A Global Review of the Perioperative Care of Patients With Aneurysmal Subarachnoid Hemorrhage Undergoing Microsurgical Repair of Ruptured Intracerebral Aneurysm

INTRODUCTION

To describe the perioperative care of patients with aneurysmal subarachnoid hemorrhage (aSAH) who undergo microsurgical repair of a ruptured intracerebral aneurysm.

METHODS

An English language survey examined 138 areas of the perioperative care of patients with aSAH. Reported practices were categorized as those reported by <20%, 21% to 40%, 41% to 60%, 61% to 80%, and 81% to 100% of participating hospitals. Data were stratified by Worldbank country income level (high-income or low/middle-income). Variation between country-income groups and between countries was presented as an intracluster correlation coefficient (ICC) and 95% confidence interval (CI).

RESULTS

Forty-eight hospitals representing 14 countries participated in the survey (response rate 64%); 33 (69%) hospitals admitted ≥60 aSAH patients per year. Clinical practices reported by 81 to 100% of the hospitals included placement of an arterial catheter, preinduction blood type/cross match, use of neuromuscular blockade during induction of general anesthesia, delivering 6 to 8 mL/kg tidal volume, and checking hemoglobin and electrolyte panels. Reported use of intraoperative neurophysiological monitoring was 25% (41% in high-income and 10% in low/middle-income countries), with variation between Worldbank country-income group (ICC 0.15, 95% CI 0.02-2.76) and between countries (ICC 0.44, 95% CI 0.00-0.68). The use of induced hypothermia for neuroprotection was low (2%). Before aneurysm securement, variable in blood pressure targets was reported; systolic blood pressure 90 to 120 mm Hg (30%), 90 to 140 mm Hg (21%), and 90 to 160 mmHg (5%). Induced hypertension during temporary clipping was reported by 37% of hospitals (37% each in high and low/middle-income countries).

CONCLUSIONS

This global survey identifies differences in reported practices during the perioperative management of patients with aSAH.

Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury

Background

Glasgow coma scale (GCS) score is the most widely used clinical score for the initial assessment of neurologically injured patients and is also frequently used for prognostication. Other scores such as the Full Outline of UnResponsivness (FOUR) score and the Glasgow Coma Scale-Pupils (GCS-P) score have been more recently developed and are gaining popularity. This prospective cohort study was conducted to compare various scores in terms of their ability to predict outcomes at 3 months in patients with traumatic brain injury (TBI).

Materials and methods

The study was carried out between October 2020 and March 2022. Patients who presented to the hospital with TBI were assessed for inclusion. Initial coma scores were assessed in the emergency department and again after 48 hours of admission. Outcome was assessed using the extended Glasgow outcome score (GOSE) at 3 months after injury. The receiver operating curve (ROC) was plotted to correlate coma scores with the outcome, and the area under the curve (AUC) was compared.

Results

A total of 355 patients with TBI were assessed for eligibility, of which 204 patients were included in the study. The AUC values to predict poor outcomes for initial GCS, FOUR, and GCS-P scores were 0.75 each. The AUC values for 48-hour coma scores were 0.88, 0.87, and 0.88, respectively.

Conclusion

The GCS, FOUR, and GCS-P scores were found to be comparable in predicting the functional outcome at 3 months as assessed by GOSE. However, coma scores assessed at 48 hours were better predictors of poor outcomes at 3 months than coma scores recorded initially at the time of hospital admission.

How to cite this article

Chawnchhim AL, Mahajan C, Kapoor I, Sinha TP, Prabhakar H, Chaturvedi A. Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2024;28(3):256-264.

Endocrine Dysfunction After Traumatic Brain Injury: An Ignored Clinical Syndrome?

Traumatic brain injury (TBI) incurs substantial health and economic burden, as it is the leading reason for death and disability globally. Endocrine abnormalities are no longer considered a rare complication of TBI. The reported prevalence is variable across studies, depending on the time frame of injury, time and type of testing, and variability in hormonal values considered normal across different studies. The present review reports evidence on the endocrine dysfunction that can occur after TBI. Several aspects, including the pathophysiological mechanisms, clinical consequences/challenges (in the acute and chronic phases), screening and diagnostic workup, principles of therapeutic management, and insights on future directions/research agenda, are presented. The management of hypopituitarism following TBI involves hormonal replacement therapy. It is essential for health care providers to be aware of this complication because at times, symptoms may be subtle and may be mistaken to be caused by brain injury itself. There is a need for stronger evidence for establishing recommendations for optimum management so that they can be incorporated as standard of care in TBI management.

A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey

BACKGROUND

The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent.

METHODS

This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant.

RESULTS

The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%).

CONCLUSIONS

Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.

Evaluation of the GCS-Pupils Score for PrOgnosis in trauMatic brAin injury- The COMA Study

OBJECTIVES

Glasgow Coma Scale-Pupils (GCS-P) score has been found to be strongly related to in-hospital mortality in retrospective studies. We hypothesized that GCS-P would be better prognosticator than Glasgow Coma Scale (GCS) in patients with traumatic brain injury (TBI).

METHODS

In this prospective, multicentric, observational study, GCS and GCS-P scores were noted in adult TBI patients at ICU admission. Demographic variables, relevant clinical history, clinical/radiological findings and ICU complications were also noted. Extended Glasgow Outcome scale was noted at hospital discharge and at 6 months post-injury. Logistic regression analysis was carried out to estimate the odds for poor outcome adjusted for covariates. Sensitivity, specificity, area under curve (AUC) and odds ratio are reported for poor outcome at estimated cutoff point.

RESULTS

A total of 573 patients were included in this study. The predictive power for mortality, shown by the AUC, was 0.81 [95% CI: 0.77-0.85] for GCS and 0.81 [95% CI: 0.77-0.86] for GCS-P score, both being comparable. Similarly, the predictive ability for outcome at discharge and 6 months, the AUC-ROC for both GCS and GCS-P were comparable.

CONCLUSIONS

GCS-P is a good predictor of mortality and poor outcome. However, the predictive performance of GCS and GCS-P for in-hospital mortality and functional outcome at discharge and at 6 months remains comparable.

A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India

Background

End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India.

Methods

The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database.

Results

In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage).

Conclusion

The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better.

How to cite this article

Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, et al. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023;27(5):305-314.

The Curing Coma Campaign®: Concerns in the Indian Subcontinent

Background

The Curing Coma Campaign (CCC) was launched by the Neurocritical Care Society (NCS) in 2019, with the purpose to bring together a diverse group of coma scientists, neurointensivists, and neurorehabilitationists.

Methods

The aim of this campaign is to move beyond the limitations imposed by current definitions of coma and identify mechanisms to improve prognostication, identify test therapies, and impact outcomes. At the moment, whole approach of the CCC appears ambitiously challenging.

Results

This could be true only for the Western world, such as the North America, Europe, and few developed countries. However, the whole concept of CCC may face potential challenges in the lower-middle income countries. India has several stumbling blocks that need to and can be addressed in the future, for a meaningful outcome, as envisaged in the CCC.

Conclusion

India has several potential challenges, which we aim to discuss in this article.

How to cite this article

Kapoor I, Mahajan C, Zirpe KG, Samavedam S, Sahoo TK, Sapra H, et al. The Curing Coma Campaign®: Concerns in the Indian Subcontinent. Indian J Crit Care Med 2023;27(2):89-92.

Comparison between Transcranial Sonography and Computerized Tomography Scans to Assess the Midline Shift in Patients with Traumatic Brain Injury

Background

Midline shift (MLS) of the brain is an important clinical finding diagnosed on computed tomography (CT) imaging and transcranial sonography (TCS) can help diagnose MLS at the bedside and facilitate interventions to improve outcomes. The study aimed to find an association between TCS- and CT-based assessments of MLS in patients with traumatic brain injury (TBI).

Patients and methods

We included all adult patients with moderate-to-severe TBI of either gender, aged between 18 and 65 years, undergoing intracranial surgery under general anesthesia over a period of 3 months. Consciousness was assessed with the help of the Glasgow coma scale (GCS) and Glasgow coma scale-pupillary (GCS-P) score. We calculated MLS using a CT scan and TCS. Bland Altman graph along with Pearson's and Spearman's coefficient tests was used.

Results

A total of 17 patients were analyzed in this study. The MLS was 0.52 ± 0.90 cm using TCS and 0.58 ± 0.39 cm using CT scan. The Pearson's correlation coefficient (r ²) of the difference between MLS measured by TCS and CT imaging was 0.002 (p < 0.05).

Conclusion

Transcranial sonography could detect MLS in patients with TBI, provided a minimum time window is used between MLS measurements by TCS and CT scan.

How to cite this article

Kapoor I, Pandit S, Prabhakar H, Mahajan C. Comparison between Transcranial Sonography and Computerized Tomography Scans to Assess the Midline Shift in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2023;27(1):64-66.

Brain Biomarkers in Patients with COVID-19 and Neurological Manifestations: A Narrative Review

Acute hyperinflammatory response (cytokine storm) and immunosuppression are responsible for critical illness in patients infected with coronavirus disease 2019 (COVID-19). It is a serious public health crisis that has affected millions of people worldwide. The main clinical manifestations are mostly by respiratory tract involvement and have been extensively researched. Increasing numbers of evidence from emerging studies point out the possibility of neurological involvement by COVID-19 highlighting the need for developing technology to diagnose, manage, and treat brain injury in such patients. Here, we aimed to discuss the rationale for the use of an emerging spectrum of blood biomarkers to guide future diagnostic strategies to mitigate brain injury-associated morbidity and mortality risks in COVID-19 patients, their use in clinical practice, and prediction of neurological outcomes.

A Narrative Review on Translational Research in Acute Brain Injury

There has been a constant endeavor to reduce the mortality and morbidity associated with acute brain injury. The associated complex mechanisms involving biomechanics, markers, and neuroprotective drugs/measures have been extensively studied in preclinical studies with an ultimate aim to improve the patients' outcomes. Despite such efforts, only few have been successfully translated into clinical practice. In this review, we shall be discussing the major hurdles in the translation of preclinical results into clinical practice. The need is to choose an appropriate animal model, keeping in mind the species, age, and gender of the animal, choosing suitable outcome measures, ensuring quality of animal trials, and carrying out systematic review and meta-analysis of experimental studies before proceeding to human trials. The interdisciplinary collaboration between the preclinical and clinical scientists will help to design better, meaningful trials which might help a long way in successful translation. Although challenging at this stage, the advent of translational precision medicine will help the integration of mechanism-centric translational medicine and patient-centric precision medicine.

A Rare Case of Postoperative Extradural Hematoma in the Posterior Fossa Complicated by Both Stunned Myocardium and Neurogenic Pulmonary Edema

Acute neurological insult can trigger a cascade of events in other organ systems such as the heart and lung. Neurogenic stunned myocardium (NSM) and Neurogenic pulmonary edema (NPE) are mostly reported after stroke, subarachnoid hemorrhage, or seizures whenever sympathetic storm and autonomic dysregulation occurs. We report here for the first time, a case of postoperative infratentorial extradural hematoma in a patient triggering NSM and NPE at the same time. The challenges involved in the management of such a patient are described in this case report. The patient was successfully managed and discharged home with no new neurological deficits.

Assessment of Airway in Patients with Acromegaly Undergoing Surgery: Predicting Successful Tracheal Intubation

Background In the field of anesthesia, acromegaly is considered a cause of difficult tracheal intubation and airway management. There is a high probability of unanticipated difficult intubation in acromegalic patients despite a lower percentage of patients being identified preoperatively as having a difficult airway. In this study, we carried out various airway assessment tests preoperatively and during induction of anesthesia to find out the predictors of easy tracheal intubation in patients with acromegaly.

Methods All patients of either sex, diagnosed as a case of acromegaly and scheduled to undergo pituitary surgery were enrolled over a period of 3 years. Various airway assessment tests were performed prior to surgery, which included modified Mallampati (MP) classification (sitting and supine), mouth opening (MO), upper lip bite test (ULBT), neck movement (NM), thyromental (TM) distance, thyrohyoid (TH) distance, sternomental (SM) distance, hyomental (HM) distance, length of upper incisors (IL), receding mandible (RM), any history of obstructive sleep apnea (OSA), mask ventilation (MV), Cormack-Lehane (CL) III and IV, and external laryngeal manipulation (ELM). Results were reported as odds ratios (95% confidence interval [CI]). The p-value < 0.05 was considered statistically significant.

Results A total of 42 patients were enrolled over a period of 3 years. The male-to-female ratio was 19:23 with a mean age of 37.95 years and mean weight of 72.7 kg. Out of 15 airway assessment parameters, only ULBT and CL grade showed significant results.

Conclusion We conclude that ULBT and CL grading are reliable predictors of easy intubation in patients with acromegaly undergoing surgery.

Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature

Aim and objective

Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs).

Background

Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols.

Review results

Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation.

Conclusion

This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles.

Clinical significance

In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice.

How to cite this article

Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, et al. Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021;25(2):126–133.

COVID-19 and the perioperative neuroscience - A narrative review

Among the several medical specialties, anesthesiologists are probably the most affected ones from the coronavirus disease (COVID-19) pandemic as they are at the frontline. In the present stage of the pandemic, where we are observing community transmission, more people with elective neurologic and neurosurgical problems are likely to be tested positive for this virulent disease. Neuroanesthesiologists play an important role in the perioperative period and in neuroradiology suite. It is imperative to know the best available ways by which health care providers can manage their patients and also necessary steps to prevent the spread of infection, not only amongst themselves but also between patients. A high index of suspicion in such patients may help avoid delay in diagnosis and catastrophic sequelae. An overall knowledge about the disease will help plan the clinical management of neurologic patients, during the perioperative period.

Phenytoin Sodium and Acetate-Maleate Buffered Balanced Salt Solutions are Physically Incompatible!

How to cite this article: Mahajan C, Singh BP, Kapoor I, Prabhakar H. Phenytoin Sodium and Acetate–Maleate Buffered Balanced Salt Solutions are Physically Incompatible! Indian J Crit Care Med 2021;25(3):352.

Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]

Background

Elective percutaneous tracheostomy [PCT] is the widely performed procedure in neurocritically ill patients as an airway management choice in neurocritical care unit [NICU]. Intracranial pressure [ICP] is a vital parameter to be monitored in these patients while undergoing any surgical procedure including PCT. Optic nerve sheath diameter [ONSD], being a surrogate of ICP, can be done bedside and carries less complications than invasive ICP monitoring. The aim of our study was to assess the effect of PCT on ONSD at different stages of PCT.

Materials and methods

A total of 158 patients with various intracranial pathologies scheduled for PCT in NICU were screened for eligibility in our study. We assessed mean values of ONSD, HR, MBP, and SpO₂ for changes over various time points during PCT using generalized estimating equation (GEE). A p value of <0.05 was considered significant.

Results

A total of 135 patients who underwent PCT were analyzed for the study. The values of ONSD changed significantly at different stages of PCT procedure compared to baseline. The baseline ONSD value was 0.39 ± 0.05 cm. ONSD rose significantly to 0.40 ± 0.06 cm during positioning, 0.41 ± 0.06 cm during skin incision, 0.42 ± 0.07 cm during dilatation of tract, 0.41 ± 0.07 cm during insertion of tracheostomy, and 0.41 ± 0.06 cm at the end of the procedure.

Conclusions

PCT leads to a significant rise of ONSD values during all stages of PCT. The available evidences point toward detrimental rise in ICP during PCT. ICP can be monitored noninvasively by measuring ONSD using bedside ultrasound.

How to cite this article

Kapoor I, Wanchoo J, Mahajan C, Singhal V, Roy H, Kumar S, et al. Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]. Indian J Crit Care Med 2021;25(4):382-387.

Radiation Concerns for the Neuroanesthesiologists

With the advent of minimally invasive neurosurgical techniques and rapid innovations in the field of neurointervention, there has been a sharp rise in diagnostic and therapeutic modalities requiring radiation exposure. Neuroanesthesiologists are currently involved in various procedures inside as well as outside the operating room (OR) like intensive care units, interventional suites, and gamma knife units. The ambit expands from short-lasting diagnostic scans to lengthy therapeutic procedures performed under fluoroscopic guidance. Hence, a modern-day neuroanesthesiologist has to bear the brunt of the radiation exposure in both inside and outside the OR. However, obliviousness and nonadherence to the relevant radiation safety measures are still prevalent. Radiation protection and safety are topics that need to be discussed with new vigor in the light of current practice.

Transference of COVID-19 patient in hospitals - A crucial phase

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COVID-19 virus is primarily transmitted between humans through respiratory droplets and contact routes.

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Transportation of COVID-19 patient carries very high transmission risk to personals involved.

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Worldwide, clinicians are using many measures that can be executed easily to prevent aerosol exposure.

Cardiopulmonary resuscitation in COVID-19 patients - To do or not to?

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COVID-19 pandemic has changed the risk-benefit balance for cardiopulmonary resuscitation.

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Cardiopulmonary resuscitation is a highly aerosol-generating procedure.

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Literature is inadequate to direct clinicians towards cardiopulmonary resuscitation in COVID-19 patient.

Comparison of Bispectral Index-Guided Administration of Desflurane and Propofol for Endoscopic Transnasal Transsphenoidal Resection of Pituitary Tumors

Background Use of short-acting anesthetic agents such as propofol and desflurane allows rapid awakening and prompt neurological assessment of patients undergoing endoscopic transnasal transsphenoidal resection of pituitary tumors. However, there are no studies comparing the effect of these two agents in these patients. We performed this study to compare the intraoperative hemodynamics and postoperative recovery characteristics of patients undergoing endoscopic transnasal transsphenoidal (TNTS) pituitary tumor surgery using bispectral index (BIS)-guided administration of desflurane and propofol.

Materials and Methods In this prospective, randomized trial, 60 patients undergoing endoscopic TNTS pituitary surgery were randomized to receive BIS-guided administration of either propofol (Group P) or desflurane (Group D) for the maintenance of anesthesia. Heart rate (HR), mean arterial pressure (MAP), intraoperative complications, time to emergence, extubation, cognition, and modified Aldrete score were evaluated. Statistical analysis was performed using STATA 12.0. Categorical and continuous variables were compared between the groups using Fisher’s exact test and t-test, respectively. Emergence from anesthesia and hemodynamics at various stages of surgery was compared between the groups using Wilcoxon rank sum test. The p-value < 0.05 was considered statistically significant.

Results The HR was significantly higher at all stages of surgery in group P (p = 0.01). MAP was comparable between the groups at various time points (p > 0.05). Both emergence time (8.5 vs. 15 minutes; p < 0.00) and extubation time (10 vs. 17.5 minutes; p < 0.00) were significantly shorter in Group D compared with Group P. Modified Aldrete score at 5 and 10 minutes after extubation was higher with desflurane than propofol, but early cognition was comparable between the two groups.

Conclusion The hemodynamics and early cognition score were comparable in patients receiving propofol or desflurane. Desflurane provides rapid emergence and recovery when compared with propofol.

Relationship between Maternal and Perinatal Outcome with High Vaginal Swab Culture: A Cross-sectional Study

Introduction: Most of the pregnancies progress normally but unfortunately, few are prone to developing complications. Some antenatal and intra-partum conditions place the mother and the developing foetus or both at risk for complications and infections which undoubtedly play a major role in the same. Vaginal microbiome composition changes during pregnancy. This change is believed to inhibit pathogen growth through secretion of bacteriocins such as lactic acid that maintain acidic pH. Disturbed vaginal environment is associated with complications of pregnancy. Aim: To find the relationship between the microbiological study of High Vaginal Swab (HVS) in pregnancy at term with the maternal and foetal outcome. Materials and Methods: This cross-sectional study was conducted on 200 women who underwent vaginal swab culture during routine prenatal check-up from July 2019 to January 2020, in a hospital in Lucknow, Uttar Pradesh, India.The maternal and perinatal outcome and their relation with microbiological study of HVS were studied. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 11.5. Chi-square test was used for comparison of data for statistical significance. For descriptive statistics percentage, mean and Standard Deviation (SD) was calculated. Results:E.coli (18%) was the most common organism isolated from HVS cultures in this study. Maternal complications, rate of Lower Segment Caesarean Section (LSCS), low APGAR scores (Appearance, Pulse, Grimace, Activity and Respiration), need for neonatal resuscitation and Neonatal Intensive Care Unit (NICU) admission were more in the culture positive group. Conclusion: The study suggests that the abnormal vaginal microbiota is associated with adverse pregnancy outcomes. HVS cultures are simple and non-invasive screening tool which should be used as a routine procedure in all antenatal patients for preventing complications and improving the foeto-maternal outcome.

Effect of Pregabalin on Postcraniotomy Pain in Patients Undergoing Supratentorial Tumor Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

Background and Objectives Suboptimal management of postcraniotomy pain causes sympathetic and hemodynamic perturbations, leading to deleterious effects on the neurological system and overall patient outcome. Opioids are the mainstay of postoperative pain management but have various problems when given in high doses, or for prolonged durations in neurosurgical patients. The ideal method of pain control following craniotomy generally relies on a combination of various drugs. Oral pregabalin may be an attractive alternative in these patients.

Materials and Methods Sixty, American Society of Anesthesiologists class I and II patients posted for elective supratentorial craniotomy, aged 18 and 60 years, were randomly assigned into three groups of 20 each to receive oral placebo (Group A), pregabalin 75 mg (Group B), or pregabalin 150 mg (Group C) before the induction of anesthesia. At the end of the surgery, patient-controlled analgesia was started with intravenous fentanyl. Visual analog scale (VAS) score was recorded every 2 hours for 24 hours, along with total postoperative fentanyl requirement.

Results There were no differences in sex, duration of surgery or anesthesia and total intraoperative fentanyl administered among the three groups. The median postoperative VAS score (Group A—18.0, Group B—20, and Group C—22.0; p = 0.63) was similar in all the groups. However, postoperative fentanyl requirement over 24 hours was least in the group that received 150 mg pregabalin (Group A—190 μg, Group B—240 μg, and Group C—100 μg; p = 0.03).

Conclusions Even though pain scores were not significantly different, patients receiving 150 mg oral pregabalin required the least amount of postoperative opioids.