. This comprehensive manuscript will help teams to prepare and train, stockpile necessary equipment and prepare their staff to deal with current crisis if there is a surge in infected cases.

Background and Aims: In clinical practice, in the majority of patients, recovery from the effect of muscle relaxants is assessed using subjective methods such as head lift, eye-opening, or by sustained hand grip after giving anticholinesterases (neostigmine) at the end of surgery. We planned a prospective observational cohort study to test the hypothesis that objective neuromuscular monitoring can help us in avoiding the use of anticholinesterases for reversal. Methods: The patients posted for surgery of

Intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE) are well-known therapeutic modalities in Guillain–Barré syndrome (GBS). In developing countries like India, where plasma-derived products (IVIG) are not easily available, and affordable TPE is preferred. Here, we reported a case of severe GBS, who was treated with daily plasma exchange (PLEX) rather than recommended alternate day schedule. A 16-year-old male adolescent of severe GBS, i.e., on mechanical ventilator was treated with the plasmapheresis regimen consisted of removal of 1.3 plasma volumes in each cycle for total of five cycles, on daily basis. The patient's condition started improving after three cycles of TPE with power in the upper limbs 4/5 and lower limbs 3/5 and completely weaned off from ventilator after the 4th TPE, i.e. the 4th day of admission. This case emphasizes the need of daily PLEX regimen particularly in severe GBS patients because early weaning from ventilator reduces the ventilator-associated complications, hospital stay as wells as less morbidity, and mortality in severe GBS.

This study examined the role of interleukin (IL)-1 receptor-associated kinase (IRAK) and protein kinase C (PKC) in oxidized LDL (Ox-LDL)-induced monocyte IL-1β production. In THP1 cells, Ox-LDL induced time-dependent secretory IL-1β and IRAK1 activity; IRAK4, IRAK3, and CD36 protein expression; PKCδ-JNK1 phosphorylation; and AP-1 activation. IRAK1/4 siRNA and inhibitor (INH)-attenuated Ox-LDL induced secreted IL-1β and pro-IL-1β mRNA and pro-IL-1β and mature IL-1β protein expression, respectively. Diphenyleneiodonium chloride (NADPH oxidase INH) and N-acetylcysteine (free radical scavenger) attenuated Ox-LDL-induced reactive oxygen species generation, caspase-1 activity, and pro-IL-1β and mature IL-1β expression. Ox-LDL-induced secretory IL-1β production was abrogated in the presence of JNK INH II, Tanshinone IIa, Ro-31-8220, Go6976, Rottlerin, and PKCδ siRNA. PKCδ siRNA attenuated the Ox-LDL-induced increase in IRAK1 kinase activity, JNK1 phosphorylation, and AP-1 activation. In THP1 macrophages, CD36, toll-like receptor (TLR)2, TLR4, TLR6, and PKCδ siRNA prevented Ox-LDL-induced PKCδ and IRAK1 activation and IL-1β production. Enhanced Ox-LDL and IL-1β in systemic inflammatory response syndrome (SIRS) patient plasma demonstrated positive correlation with each other and with disease severity scores. Ox-LDL-containing plasma induced PKCδ and IRAK1 phosphorylation and IL-1β production in a CD36-, TLR2-, TLR4-, and TLR6-dependent manner in primary human monocytes. Results suggest involvement of CD36, TLR2, TLR4, TLR6, and the PKCδ-IRAK1-JNK1-AP-1 axis in Ox-LDL-induced IL-1β production.

Autistic spectrum disorder (ASD) is a developmental disability of the central nervous system with rapid worsening. A subset of patients also has mitochondrial dysfunction leading to increased sensitivity to various anesthetic agents. Rarely, gene mutation in these patients results in homocysteinemia which causes higher incidences of thromboembolism, hypoglycemia, and seizures. Anesthetic management of ASD with homocysteinemia and refractory seizures has not been previously reported.

Cystinosis is a lysosomal storage disorder which is characterized by abnormal accumulation of amino acid cysteine. Cystinosis affects various tissues of the body and has several anesthetic implications. We discuss successful management of a 5 years old child with infantile nephropathic cystinosis and Fanconi‘s syndrome who underwent osteotomy for rickets. Keywords: Anesthesia, Lysosomal Storage Diseases, Fanconi Syndrome, Polyuria, Osteomalacia, Acidosis

Aims and Context: The objective of the present study was to evaluate the analgesic and adverse effects of intrathecal clonidine with hyperbaric bupivacaine in spinal anesthesia. Settings and Design : Randomized single blind trial. Methods: 210 ASA I-II pregnant females undergoing emergency cesarean section were randomized in a single-blind fashion to one of the three groups. In group I (n=70) patients received 12.5 mg of 0.5% hyperbaric bupivacaine intrathecally. In group II (n=70) patients received intrathecal mixture of 0.5% hyperbaric bupivacaine (8 mg) and clonidine 50 μg. In group III (n=70) , patients received 0.5% hyperbaric bupivacaine (10 mg) intrathecally along with 50 μg of clonidine. Statistical Analysis Used: Groups were compared using one-way ANOVA with the Bonferroni multiple comparison post hoc test. The proportion of adverse events was compared using the chi-square test (χ2 =57.2410). Results: On adding 50 μg clonidine, we were able to reduce intrathecal dose of bupivacaine for cesarean section to 8 mg. Patients receiving intrathecal clonidine along with bupivacaine had significantly long lasting analgesia with lower bupivacaine dose [246.21±5.15 min. (group II) vs 146.0±4.55 min (group I), P=0.021; 95% confidence interval: 238.01-257.40, group II and 134.99-157.0 group I]. Conclusions: Addition of intrathecal clonidine causes some sedation in the postoperative period, but it provides adequate analgesia and motor paralysis at lower dose of bupivacaine. It also significantly prolongs postoperative pain relief.

Neutrophils (PMNs) and cytokines have a critical role to play in host defense and systemic inflammatory response syndrome (SIRS). Neutrophil extracellular traps (NETs) have been shown to extracellularly kill pathogens, and inflammatory potential of NETs has been shown. Microbial killing inside the phagosomes or by NETs is mediated by reactive oxygen and nitrogen species (ROS/RNS). The present study was undertaken to assess circulating NETs contents and frequency of NETs generation by isolated PMNs from SIRS patients. These patients displayed significant augmentation in the circulating myeloperoxidase (MPO) activity and DNA content, while PMA stimulated PMNs from these patients, generated more free radicals and NETs. Plasma obtained from SIRS patients, if added to the PMNs isolated from healthy subjects, enhanced NETs release and free radical formation. Expressions of inflammatory cytokines (IL-1β, TNFα and IL-8) in the PMNs as well as their circulating levels were significantly augmented in SIRS subjects. Treatment of neutrophils from healthy subjects with TNFα, IL-1β, or IL-8 enhanced free radicals generation and NETs formation, which was mediated through the activation of NADPH oxidase and MPO. Pre-incubation of plasma from SIRS with TNFα, IL-1β, or IL-8 antibodies reduced the NETs release. Role of IL-1β, TNFα and IL-8 thus seems to be involved in the enhanced release of NETs in SIRS subjects.