Drug extravasation: can ultrasound-guided puncture and aspiration help?

Summary: The authors have drawn the attention towards perhaps a common complication during intravascular techniques, and a novel use of ultrasound to aspirate the extravasated fluids / drugs to minimize the damaging effects. Abbreviations: GA: general anesthesia; MAC-age: Age-adjusted minimum alveolar concentration Key words: Patient Safety; Perioperative; Point-of-Care Ultrasound; Anesthetics Citation:  Vankdavath L, Karim HMR, Arora P. Drug extravasation: can ultrasound-guided puncture and aspiration help? Anaesth. pain intensive care 2022;26(6):831−832; DOI: 10.35975/apic.v26i6.2073

Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study

How to cite this article: Karim HMR, Mitra JK. Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study. Indian J Crit Care Med 2022;26(11):1227-1228.

Alveolar-arterial Oxygen Gradient in COVID-19 Pneumonia Initiated on Noninvasive Ventilation: Looking into the Mortality-prediction Ability

How to cite this article: Karim HMR, Esquinas AM. Alveolar-arterial Oxygen Gradient in COVID-19 Pneumonia Initiated on Noninvasive Ventilation: Looking into the Mortality-prediction Ability. Indian J Crit Care Med 2022;26(10):1152.

Ketamine Sedation for Noninvasive Ventilation in Distressed Elderly Patients with Acute Decompensated Heart Failure: Is it Safe?

How to cite this article: Karim HMR, Esquinas AM. Ketamine Sedation for Noninvasive Ventilation in Distressed Elderly Patients with Acute Decompensated Heart Failure: Is it Safe? Indian J Crit Care Med 2022;26(10):1161.

A multinational online survey on the current perioperative practice for the management of patients with diabetes mellitus: a descriptive study

Background & Objective: Diabetes mellitus is widely prevalent and significantly impacts the perioperative outcome. We aimed to assess the perioperative practice for managing diabetes mellitus patients and variation across different establishments. Methodology: A questionnaire-based online survey was conducted for the present cross-sectional, multinational study; data collection followed a snowball method and was conducted from November 2020 to January 2021. Responses were presented in absolute number and percentage scale, and response rates among the subgroups were analyzed using Fisher’s exact test; p < 0.05 was considered significant. Results: Responses from 556 out of 637 from six South Asian Association for Regional Cooperation countries were analyzed. A considerable amount of practice variation was noted; variation increased as the invasiveness of surgery increased. Perioperative insulin administration strategy and case postponement based on blood sugar level differed between the teaching and non-teaching sectors and private and public sectors. However, a majority (64.8%) of the respondents did not favor postponing a case based on the glycosylated hemoglobin (HbA1c) level. Confusion and diverse opinions were present even for emergency cases, including postponement based on blood sugar. Conclusion: There is a wide variation in the perioperative practice for managing diabetes mellitus patients. The variation increases with the increasing invasiveness of surgery. Although there were similar practices between private versus public sectors and teaching versus non-teaching institutions, significant differences were noticed about case postponement, indicating that an authoritative guideline is the need of the hour. Key words: HbA1c level; Sugar, Cut-off; Sugar level; Anesthesia; Perioperative practice; Hyperglycemia Trial Registration: The study was an online survey and as per the clinical trial registry of India, it was not required to be registered. Citation: Karim HMR, Sharma A, Khan TH, Abayadeera AU, Alam MR. A multinational online survey on the current perioperative practice for the management of patients with diabetes mellitus: a descriptive study. Anaesth. pain intensive care 2022;26(1):382-390. DOI: 10.35975/apic.v26i3.1914 Received: April 27, 2021; Reviewed: October 11, 2021; Accepted: December 16, 2021  

Oxygen therapy using Bain’s Circuit as an alternate option for moderate COVID-19 patients in resource-limited set-ups

Dear Editor, Coronavirus disease of 2019 (COVID- 19) has been slowly engulfing society since December 2019. Many parts of the world are facing the second and third waves of the pandemic. The virus is rapidly getting mutated, posing a significant challenge. Oxygen therapy is required in most symptomatic patients, and most mild-to-moderate cases are managed by supportive therapy using a face mask. Non-Rebreathing Facemask (NRBM) is frequently used as it can provide a higher fraction of inspired Oxygen (FiO2). However, it cannot deliver a Positive End- Expiratory Pressure (PEEP). Even the positive pressure generated inside the mask is nearly zero.

High-Flow Nasal Oxygen Therapy in Acute Hypoxemic Respiratory Failure: Concise Review on Technology and Initial Methodology

High-flow nasal cannula oxygen therapy (HFNCOT) system consists of an air/oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 80 L/min. The system includes a blender, active humidifier, single heated tube, and nasal cannula. HFNCOT has many physiological advantages compared with other standard oxygen therapies, such as anatomical dead space washout, more constant fraction of inspired oxygen, positive end-expiratory (PEEP) effect, supplement of adequate humidification and maintenance of muco-ciliary function. HFNCOT is mostly used for hypoxemic acute respiratory failure, although it also has other indications. HFNCOT is a common choice of physicians as its technology makes it more silent and comfortable. Though HFNCOT is used in many clinical settings, there is a lack of publications addressing devices and initial settings. We present a review on HFNCOT, with focus on device and application methodology.

Information technology-based joint preoperative assessment, risk stratification and its impact on patient management, perioperative outcome, and cost

Background: Despite negative recommendations, routine preoperative testing practice is nearly universal. Our aim is to bring the healthcare providers on one platform by using information-technology based preanaesthetic assessment and evaluate the routine preoperative testing’s impact on patient outcome and cost. Methods: A prospective, non-randomised study was conducted in a teaching hospital during January 2019-August 2020. A locally developed software and cloud-computing were used as a tool to modify preanaesthesia evaluation. The number of investigations ordered, time taken, cost incurred, were compared with the routine practice. Further data were matched as per surgical invasiveness and the patient's physical status. Appropriate tests compared intergroup differences and p-value <0.05 was considered significant.  Results: Data from 114 patients (58 in routine and 56 in patient and surgery specific) were analysed. Patient and surgery specific investigation led to a reduction in the investigations by 80-90%, hospital visit by 50%, and the total cost by 80%, without increasing the day of surgery cancellation or complications. Conclusion: Information technology-based joint preoperative assessment and risk stratification are feasible through locally developed software with minimal cost. It helps in applying patient and surgery specific investigation, reducing the number of tests, hospital visit, and cost, without adversely affecting the perioperative outcome. The application of the modified method will help in cost-effective, yet quality and safe perioperative healthcare delivery. It will also benefit the public from both service and economic perspective.

Elderly with refractory chronic severe hyponatremia and anesthesia management dilemma: a case report with literature review

Hyponatremia is a common electrolyte disorder, especially in the frail elderly population. With the increasing number of surgeries in the aging population, hyponatremia is frequently encountered by anesthesiologists and surgeons. Unfortunately, management of hyponatremia is often complex in the elderly population as it is often multifactorial, and they are physiologically susceptible. While it is well known that preoperative hyponatremia is associated with increased perioperative morbidity and mortality, a lack of recommendations or guidelines adds to the dilemma in managing such cases. The most common cause of chronic hyponatremia in the elderly is the syndrome of inappropriate antidiuretic hormone (SIADH), which can be resistant to conventional treatment. On the other hand, paraneoplastic SIADH leading to hyponatremia is rare, and surgery may be the only option available for its correction. We present a case of a 78- years-gentleman to highlight such a dilemma. He was diagnosed with renal cell carcinoma and had chronic refractory severe hyponatremia despite treatment with fluid restriction, low dose hydrocortisone, tolvaptan, and 3% sodium chloride.

Successful noninvasive ventilation in a severely acidotic and hypercapnic comatose COVID-19 patient with multiple comorbidities: a case report

Effective use of noninvasive ventilation in patients with chronic obstructive pulmonary disease is well-known. However, noninvasive ventilation in patients presenting with altered sensorium and severe acidosis (pH <7.1) has been rarely described. Invasive mechanical ventilation is associated with high mortality in coronavirus disease 2019 (COVID-19), and use of noninvasive ventilation over invasive ventilation is an area of investigation. We report a case of COVID-19-induced acute exacerbation of chronic obstructive pulmonary disease in a 66-year-old male. His past medical history included obstructive sleep apnea, hypertension, cor pulmonale, atrial fibrillation, and amiodarone-induced hypothyroidism. On presentation, he had acute hypercapnic respiratory failure, severe acidosis (partial pressure of carbon dioxide [PCO₂], 147 mm Hg; pH, 7.06), and altered mentation. The patient was successfully managed with noninvasive ventilation, avoiding endotracheal intubation, invasive ventilation, and related complications. Although precarious, a trial of noninvasive ventilation can be considered in COVID-19-induced acute exacerbation of chronic obstructive pulmonary disease with hypercapnic respiratory failure, severe acidosis, and altered mentation.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

Lessons Learned from A Case of Functional Total Laryngeal Obstruction Under Anaesthesia by Vocal Cord Polyp Managed by Vortex Approach

Dynamic airway obstruction is a terrifying situation. Most of the time, the obstruction is intermittent. The situation becomes horrifying and panicky when this intermittent dynamic airway obstruction turns into a total laryngeal obstruction under anaesthesia. Herein, we present a case of a 56-year-old male with vocal cord polyp, who was posted for excision. The difficult airway was anticipated in view of a thick neck. He was also hypertensive and a suggestive case of obstructive sleep apnoea. The patient went to the cannot ventilate, cannot intubate, cannot oxygenate situation because of the polyp taking position between the vocal cords and completely obstructing the central airway gateway. The case was successfully managed by emergency cricothyroidotomy by following the Vortex approach but taught us a few lessons. The case shows us the relevance of clinical findings and the importance of vocal polyp as a cause of inducible laryngeal obstruction and highlights the consequences of intuition and minor lacuna in airway management.

A retrospective comparison of preoperative estimated glomerular filtration rate as a predictor of postoperative cardiac surgery associated acute kidney injury

Background:

Cardiac surgery-associated acute kidney injury (CSA-AKI) remains common with distressingly high mortality. Over time, risk scorings systems have been developed to predict it and preoperative low estimated glomerular filtration rate (eGFR) has been regarded as one of the predicting risk factors.

Objectives:

The present study is aimed at assessing the relation of different ranges of preoperative eGFR with an incidence of CSA-AKI defined by the AKI network (AKIN) criteria.

Materials and Methods:

Files of 134 patients with eGFR of >40 cc/min/1.73 m² body surface area (BSA) who underwent cardiac surgeries on cardiopulmonary bypass were screened for data collection. Occurrences of CSA-AKI were evaluated as per the AKIN criteria over the course of 3 postoperative days. The relationships of different ranges of preoperative eGFR with CSA-AKI were analyzed by appropriate statistical tests using Instat software and P < 0.05 was considered statistically significant.

Results:

A total of 60 males and 74 females with a mean + standard deviation (SD) age of 37.98 ± 12.50 years and mean + SD preoperative eGFR of 70.20 ± 20.89 cc/min/1.73 m² were analyzed in this study. About 49.25% of patients suffered from CSA-AKI by the 3^rd postoperative day. The crude risk of CSA-AKI in patients with eGFR 40–60 cc/min/1.73 m² was not higher (odds ratio 0.29) as compared to patients in patients with eGFR >100 cc/min/1.73 m². The CSA-AKI trend with different eGFR was also statistically insignificant (P > 0.05).

Conclusion:

In patients with preoperative eGFR >40 cc/min/1.73 m² BSA, a lower preoperative eGFR (40–60 cc/min/1.73 m²) does not predict higher incidence of CSA-AKI as defined by AKIN criteria as compared to higher preoperative eGFR (>100 cc/min/1.73 m²). Lower height is independently associated with higher incidence of CSA-AKI in such patients.

Revisiting electronic systems and gadgets for patient management in COVID-19 Intensive Care Unit

Monitoring and highly sophisticated care of the Covid-19 pandemic patients has taught us many new lessons. The ever-changing management strategies and the therapies for the disease containment is one aspect of the wide spectrum of innovations and refinements, which were the result of global effort by the scientists and the healthcare workers; the self-protection of front-line workers soon became immensely important to save them from contracting the disease and thus prevent rapid reduction in their numbers. Personal protective measures were vehemently enforced and means and measures to reduce (if not eliminate) direct contact with the known as well as yet unknown Covid positive patients were advocated. Different countries adopted different measures according to their customs and resources, but all with the same purpose. This paper is written to highlight the same and present our approach at our center. Key words: COVID-19; Monitoring; Surveillance; Intensive Care; Gadgets Citation: Poonuraparampil JA, Karim HMK, Varghese AR. Revisiting electronic systems and gadgets for patient management in COVID-19 Intensive Care Units. Anaesth. pain intensive care 2021;25(1):5–7; DOI: 10.35975/apic.v25i1.1370 Received: 11 October 2020, Reviewed & Accepted: 25 November 2020

COVID-19 induced mental suffering is more painful than physical suffering: an experience-based perspective

COVID-19 pandemic has affected the lives of billions of human beings, either directly or indirectly. The physical presentation of the disease and its course to cure, permanent residual structural damage or death has been well documented. Few aspects that have recently been emphasized are the COVID fatigue and the mental suffering, not only by the general population, the COVID patients but also the healthcare professionals who are deputed to look after these patients. This manuscript throws some light on this very important aspect with long lasting impact. Keywords: COVID-19; Healthcare worker; Mental health; Stress Citation: Karim HMR.COVID-19 induced mental suffering is more painful than physical suffering: an experience-based perspective (Perspective). Anaesth. pain intensive care 2020;24(5):

Sedation in a patient with William Syndrome without supravalvular aortic stenosis and normal QT: Challenge still remains

William Syndrome (WS) is a rare genetic condition related to deletion of elastin gene resulting in distinctive facies, cardiovascular diseases, learning difficulties, developmental delay, unique personality characteristics, endocrine involvement, etc.1 Although successful anaesthesia is reported, literature review indicate significant major adverse cardiac events (MACE) including sudden death, as frequent.2 So anaesthetic management of these patients has proved to be challenging. The cardiovascular abnormality, corrected QT, and cardio-depressant actions of anaesthetic drugs need critical considerations.

An observation from an online survey: is fresh gas flow used for sevoflurane and desflurane different from isoflurane based anesthesia?

Minimal uses of fresh gas flow (FGF) during volatile inhalational agents based anesthesia are gaining popularity for many reasons. However, the practice pattern is not uniform. Even the same anesthesiologist uses different FGF for different agents. The present study was aimed to evaluate the variation in the practice pattern of FGF used in context to volatile agents used. With departmental approval, the present study was conducted by reviewing the data of a previously conducted cross-sectional survey. The survey was conducted from January 2018 to May 2018 using SurveyMonkey^®. Anesthesiologists working in different organizations across India were approached through e-mail and WhatsApp and anonymous responses were collected. The responses which contained FGF data for isoflurane and for at least one of either sevoflurane and/or desflurane were included. A total of 236 eligible responses were analyzed. The FGFs used by different anesthesiologists were very much inconsistent; only 5.1% used FGF < 600 mL/min and 19.1% used 600–1000 mL/min consistently for all three agents. There was a significant variation of FGF used for sevoflurane and desflurane as compared to isoflurane. Use of FGF of < 1000 mL/min was significantly higher for the desflurane as compared to both isoflurane and sevoflurane. The uses of lower FGF greatly vary both at intrapersonal as well as interpersonal level. The possibility of using FGF < 1000 mL/min is significantly higher with desflurane as compared to isoflurane. Volatile anesthetic agent appears to be a factor for the decision making on the use of low flow anesthesia.

Online survey about anesthesia-related practice and patient safety in Indian hospitals

BACKGROUND

Patient safety is a global concern, and anaesthesiologists are critically involved in patient safety-related measures and practices. Although anesthesia service has improved a lot over the last few decades, the information on the anesthesia practice and patient safety in India is lacking. The present survey was aimed to get the information on these aspects.

METHODS

A cross-sectional, questionnaire-based survey including both postgraduate trainees and anaesthesiologists, working across the different hospitals of India was conducted during February-May 2019. Google form was used as the survey; responses were directly downloaded as an Excel file and calculated in absolute numbers and percentages. Autonomous teaching institutes (ATI) were taken as standard, and Fisher's exact test was used for comparisons; P<0.05 was considered significant.

RESULTS

Six-hundred (86.1%) responses were included for analysis. Pulse oximetry and non-invasive blood pressure (NIBP) were available in nearly 99% set-ups, but end-tidal carbon-di-oxide (EtCO₂), temperature, oxygen, and anesthesia gas analyzer were lacking. ATI and corporate teaching hospitals were having almost all standard monitoring, but patient safety-related advanced equipment and medications were not present in many of the hospitals. The lack was highest in both public and private non-teaching hospitals (P<0.0001).

CONCLUSION

Patient safety and anesthesia-related services in India are unsatisfactory. Except for pulse oximetry and NIBP, the public and private sector non-teaching hospitals were lacking even the standard monitoring. Referral and top-level corporate and public sector institutes also have scope for improvement.

Autocycling During Noninvasive Positive Pressure Ventilation as a Factor for Severe Syncope: Exciting Observation, But Needs More Scrutiny

CITATION

Karim HMR, Esquinas AM. Autocycling during noninvasive positive pressure ventilation as a factor for severe syncope: exciting observation, but needs more scrutiny. J Clin Sleep Med. 2019;15(9):1377.

Cardio circulatory and respiratory monitoring of mechanically ventilated critically ill patients

Respiratory support in terms of mechanical ventilation is very common in critically ill patients. These patients are often hemodynamically unstable too. The mechanophysiology of mechanical ventilation also affects other organ system and needs assessment and management accordingly. The procedure is not devoid of complication. It also has potential to failure to achieve the treatment objective requiring frequent assessment and adjustment. There is a very close temporal relationship between patients monitoring and management decision in critically ill patients in critical care practice. Early and appropriate information from monitoring can lead to better outcome including reduced mortality. The present review is intended to briefly highlight the current opinions and strategies for cardio circulatory and respiratory monitoring in such patients in critical care unit. Received: 4 Jun 2018Reviewed: 6 Jun 2018Accepted: 13 Sep 2018 Citation: Karim HMR. Cardio circulatory and respiratory monitoring of mechanically ventilated critically ill patients. Anaesth Pain & Intensive Care 2018;22 Suppl 1:S142-S149