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Purpose and objectives Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic modality for patients with phantom limb pain. Primary objective was to study the incidence of PLP at 6 months following below-knee amputation between the mirror therapy group and control group. Methods Patients posted for below-knee amputation surgery were randomized into two groups. Patients allocated to group M received mirror therapy in post-operative period. Two sessions of therapy were given per day for 7 days and each session lasted for 20 min. Patients who developed pain from the missing portion of the amputated limb were considered to have PLP. All patients were followed up for six months and the time of occurrence of PLP and intensity of the pain were recorded among other demographic factors. Results A total of 120 patients completed the study after recruitment. The demographic parameters were comparable between the two groups. Overall incidence of phantom limb pain was significantly higher in the control group (Group C) when compared to the mirror therapy (Group M) group [Group M = 7 (11.7%) vs Group C = 17 (28.3%); p = 0.022]. Intensity of PLP measured on the Numerical Rating Scale (NRS) was significantly lower at 3 months in Group M compared to Group C among patients who developed PLP [NRS - median (Inter quartile range): Group M 5 (4,5) vs Group C 6 (5,6); p 0.001]. Conclusion Mirror therapy reduced the incidence of phantom limb pain when administered pre-emptively in patients undergoing amputation surgeries. The severity of the pain was also found to be lower at 3 months in patients who received pre-emptive mirror therapy. Trial Registration This prospective study was registered in the clinical trial registry of India. Trial Registration number: CTRI/2020/07/026488., Author(s): Samatharman Purushothaman [sup.1], Pankaj Kundra [sup.1], Muthapillai Senthilnathan [sup.1], Sarath Chandra Sistla [sup.2], Shathish Kumar [sup.3] Author Affiliations: (1) grid.414953.e, 0000000417678301, Department of Anaesthesiology and Critical Care, Second Floor, [...]

Byline: Pankaj. Kundra, Muthapillai. Senthilnathan The art of educating the trainees is always challenging to the medical fraternity. Teaching is much more challenging in the speciality of anaesthesiology, as there [...]

Byline: Protiti. Chatterjee, Muthapillai. Senthilnathan, Emayah. Tenzing Dear Editor, We read with interest the comments[1] to our published article,[2] and we would like to address the queries raised on a [...]

Byline: Ramya. Ravi, Ranjith. Sivakumar, Srinivasan. Suganya, Muthapillai. Senthilnathan Sir, We read with interest the captioned letter 'Use of a pre-injection technique to identify neural elements in the costoclavicular space [...]

Byline: Ramya. Ravi, Suganya. Srinivasan, Ranjith. Sivakumar, Muthapillai. Senthilnathan Sir, We read the letter titled 'Scapular surgery under combined thoracic paravertebral and interscalene blocks' in a recent issue of IJA,[1] [...]

Byline: Anusha. Cherian, Ajay. Jha, Sri. Nagabhushanam Padala, Muthapillai. Senthilnathan Introduction Coronavirus disease of 2019 (COVID-19) pneumonia caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus was first reported in [...]

Byline: Suganya. Srinivasan, Muthapillai. Senthilnathan, Ranjith. Sivakumar, Sandeep. Mishra Sir, A 42 year old male patient, a case of polytrauma with multiple long bone fractures with acute kidney injury was [...]

Background. The pulse characteristics of arterial circulation might affect radial artery catheterization's success rate. Therefore, we hypothesized that the success rate of radial artery catheterization would be lower in the left-sided severe stenotic valvular lesion group than severe regurgitant valvular lesion group. Methods. This prospective study was conducted among patients with left-sided cardiac valvular lesions undergoing cardiac and non-cardiac surgery. The patients with left-sided severe valvular stenosis and left-sided severe valvular regurgitation were included in the study. Radial artery cannulation was performed using an ultrasound-guided out-of-plane short-axis approach. The outcome measures were success rate, number of attempts, and cannulation time. Result. One hundred fifty-two patients were recruited for the study, and all were eligible for final analysis. The first attempt success rate was non-significantly higher in the stenotic valvular lesion group than the regurgitant group (69.7% vs 56.6%; P =.09). Furthermore, the number of attempts (median; 95% CI) was significantly higher in the regurgitant group (1; 1.2–1.43 vs 1; 1.38–1.67; P =.04). However, it may not be of clinical relevance. Moreover, the cannulation time and the number of redirections of the cannula were comparable. Heart rate was significantly higher in the regurgitant group (91.8 ± 13.9 vs 82.26 ± 15.92 beats/min; P =.00), while the incidence of atrial fibrillation was significantly higher in the stenotic lesion (P =.00). No failure was reported, and the incidence of periarterial hematoma was comparable. Conclusion. The success rate of ultrasound-guided radial arterial catheterization is comparable in left-sided stenotic valvular and regurgitant lesion groups. Graphical Abstract [ABSTRACT FROM AUTHOR]

Byline: Ramya. Ravi, Muthapillai. Senthilnathan, Ranjith. Sivakumar, Chanjeeviram. Suganthapriya Capnography and end tidal CO2 (EtCO2) aids the anaesthesiologist in diagnosing problems during all phases of general anaesthesia. Negative arterial to [...]

Byline: Sandeep. Mishra, Ayyappan. Chandrasekaran, Satyen. Parida, Muthapillai. Senthilnathan, Prasanna. Bidkar, Suman. Gupta Background and Aims: Dexmedetomidine is a drug that is being widely used as an adjuvant to anaesthesia [...]

Byline: Ramya. Ravi, Srinivasan. Swaminathan, Muthapillai. Senthilnathan, Varun. Rajendran Sir, Bilateral diaphragmatic palsy in a parturient is a rare condition and increases the peri-operative pulmonary complications.[1],[2] A 27-year-old female (G[sub]2P[sub]2L[sub]1) [...]

Machine learning is artificial intelligence (AI) which can predict the output variable with the fed input features. This allows computers to learn from experience without being programmed. The outcome variable in machine learning algorithm may be continuous variable or categorical variable. Supervised machine learning is commonly applied artificial intelligence (AI) in medical field. Decision tree, gradient boost machine (GBM) learning, extreme GBM (XGBM), Support vector machine, K nearest neighbour and multi-layer perceptron are few machine learning algorithms which are being utilised to address the classification and regression problems. Though the incidence of difficult intubation (DI) is rare, occurrence of such event in an unanticipated situation can result in development of arrhythmias due to desaturation and cardiac arrest if not intervened on time. It is preferred to choose the physical parameters that can predict the difficult airway more accurately in clinical scenario and train the algorithm rather than including all the non-specific parameters. Body mass index (BMI) [>30 kg.m-2: anticipated difficult mask ventilation (DMV), direct laryngoscopy (DL) and DI], inter-insicor distance (IID) (<2 cm: anticipated DL), modified Mallampati (MMP) (Grade 1 and 2: Ease of intubation; Grade 3 and 4: anticipated DI), temporomandibular distance (TMD) (<6.5 cm - anticipated DI), restriction of neck extension (if present: anticipated DL and DI), receded mandible (if present: anticipated DL and DI), and poor submandibular space compliance (if present: anticipated DL and DI) parameters which are used to predict DA by clinical assessment, can be used to feed to train the machine learning algorithm. Despite using these sophisticated tools, extubation may fail and patients require reintubation in ICU. It is very challenging to assess the lung compliance in spontaneously breathing patients as compliance will be overestimated due to generation of negative pressure. Cause for which patient has been placed on mechanical ventilation is resolved/resolving, BMI (>30 kg.m-2), intact sensorium (absence of delirium), absence of consolidation, absence of copious secretions, oxygenation status (PaO2/FiO2: >250), ventilation status (paCO2: 30-45 mmHg), measure of work of breathing (respiratory rate, rapid shallow breathing index), heart rate and blood pressure during spontaneous breathing trial (SBT) and diaphragmatic thickness fraction can be used as input features to predict the success of extubation in critically ill patients. With widespread utility of applications in medical fraternity, applications for prediction of difficult airway (or for weaning success) can be programmed which can be accessed by the clinicians to predict DA, thereby all the preparations for managing DA may be done to prevent adverse consequences of unanticipated difficult airway. [ABSTRACT FROM AUTHOR]

Recurrent respiratory papillomatosis (RRP) is one of the most common laryngeal lesions in children. A 14-year-old female presented with complaints of a change in voice and noisy breathing. She underwent excision of laryngeal papillomatosis thrice before. Fibreoptic laryngoscopy revealed that the lesion was occluding the entire glottic chink except for a small opening through which she was breathing. As there was a risk of seeding of the distal airway following tracheostomy, the initial plan of tracheostomy was deferred. Anaesthesia was induced with sevoflurane. C-MAC™ laryngoscopy revealed that the entire glottic chink was occupied with the papillomatous lesion, and no opening was visualised. The lesion could not be negotiated with a 4 mm endotracheal tube and started bleeding. Immediately, surgeon was asked to perform a tracheostomy. With each recurring incidence of RRP, the probability of the papilloma's non-yielding nature may increase, making the negotiation of the lesion impossible. [ABSTRACT FROM AUTHOR]

Byline: Muthapillai. Senthilnathan, Pankaj. Kundra, Sandeep. Mishra, Savitri. Velayudhan, Ajith. Pillai Objectives: Focused transthoracic echocardiography (fTTE) in critical care can be used to assess patient's volume status, ventricular contractility, right [...]

Background: Ambu® AuraGain™ laryngeal airway is a supraglottic airway device designed to provide better airway protection and airway seal pressures. Aim of Study: To quantify oropharyngeal leak pressures (OPLPs), fibreoptic view, peak airway pressure and ventilation scoring with Ambu® AuraGain™ in children in different head and neck positions such as maximum flexion, maximum extension and lateral rotation. Patients and Methods: Sixty-eight children aged between 1 and 6 years posted for surgery were enrolled. Ambu® AuraGain™ was inserted after the induction of anaesthesia and ventilation was confirmed. OPLP, fibreoptic view, peak airway pressure and ventilation scores were noted in different head and neck positions such as maximum flexion, maximum extension and lateral rotation. Results: The OPLP significantly increased in flexion (P < 0.001) and significantly decreased in extension (P < 0.001) when compared to the neutral position. Airway pressure (Paw) increased significantly in flexion (P < 0.001) and decreased in extension (P = 0.04) when compared to the neutral position. Tidal volume delivery was comparable in all positions. There was a statistically significant decrease in ventilation scoring in the flexed position when compared to the neutral position (P = 0.005). There was a significant worsening of fibreoptic view in flexion when compared to the neutral position (P < 0.001). Fibreoptic view in the lateral position and extension was comparable with the neutral position. Conclusions: Use of Ambu® AuraGain™ laryngeal airway provides the best ventilatory parameters and Paw in children with head in the neutral and lateral position but lower OPLP with head in extension. However, flexing the head results in the worst ventilatory parameters and Paw among the positions studied. [ABSTRACT FROM AUTHOR]

Background: Use of uncuffed tubes causes lots of morbidity, and there is a surge in the use of microcuff pediatric endotracheal tubes. These tubes are not evaluated in the Indian population. Aims: The study aimed to evaluate the pediatric microcuff endotracheal tubes in terms of cuff sealing pressure, fiber-optic assessment of tube tip, and cuff position to assess postextubation airway morbidity. Settings and Design: Study design involves follow-up analytical study. Subjects and Methods: Thirty-four children in the age group of 2–12 years were studied. Patients with leak pressure >20 cm H2O were exchanged with smaller size tube and excluded. Cuff pressure, fiber-optic assessment of tube tip to carina distance in neutral and flexion, ultrasound assessment of cuff position, and postextubation airway morbidity were assessed. Statistical Analysis Used: Parameters expressed as the median with the interquartile range. Nonparametric data were analyzed using the Wilcoxon signed-rank test. Results: The tracheal leak pressure was <20 cm H2O (median 14.5 cm H2O) in 30 children. Tube exchange was required in four patients. A complete seal was achieved in 30 patients with cuff pressures ranging from 6 to 8.25 cm of H2O (median 8 cm of H2O). The median caudal displacement is 0.8 cm (0.47–1.22 cm) with flexion. There was no airway-related morbidity in any of these patients. Conclusions: The microcuff pediatric endotracheal tubes when used according to the age-based formula had a higher tube exchange rate in our study population. However, in children in whom the tube size was appropriate, the tubes provided good sealing without increasing airway morbidity. Further studies with a larger sample size might be required to confirm the findings. [ABSTRACT FROM AUTHOR]

Background: Rapid sequence induction and intubation (RSII) with application of "Cricoid pressure" and avoidance of "facemask ventilation" (FMV) is believed to minimize the risk of pulmonary aspiration of gastric contents during general anesthesia. However, some patients may be at risk of developing hypoxemia and may benefit from FMV during RSII. The purpose of this study was to assess the effectiveness of "cricoid pressure" in preventing gastric insufflation during FMV using gastric ultrasonography. Materials and Methods: Eighty-four adult patients were randomized to receive cricoid pressure (CP) or no cricoid pressure (NCP), during FMV after induction of general anesthesia. Gastric antral cross-sectional area (CSA) was measured with ultrasonography before and after FMV in supine and right lateral decubitus positions (LDP). Appearance of "comet tail" artifacts created by acoustic shadows of gas in the gastric antrum was noted. Results: The incidence of insufflation indicated by "comet tail" artifacts during FMV was lower in group CP (17 vs 71%; P < 0.001). The lowest Paw at which gastric insufflation occurred was higher in group CP (20 vs 14 cmH2O). The change in mean gastric antral CSA was significantly lower in group CP than in group NCP in supine (0.02 vs 0.36 cm², P = 0.012) and right LDP (0.03 vs 0.67 cm², P < 0.001). Conclusion: Cricoid pressure is effective in preventing gastric insufflation during FMV at Paw less than 20 cmH2O. Observation of comet tail artifacts in gastric antrum along with measurement of change in antral CSA on ultrasound examination is a feasible and reliable method to detect gastric insufflation. [ABSTRACT FROM AUTHOR]

Capnography and end tidal CO2 (EtCO2) aids the anaesthesiologist in diagnosing problems during all phases of general anaesthesia. Negative arterial to end-tidal carbon-dioxide gradient during anaesthesia has been reported in various conditions including pregnancy, infants and inadvertent exogenous addition of carbon dioxide (CO2) to the expired gas in case of thoracoscopic procedures with iatrogenic injury to lung parenchyma/bronchial tree. Thus, airway injury or intentional opening of airway as a part of surgical step can be diagnosed using a negative arterial and end tidal CO2 gradient. Higher optimal PEEP can be used as a splint across the bronchial cuff in one-lung ventilation which prevents leak from capnothorax and decrease inadvertent entry of CO2 in to the expired gases which erroneously increase arteriolar to end tidal CO2 gradient. [ABSTRACT FROM AUTHOR]