Search

Background and Aims: Tracheal extubation often causes cardiovascular and airway responses, potentially resulting in hazardous consequences. It remains unknown whether dexmedetomidine or lidocaine is more effective for cough suppression. Hence, we conducted a systematic review and meta‑analysis of randomised controlled trials to compare the effectiveness and safety of dexmedetomidine and lidocaine in reducing cough response after tracheal extubation in adult patients. Methods: A thorough search of electronic databases, including PubMed, Embase, Cochrane Library, and Web of Science, was conducted to identify relevant studies (from inception to 31 January 2023). Randomised controlled trials comparing intravenous (IV) dexmedetomidine versus IV lidocaine administration during emergence from anaesthesia to prevent tracheal extubation response in adult patients under general anaesthesia were included. The primary outcome was the incidence of post‑extubation cough. Secondary outcomes included emergence time, extubation time, residual sedation, and incidences of bradycardia. Statistical analysis was conducted using RevMan software. The Cochrane risk of bias tool was used to evaluate the potential risk for bias. Results: In total, seven studies with 450 participants were included. There was no statistically significant difference in the incidence of cough between dexmedetomidine and lidocaine groups [Risk Ratio = 0.76; 95% Confidence Interval: 0.46, 1.24]. Emergence and extubation times were not significantly different between the two groups. Meta‑analysis revealed a higher incidence of bradycardia and residual sedation in dexmedetomidine compared to the lidocaine group. Conclusion: This meta‑analysis found no difference in cough, emergence, and extubation time between dexmedetomidine and lidocaine after tracheal extubation. However, residual sedation and bradycardia were more significant in dexmedetomidine than in lidocaine. [ABSTRACT FROM AUTHOR]

Background and Aims: The incidence of tracheal extubation failure in high-risk patients is higher, and non-invasive ventilation is suggested to avoid tracheal reintubation. This study compares the effectiveness of bilevel positive airway pressure (BiPAP) and high flow nasal cannula (HFNC) to reduce the rate of reintubation in intensive care unit (ICU) patients with increased risk of extubation failure. Methods: This randomised comparative trial was conducted on 60 high-risk patients on mechanical ventilators admitted to the ICU, ready for weaning after a spontaneous breathing trial. They were randomised to Group H for HFNC and Group B for BiPAP therapy. Designated therapy was administered in these high-risk patients for up to 48 hours after tracheal extubation. Haemodynamic parameters [mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), a saturation of peripheral oxygen (SpO2), electrocardiogram (ECG)], arterial blood gas analysis (ABG) parameter [potential of hydrogen (pH), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen/fraction of inspired oxygen (paO2/FiO2) ratio], the effectiveness of cough, comfort level was recorded and continuous monitoring for signs of respiratory distress and failure was done. Results: Most of the patients were obese and had more than two risk factors for extubation failure. Several patients in Group B have significantly higher successful extubation than in Group H (P = 0.044). Most of the reintubation took place within 24 hours. The HFNC therapy was more comfortable and acceptable to patients. Conclusion: BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure. [ABSTRACT FROM AUTHOR]

Background and Aims: The postoperative residual neuromuscular block (PRNB) has a significant impact on patient safety and well-being, but continues to remain underestimated. Objective evaluation of handgrip strength using a force dynamometer can be useful to identify postoperative muscle weakness. Material and Methods: Thirty-two American Society of Anesthesiologists (ASA) class I and II patients who received general anesthesia were included. Patients were extubated after the train-of-four (TOR) ratio (TOFR) was >0.90 and the clinical criteria for motor power recovery were judged as adequate. The measurements of handgrip strength and peak expiratory flow rate (PEFR) were obtained at baseline, 15 min after extubation, and 1, 2, and 4 h postoperatively. The incidence of significant decline from baseline (>25%) was determined. The correlation between handgrip strength and PEFR was assessed using Spearman correlation. The time to return to baseline for muscle grip strength and PEFR was performed using Kaplan-Meier survival analysis. A P value of 0.05 was considered significant for all tests. Results: The incidence of the significant decline in handgrip strength from baseline was 100% at 15 and 60 min, 76% at 2 h, and 9.4% at 4 h. There was a strong correlation between muscle grip strength and PEFR (0.89, P < 0.001). None of the patients exhibited the potential complications of PRNB. (PRMB in abstract. It should be uniform) The mean time to return to the baseline value of muscle grip strength was 3.8 h (95% confidence interval [CI] 3.6-3.9), and the mean time to return to baseline for PEFR was 3.2 h (95% CI 2.9-3.4 h). Conclusion: Objective assessment of muscle grip strength using a force dynamometer has the potential to be a new objective metric to monitor postoperative muscle weakness. [ABSTRACT FROM AUTHOR]

A person with thoracolumbar scoliosis for cardiac surgery presents with problems of restrictive lung disease with the additional risk of reduced lung compliance and respiratory complications compared to the other patients. Post‑operative analgesia in the form of continuous bilateral transversus thoracic muscle plane block (TTMPB) may help such patients in early respiratory rehabilitation by decreasing the time to extubation, reducing the opioid requirement, and early initiation of physiotherapy decreasing the risk of complications. [ABSTRACT FROM AUTHOR]

Objective: To study the applicability of on table extubation (OTE) protocol following congenital cardiac surgery in a low-resource setting and its impact on the length of intensive care unit (ICU) stay, hospital stay, hospitalization cost, parental anxiety, and nurse anxiety. Materials and Methods: In this prospective, nonrandomized, observational single-center study, we included all children above 1 year of age undergoing congenital cardiac surgery. We evaluated them for the feasibility of OTE using a prespecified protocol following separation from cardiopulmonary bypass. The data were prospectively collected on 60 children more than 1 year of age, belonging to the Risk Adjustment for Congenital Heart Surgery 1, 2, 3, and 4 groups and divided into two groups: those who underwent successful OTE and those who were ventilated for any duration postoperatively (30 children in each group). Duration of hospital stay, ICU stay, and total hospital cost were collected. Anxiety levels of the primary caregiver (nurse) in the ICU and the mother were assessed immediately after the arrival of the child in the ICU using the State Trait Anxiety Inventory (STAI). Results: Children who were extubated immediately following congenital cardiac surgery had significantly shorter ICU stay (median 20 [19, 22] h vs. 22 [20, 43] h [P < 0.05]). Patients extubated on table had a significant reduction in hospital cost {median Rs. 161,000 (138,330; 211,900), approximately USD 1970 (P < 0.05)} when compared to children who were ventilated postoperatively {median Rs. 201,422 (151,211; 211,900), approximately USD 2464}. The anxiety level in mothers was significantly less when their child was extubated in the operating room (STAI 36.5 ± 5.4 vs. 47.4 ± 7.4, P < 0.001). However, for the same subset of patients, anxiety level was significantly higher in the ICU nurse (STAI 46.0 ± 5.6 vs. 37.8 ± 4.1, P < 0.05). Conclusion: OTE following congenital cardiac surgery is associated with a shorter duration of ICU stay and hospital stay. It also reduces the total hospital cost and the anxiety level in mothers of children undergoing congenital heart surgery. However, the primary bedside caregiver during the child's ICU stay had increased anxiety managing patients with OTE. [ABSTRACT FROM AUTHOR]

We describe a case of life-threatening pulmonary hemorrhage in a boy with leukemia. He had episodes of massive hemoptysis for which he was intubated and resuscitated with multiple blood products, hemostatic measures (tranexamic acid and recombinant factor VIIa), and inotropes. Chest X-ray revealed left upper lobe homogeneous opacity. Within 12 h, in view of persistent massive pulmonary bleed and hypoxia, he was reintubated with a left-sided double-lumen endotracheal tube (DLT). Following reintubation with DLT, pulmonary bleed could be managed. He was treated for probable left upper lobe angioinvasive aspergillosis. He was weaned off ventilatory support and extubated after 48 h to high flow nasal canula (HFNC). This case is to highlight the importance of early use of DLTs in pulmonary hemorrhage due to suspected unilateral lung pathologies to facilitate isolation of diseased lung, improve ventilation, and prevent spillage of blood to the contralateral normal lung. It serves as a temporizing measure, while aggressive efforts to identify and control the bleed are underway. [ABSTRACT FROM AUTHOR]

BACKGROUND: Sedation is fundamental to the management of patients in the intensive care unit (ICU). Its indications in the ICU are vast, including the facilitating of mechanical ventilation, permitting invasive procedures, and managing anxiety and agitation. Inhaled sedation with halogenated agents, such as isoflurane or sevoflurane, is now feasible in ICU patients using dedicated devices/systems. Its use may reduce adverse events and improve ICU outcomes compared to conventional intravenous (IV) sedation in the ICU. This review examined the effectiveness of inhalational sedation using the anesthetic conserving device (ACD) compared to standard IV sedation for adult patients in ICU and highlights the technical aspects of its functioning. METHODS: We searched the PubMed, Cochrane Central Register of Controlled Trials, The Cochrane Library, MEDLINE, Web of Science, and Sage Journals databases using the terms "anesthetic conserving device," "Anaconda," "sedation" and "intensive care unit" in randomized clinical studies that were performed between 2012 and 2022 and compared volatile sedation using an ACD with IV sedation in terms of time to extubation, duration of mechanical ventilation, and lengths of ICU and hospital stay. RESULTS: Nine trials were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time compared to IV sedation (midazolam or propofol). CONCLUSION: Compared to IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times, ICU length of stay, and duration of mechanical ventilation. More clinical trials that assess additional clinical outcomes on a large scale are needed. [ABSTRACT FROM AUTHOR]

Perioperative airway management is a crucial task for anesthesiologists. Several perioperatively techniques make it difficult to predict the appropriate time for tracheal extubation. The aim of this article is to report the successful anticipation of an appropriate time for awake tracheal extubation. Three cases were observed related to smooth recovery without airway complication following intentionally removing airway devices after specific time. These reports demonstrate the relationship between awake status and return of spontaneous breathing which may demonstrate a good recovery of different sites of central nervous system from anesthesia effects. Theoretically, the appropriate time for awake tracheal extubation can be anticipated. [ABSTRACT FROM AUTHOR]

A neonate, with complete fibrous congenital alveolar synechiae and amniotic band syndrome affecting the upper and lower limbs, was posted for surgical release of synechiae under anaesthesia. A neonate with no mouth opening poses many anaesthesia challenges. The surgical and anaesthesia plan was discussed with ear, nose and throat surgeons. Topicalisation of airway, small aliquots of intravenous (IV) ketamine and propofol and sevoflurane inhalation helped achieve adequate depth of anaesthesia to carry out flexible intubating video endoscope-guided nasotracheal intubation successfully. Post-surgery, a check laryngoscopy with D-Blade of C-MACR (Karl Storz Video Macintosh Laryngoscope) video laryngoscope revealed a Cormack Lehane view of grade IV. The trachea was not extubated on table and the baby was shifted back to the neonatal intensive care unit with pressure support ventilation and followed by tracheal extubation next morning. Rest of the course for the baby was uneventful. Anticipation, planning, preparedness, vigilance and team work during anaesthesia management led to a successful outcome in this case. [ABSTRACT FROM AUTHOR]

Background and Aims: The pediatric cardiac intensive care unit (PCICU) frequently uses noninvasive ventilation (NIV). There are several reasons for its use, including prophylactic use right after the patient has been extubated. It is also used when patients are experiencing acute respiratory failure due to either cardiac or noncardiac reasons but are still able to maintain their airways. The objective of this study was to understand the spectrum of use of NIV following congenital cardiac surgery and analyze the outcome. Methods and Results: A retrospective observational study was conducted in a 14-bed PCICU, reviewing data from August 2019 to August 2022. Among 1750 congenital cardiac surgeries, 523 patients (29.9%) received NIV. The median age of the population was 2.5 months. Factors such as higher Risk-Adjusted Classification for Congenital Heart Surgery-1 category, longer intraoperative cardiopulmonary bypass time, and aortic cross-clamp time were associated with increased NIV use. Preoperative ventilator needs, infections, genetic syndromes, diaphragmatic paralysis, high vasoactive inotrope score (VIS) in the first 24 h, neonatal age, and weight <5 kg were independently associated with increased NIV need. The NIV group had a longer intensive care unit (ICU) stay compared to non-NIV patients. The success rate of NIV was 84%, with 440 successful cases and 83 failures. The mortality rate in the success and failure groups was not significantly different (5.27% vs. 6.0%). Conclusions: NIV is widely used in PCICU, but it is associated with longer ICU stays. It proves beneficial after congenital cardiac surgery, especially for patients with specific risk factors. However, NIV may not directly impact mortality rates, suggesting that other factors contribute to patient survival. [ABSTRACT FROM AUTHOR]

Background and Aim: To assess the utility of ultrasonic markers like B-line score (LUS), diaphragm thickness (DT), thickening fraction (DTF), and excursion (DE) as predictors of weaning outcomes in children on mechanical ventilation (MV) after cardiac surgery. Methods: This was a prospective observational study done in postcardiac surgical intensive care unit (ICU) of a tertiary care hospital. Children aged 1 month to 18 years, on MV after cardiac surgery from January to November 2017, were included. They were extubated after satisfying institutional weaning criteria. Ultrasound for LUS, DT, DTF, and DE was performed preoperatively, during pressure support ventilation (PSV) before extubation and 4 h after extubation. Results: Patients were divided into weaning failure and success groups based on reintubation within 48 h of extubation. Of the 50 evaluated patients, 43 (86%) were weaned successfully and 7 (14%) had weaning failure. The left DTF during PSV was lower in patients weaning failure (0.00%, interquartile range (IQR) 0.00-14.28 vs 16.67%, IQR 8.33-22.20, P = 0. 012). The left DTF= 14.64% during PSV (area under receiver's operating curve 0.795, P = 0.014), 85% sensitivity, and 57% specificity (positive likelihood ratio 1.97, negative likelihood ratio 0.25) could predict weaning failure. Conclusion: The left DTF during PSV is a good predictor of weaning failure in children on MV in postoperative ICU after congenital cardiac surgery. Take home message: In children on mechanical ventilation after cardiac surgery, left DTF during pressure support ventilation is a good predictor of weaning failure. [ABSTRACT FROM AUTHOR]

Background: Postextubation airway obstruction, also called postextubation stridor, is one of the most frequent complications of orotracheal intubation and the main cause of extubation failure (EF). Several potential predictors of extubation outcomes have been investigated, although their predictive value and clinical usefulness are limited. Laryngeal ultrasound and measurements are new, noninvasive, easily reproducible methods for extubation success. The objective of the study was to determine the usefulness of measuring the laryngeal air column width difference (LACWD) as a predictor of EF. Subjects and Methods: This prospective observational study was conducted from December 2022 to March 2023. Patients older than 30 days and up to 16 years of age admitted to the pediatric intensive care unit (PICU) and intubated with an endotracheal tube with a balloon for >24 h and with their first attempt at extubation were evaluated. The LACWD was measured before extubation. The first measurement was made with the balloon inflated and the second with the balloon deflated, calculating the difference between the two measurements. Results: Forty-five patients were assessed. The median number of days in the PICU was 8 (interquartile range 2–6). We found that the greater the difference in the air column, the lower the risk of EF ([P = 0.418] odds ratio [OR] =0.101 95% confidence interval [CI] =0.000–26.000), and the greater the number of days (>3), the greater the risk of EF ([P = 0.819] OR = 0.996; 85% CI = 0.965–1.028). Conclusions: No statistically significant relationship was found in the LACWD in our patients. We believe that it is important to carry out an extended study, with age group stratification, to assess its use. [ABSTRACT FROM AUTHOR]

COVID-19 infection has myriad manifestations from self-limiting illness to stormy multi-organ failure. A 28-year-old woman negative for COVID reverse transcription-polymerase chain reaction underwent an uneventful elective device closure of atrial septal defect on intubation anesthesia. While a brief postprocedural endotracheal bleed was noted, significant hypoxia and respiratory distress ensued after extubation with biventricular dysfunction, pleural effusion, and radiographic evidence of acute respiratory distress syndrome. COVID antibodies were positive, and inflammatory markers were elevated. After a conservative multipronged medical management including anticoagulation, antibiotics, aspirin, beta-blocker, diuretics, and sildenafil, she improved in 1 week. The clinical course during this pandemic era gives a possibility of a post-COVID inflammatory syndrome as a potential etiology. [ABSTRACT FROM AUTHOR]

Background: Peri-extubation cough is an undesirable event during extubation, prevention of which has been studied with multiple drugs, amongst which intravenous dexmedetomidine has emerged as one of the favourable drugs. Intratracheal route is attractive because of its ease of administration, provided it avoids the hypotension and bradycardia that occurs during intravenous bolus administration. There is a paucity of data exploring the utility, doses, and adverse effect of intratracheal dexmedetomidine. Methods: After obtaining ethical committee approval, 60 eligible, consenting adult patients undergoing surgery under general anesthesia in a tertiary teaching hospital were recruited and randomised into three groups--DEX0.3, DEX0.5, and NS. The plan of general anesthesia was standardized. Half an hour prior to extubation, study drug was instilled intratracheally-- dexmedetomidine 0.3 mic/kg, 0.5 mic/kg, and NS in groups DEX0.3, DEX0.5, and NS, respectively. 4-point cough score was used to assess extubation response. Hemodynamic response and time to Ramsay sedation score 3 was also recorded. Results: Majority of patients in DEX0.3 (60%) and DEX0.5 (85%) group had no cough (cough score 0), while majority of the patients in the NS group (70%) had either mild or moderate cough (cough score 1, 2). Kruskal Wallis test followed by post-hoc pairwise comparison showed statistically significant difference in 4-point cough score between GroupDEX0.3 and GroupNS (P< 0.001) and between GroupDEX0.5 and GroupNS (P= 0.038). DEX0.5 group, compared to DEX0.3 group, had significantly higher time from reversal to extubation (P< 0.001) and time to achieve Ramsay sedation score of 3 (P< 0.001). Conclusion: We conclude that both 0.3 mic/kg and 0.5 mic/kg of dexmedetomidine when given intratracheally are effective in preventing peri-extubation cough. Further, 0.3 mic/kg dexmedetomidine showed a better recovery profile compared to 0.5 mic/kg dexmedetomidine when administered intratracheally. [ABSTRACT FROM AUTHOR]

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]

Background and Aims: During laparoscopic surgeries, pneumoperitoneum increases intraabdominal pressure (IAP) which can increase the central venous pressure (CVP), and significant haemodynamic changes. In this study, we evaluated the effect of two different pressures of pneumoperitoneum, standard (13-15 mmHg), and low (6-8 mmHg) on the cross-sectional area (CSA) of the internal jugular vein (IJV) using ultrasonography, haemodynamic changes and duration of surgery. Surgeon's comfort and feasibility of performing laparoscopic surgeries with low pressure pneumoperitoneum was also studied. Methods: This prospective, double-blind, randomised study included 148 patients of American Society of Anesthesiologists physical status class I and II undergoing laparoscopic surgeries. They were allocated into two groups: group S (standard) (number (n) = 73) had the IAP maintained between 13-15 mmHg; group L (low) had an IAP of 6-8 mmHg (n = 75). CSA of right IJV was measured before induction of anaesthesia (T1), 5 min after intubation (T2), 5 min after pneumoperitoneum (T3), before desufflation (T4) and 5 min prior to extubation (T5). Chi-square test, and Student's paired and unpaired t test were used for statistical analysis. Results: The increase in IJV CSA at T3 when compared to T2 was statistically significant in both the groups (P < 0.001). On desufflation, the change in IJV CSA showed significant decrease in T5 value than T4 value in both the groups (P < 0.001). However, the percentage change in the IJV CSA was more in group S (35.4%) than group L (21.2%). Conclusion: CSA of IJV increased significantly even with lower IAP of 6-8 mmHg. Laparoscopic surgery can be performed conveniently even at low IAP. [ABSTRACT FROM AUTHOR]

Background and Aims: Weaning from mechanical ventilation based on clinical parameters and rapid shallow breathing index (RSBI) is associated with a higher weaning failure. Bedside ultrasound of the diaphragm is gaining popularity to assess the diaphragm function.The aim of our study was to determine the use of diaphragm ultrasound in weaning ventilated patients. Methods: This prospective study was done on 200 adult patients on mechanical ventilation for more than 24 h. After meeting the clinical weaning criteria, a spontaneous breathing trial (SBT) was performed. RSBI was recorded and a bedside ultrasound of the diaphragm was performed to measure diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) before extubation. We assessed the predictability of weaning success of RSBI, DE and DTF by determining the area under the receiver operating characteristic (AUROC) curve and Youden's index. The requirement of non-invasive ventilation or re-intubation within 48 h was considered a weaning failure. Results: Out of the 200 patients studied, 171 were successfully weaned. The AUROC values for RSBI, DTF, DE, RSBI-DTF and RSBI-DE for successful weaning prediction were 0.422, 0.654, 0.809, 0.656 and 0.807, respectively. The predictability using cut-off values were DE >1.21 cm (sensitivity 94%, specificity 71%, Youden's index 0.65), DTF >37% (sensitivity 80%, specificity 52%, Youden's index 0.31) and RSBI <82 (sensitivity 94%, specificity 31%, Youden's index 0.25). Conclusion: Diaphragm ultrasound helps in predicting successful weaning in mechanically ventilated patients. Both DE and DTF showed a higher specificity than RSBI and a combination of RSBI-DE and RSBI-DTF was better than using RSBI alone. [ABSTRACT FROM AUTHOR]

Background and Aims: End-tidal anaesthetic gas concentration (ETAG) and bispectral index (BIS) are both used to monitor depth of anaesthesia. Maintaining an accurate depth of anaesthesia helps in early post-operative recovery. This study compared the recovery times from sevoflurane-nitrous oxide anaesthesia using ETAG monitoring with BIS monitoring. Methods: Four hundred and two patients undergoing elective surgeries under sevoflurane-nitrous oxide anaesthesia were enroled in this double blinded parallel group prospective randomised trial and allocated into two groups. The depth of anaesthesia was monitored using BIS in BIS group (n = 202) and end-tidal sevoflurane concentration (EtSevo) in ETAG group (n = 200). The time to extubation and recovery were compared between the groups. Parametric, non-parametric and categorical variables were compared using Student's 't' test, Wilcoxon's rank sum test and Chi-square test, respectively. Results: Time to extubation (min) [BIS group - 10, 5; ETAG group - 10, 5 (median, inter-quartile range, IQR), P = 0.32] and time to recovery (min) [BIS group - 14, 6; ETAG group - 13.5, 7 (median, IQR), P = 0.34] did not differ significantly between the two groups. The EtSevo concentration (vol%) was significantly higher in the BIS group at 5 min [BIS group - 1.2, 0.4; ETAG group - 1.0, 0.4 (median, IQR), P < 0.001], 30 min [BIS group - 1.1, 0.4; ETAG group - 1.0, 0.3 (median, IQR), P = 0.002] and 120 min [BIS group - 1.11 ± 0.28; ETAG group - 0.96 ± 0.27 (mean ± standard deviation), P = 0.014] after induction of anaesthesia. Conclusions: BIS and ETAG monitoring are associated with comparable recovery profiles. ETAG monitoring is associated with significantly less sevoflurane consumption. [ABSTRACT FROM AUTHOR]

Background and Aims: Tracheal extubation is associated with various undesirable hemodynamic and airway responses. Various drugs are used effectively to curb these responses. But these drugs have limitations and produce side effects. Hence, the study was planned to assess the effects of superior laryngeal nerve block with inline lignocaine nebulization on awake extubation responses to suggest an alternative. The aim of this study was to assess the effect of bilateral superior laryngeal nerve block with inline lignocaine nebulization on awake extubation responses. Material and Methods: A study was conducted in 35 patients aged 18‑60 years, posted for surgery less than 3 h under general anesthesia. The hemodynamic responses like heart rate, arterial blood pressure, and mean arterial pressure were recorded preoperatively and at 1, 5, and 10 min postextubation. Undesirable respiratory responses like bucking, severity of sore throat, and cough response were also assessed. Repeated measures analysis of variance followed by the Tukey HSD test was used to find the significance of hemodynamic parameters. Qualitative data were expressed as percentages. Results: Decrease in Systolic Blood Pressure, Diastolic Blood Pressure and Mean Arterial Pressure was statistically significant at 5 mins (T2) and 10 mins (T3) postextubation as compared to baseline (T0). No cough was observed postextubation in 80% patients while 20% had mild Grade 1 cough. Conclusion: Superior laryngeal nerve block with in-line lignocaine nebulization for awake extubation is effective in curbing the haemodynamic and respiratory responses of extubation. [ABSTRACT FROM AUTHOR]

Background: Preterm infants usually have multiple complications, mainly due to their low birth weight. Multiple factors may lead to the need for intubating preterm infants. However, some infants may suffer from difficult extubation and failure to extubate from ventilation. This failure can result in increased morbidity or mortality. Objective: This study aims to evaluate the factors contributing to the failure of extubation and their outcomes in preterm infants. Materials and Methods: This is a retrospective descriptive cohort study that included records from neonatal intensive care unit for patients who had failed extubation from January 2014 to December 2020. The data included information about patients' demographics, pregnancy and delivery, description of ventilation course, and outcomes. SPSS version 26 was used for statistical analysis. Results: Seventy-seven infants were included. Males represented 61%, birth weight 37.7% had a <1 kg, 45.5% of the patients had a gestational age <28 weeks. The mean duration for mechanical ventilation was 19.21 ± 3.2 days, while the duration of intubation was 26.53 ± 2.3 days, and the average length of hospital stay was 86.2 ± 6.7 days. Male gender (P = 0.023), birth weight less than one kilogram (P = 0.004), gestational age <28 weeks (P = 0.033), sedation (P = 0.043), caffeine administration (P = 0.048), and a previous history of extubation failure (P = 0.036), lower hemoglobin levels (P = 0.039), lower APGAR score at 5 min (P = 0.013), and a previous history of extubation failure (P = 0.036) were significant factors associated with failure of extubation. Patent ductus arteriosus presence is not associated with failure of extubation. Mortality was 24.7% and prolonged length of hospital stay was significantly higher in babies with failure of extubation. Conclusion: Failure of extubation is more with babies received sedation, male gender, birth weight <1 kg, lower gestation age, and lower Apgar at 5 min. Patients with failing extubation have high in-hospital mortality and prolonged hospital stay. [ABSTRACT FROM AUTHOR]

Background Weaning and extubation follow each other in clinical practice, and are two isolated processes that pose distinct problems. Extubation failure is the need for reinstitution of ventilatory support within 24 to 72 hours of planned removal of endotracheal tube. Nearly 20% of patients require reintubation. Reintubation is more serious and may be associated with more adverse effect than the initial intubation procedure. Patients needing reintubation had significantly increase the duration of mechanical ventilation as well as ICU, hospital stay and mortality. Objective of the study To predict risk factors of reintubation in respiratory patients. Patients and methods The present study was a prospective observational study. It involved 100 mechanically ventilated patients who were admitted to RICU with different respiratory diseases. All patients met the criteria for readiness to wean: 50 patients need to be reintubated (group 1), and the other 50 patients were successfully extubated without needing for reintubation within 48-72 hours of extubation process (group 2). Different clinical, laboratory analysis, hemodynamic and respiratory variables, ventilator parameter and SAPS II score were collected in both groups. Results The mean age of reintubated patients was (66.06±10.3 years) and most of them were males (58%). We found that heamoglobin level (11.4±1.93) and Albumin level (2.47±0.61 g/dl) were significantly lower in reintubated group. Also, PH (7.11 ±0.032) and PaO2 (38.3±4.85 mmHg) at time of first intubation were significantly lower in reintubated cases. Half (50%) of reintubated cases expressed difficult weaning. On the other hand, 64% in non reintubated patients expressed simple weaning. Age (≥64 years old), PH (≤7.13), PaO2 (≤45) at first intubation, SAPS II Score, hemoglobin level (≤10.1), albumin level (≤3.1) were independent predictors of reintubation in respiratory ICU patients. Conclusion Age, arterial PH, PaO2 at first intubation, SAPS II Score, hemoglobin, albumin, higher length of ICU stay and hospital stay were an independent predictors of reintubation in respiratory ICU patients. [ABSTRACT FROM AUTHOR]

Dear Editor, Inflation and deflation of the cuff of an endotracheal tube (ETT) is a routine part of airway management. The airway management plan was nasotracheal intubation using McGrath video laryngoscope. Identical to the negative pressure test of the low-pressure system of an anaesthesia machine, a negative pressure test can be designed to confirm the integrity of the ETT cuff system prior to tracheal intubation. [Extracted from the article]

Beckwith-Wiedemann syndrome (BWS) is a complex overgrowth syndrome. Affected children require surgeries for various reasons such as correction of macroglossia, abdominal wall defects, cleft palate or neoplasms. Anaesthesiologists often face problems in the form of a difficult airway, associated congenital heart disease causing haemodynamic compromise and hypoglycaemia, especially during the neonatal period. We discuss the management of a child with BWS scheduled to undergo tongue reduction surgery for macroglossia. [ABSTRACT FROM AUTHOR]

Background: Postoperative pulmonary complications in cardiac surgery increase mortality and morbidity. High flow nasal cannula oxygen therapy (HFNC) is one of the preventive measures to reduce the incidence of lung complications. HFNC can decrease dyspnea and improve physiologic parameters after extubation, including respiratory rate and heart rate, compared with conventional oxygen therapy. In this study, we evaluated the role of THRIVE (Transnasal Humidified Rapid Insufflation Ventilatory Exchange) after extubation.Methodology: We prospectively randomized 60 adults aged between 18 and 65 years undergoing elective cardiac surgery to either High flow oxygen therapy using THRIVE (Group A) or conventional nasal cannula (group B). Arterial paO2, paCO2, pH at three points of time i.e., 1, 2, 4 hrs after extubation were evaluated using arterial blood gas analysis. Ventilation duration, the incidence of reintubation, sedation score, mortality, and other complications were also assessed.Results: Thirty adults in each group had comparable patient characteristics. There was a statistically significant decline in paCO2 in group A at 1, 2, 4 hrs post extubation (P = 0.022, 0.02, <0.001) with a significant increase in oxygenation (P < 0.001) when compared to group B.ICU stay duration was similar between two groups. No complications were noted in both groups.Conclusion: THRIVE is safe to use following extubation in adult cardiac surgical patients. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) has emerged as a pandemic and shall prevail for some time around the globe. The disease can manifest from asymptomatic to severe respiratory compromise requiring airway intervention. Transmission of COVID-19 has been reported to be by droplets, fomites, and aerosols, and airway management is an aerosol-generating procedure. The high viral load in the patient's airway puts the clinician performing intubation at a very high risk of viral load exposure. So, the need for barrier devices was considered and led to reporting of various such devices. All these devices have been reported individually and have not been compared. We present a review of all the information on these devices based on the reported literature. [ABSTRACT FROM AUTHOR]

Physiological responses remain common during anesthesia emergence and endotracheal extubation, causing some complications. We aimed to address the effect of dexmedetomidine (DEX) on decrease of cough, hemodynamic parameters and Ramsay score in comparing to lidocaine (LID) during anesthesia. In this double-blinded randomized clinical trial 120 hospitalized patients undergoing general anesthesia were enrolled after obtaining written consent. Block random allocation was used to assign patients into three groups including DEX (intravenous injection; 0.5 μg/kg), LID (1.5 mg/kg), and PBO (10 mL normal saline) at 10 minutes before anesthesia. No statistical significance was uncovered among three groups in blood pressure, oxygen saturation, frequency of laryngospasm and duration of surgery amongst the groups (P > 0.05), but DEX having lower heart rate and cough frequency (P < 0.05). Moreover, the mean of Ramsay score was statistically higher in DEX and LID groups than PBO except at the 50th and 60th minutes after extubation (P < 0.05). Since the mean of Ramsay score was higher in DEX vs. LID groups and reduced heart rate and cough frequency demonstrates in DEX, it seems that DEX could be an appropriate drug on suppressing cough during anesthesia without side effects. The study protocol was approved by the Ethical Committee of Arak University of Medical Sciences by code IR.ARAKMU.REC.1397.140 on August 19, 2018, and the protocol was registered at Iranian Registry of Clinical Trials by code IRCT20141209020258N97 on February 22, 2019. [ABSTRACT FROM AUTHOR]

Background and Aims: This study assesses the extubation practices of anaesthesiologists and whether these practices differ from existing guidelines. Methods: The literature related to tracheal extubation was searched and a validated questionnaire was designed to assess practices of tracheal extubation. The questionnaire included techniques, manoeuvres, preparation, timing and plan of extubation. The survey link was shared with eligible participants. The responses were assessed using Statistical Package for Social Sciences (SPSS) software. Results: Of the 1264 respondents, 66.8% keep difficult airway cart ready only when difficult extubation is anticipated. Only 12.3% of respondents perform deep extubation with supraglottic airway device (SAD) exchange while 73.3% of respondents perform awake extubation with pharmacological control for preventing haemodynamic fluctuations. In the case of anticipated difficult extubation, 48.3% anaesthesiologists prefer the airway exchange catheter (AEC) exchange technique. Of all, 84.8% anaesthesiologists administer 100% oxygen before performing extubation and 81.7% continue to oxygenate during and 83.9% provide oxygen after extubation in all patients. In the case of suspected airway edema or collapse or surgical cause for airway compromise, 70% anaesthesiologists perform a leak test. The most preferred plan of extubation in patients with suspected airway collapse after surgery is direct extubation in fully awake position (54.6%). In patients with anticipated difficult extubation, 50.8% anaesthesiologists prefer to ventilate for 24 hours and reassess. Conclusion: We observed that the extubation practices vary widely among anaesthesiologists. Almost half of the anaesthesiologists were unaware of extubation guidelines. [ABSTRACT FROM AUTHOR]

Background: Traditional extubation often leads to bucking, coughing, and undesirable hemodynamic changes. Extubation just before administering reversal could reduce force of coughing, bucking and may provide better extubation conditions. Aim of Study: The aim of the study was to assess the incidence of bucking with extubation just before administering reversal of neuromuscular blockade compared to traditional technique of awake extubation. Incidence of coughing during extubation, vomiting/regurgitation, aspiration, hemodynamic changes, postoperative bleeding, and extubation conditions were also assessed. Settings and Design: This was a prospective randomized study conducted in a tertiary care institute. Subjects and Methods: Forty patients were allocated into two equal groups. In Group E, at the end of surgery, extubation was performed and reversal was administered after extubation. In Group L, reversal was given and patients were extubated in the traditional way. Quality of extubation was assessed using extubation quality score. Statistical Tests Used: Pearson Chi-square test, Fisher's exact test, and independent sample t-test. Results: Group E showed significantly lower incidence of bucking (15% vs. 65%) and coughing (10% vs. 45%). Incidences of desaturation and regurgitation/aspiration were comparable. In Group E, 85% of patients did not cough during extubation compared to 50% in Group L. Extubation quality was significantly better in Group E. Although extubation time was significantly shorter in Group E, recovery time was comparable in both groups. Conclusion: Extubation just before reversal of neuromuscular blockade resulted in lesser incidence of bucking and coughing during extubation with lesser postoperative bleeding compared to traditional technique of awake extubation without added risks of regurgitation, aspiration, or delayed recovery. [ABSTRACT FROM AUTHOR]

Background : Intra-cardiac repair for tetralogy of Fallot has some degree of residual right ventricular outflow tract (RVOT) obstruction. However, the measurement of this gradient intra-operatively might get affected by the depth of anesthesia which is important for the long-term outcome. Aims : The primary aim was to compare intraoperative RVOT gradient post repair under two different anesthetic depths of 1% and 2% end-tidal sevoflurane. The secondary objective was to follow up the changes in RVOT gradient till 1 month postoperatively. Design : Observational study. Setting : Advanced Cardiac Centre of PGIMER, Chandigarh. Methods : Following intracardiac repair, RVOT gradient was measured directly by placing needle into the right ventricle and pulmonary artery at sevoflurane 1%, and subsequently, at 2% end.tidal concentration while maintaining hemodynamic stability. These gradients were also measured using transesophageal echocardiography (TEE) (ClinicalTrials.gov NCT03234582). Results : Twenty-one patients were included in this study that had intra-cardiac repair, of which pulmonary annulus was preserved for 15 cases. Mean RVOT gradients measured invasively and by TEE at end-tidal sevoflurane concentration of 1% and 2% were not significantly different (6.67 ± 4.16 mmHg vs. 6.76 ± 3.82 mmHg, P > 0.05 invasively and 13.01 ± 7.40 mmHg vs. 12.53 ± 7.11 mmHg, P > 0.05 by TEE, respectively). RVOT gradient measured by trans-thoracic echocardiography (TTE) postoperatively at the time of extubation and during follow-up at 1 month showed significant reduction (11.37 ± 6.00 mmHg, P < 0.05 and 9.23 ± 4.92 mmHg, P < 0.01 respectively). Six patients who underwent repair with transannular patch had significant pulmonary regurgitation (PR) following surgery, with no significant change in PR severity or RVOT gradient on increasing anesthetic depth. Conclusions : Postoperative RVOT gradient was not altered by changing depth of anesthesia provided systemic blood pressure was maintained. One month postrepair RVOT gradients were significantly reduced as compared to the intraoperative values. [ABSTRACT FROM AUTHOR]

In the present patient, the ET tube dislodged during TEE probe insertion after surgical repair but before the separation from CPB and decannulation of the venous drain lines. Although minimally invasive and generally safe, TEE is not free from complications including dysphagia, esophageal perforation, airway and vascular compression, and accidental endotracheal (ET) tube dislodgement. [Extracted from the article]

Background and Aims: Subcostal transversus abdominis plane (TAP) block is usually done under ultrasound guidance in laparoscopic cholecystectomy. Laparoscopic-guided subcostal TAP block is an alternate technique where ultrasound is not available. Our primary objective was to compare the success rate of ultrasound and laparoscopic approaches to the subcostal TAP block. The secondary objectives were to assess the duration of postoperative analgesia and morphine consumption postoperatively for 24 h. Methods: Eighty patients undergoing laparoscopic cholecystectomy were randomly divided into two groups with patients receiving ultrasound-guided (group U) or laparoscopy-guided (group L) subcostal TAP block at the end of surgery. The success rate was assessed by a sensory blockade of T7 and T8 dermatomes 30 min after extubation. The duration of analgesia was taken as time from block administration to the visual analogue scale of ≥3. Morphine was administered in patient-controlled analgesia (PCA) pump with a bolus of 1 mg and a lock-out interval of 10 min. The total morphine consumption was recorded. The statistical analysis was performed with student t-test and Chi-square test. Results: The success rate of group U (100%) was higher than group L (88%) but it was not statistically significant (P = 0.054). The duration of postoperative analgesia was significantly prolonged in group U (867.24 ± 135.83 min) than group L (751.31 ± 311.22 min) (P = 0.033). Morphine consumption was also less in group U (4.72 ± 0.94 mg) than group L (5.57 ± 2.53 mg) (P = 0.049). There was no significant difference in the VAS scores after 4 h postoperatively. Conclusion: Laparoscopy-guided subcostal TAP block is a suitable alternative to ultrasound-guided block and can be utilised in places where an ultrasound machine is not available. [ABSTRACT FROM AUTHOR]

Context: The concomitant use of cuffed endotracheal tubes (ETT) and transesophageal echocardiography (TEE) probes increases ETT cuff pressures (CP), which may contribute to mucosal ischemia and perioperative complications such as failed extubation.Aims: To assess changes in ETT CP after TEE insertion in patients of different age groups undergoing congenital heart surgery and examine the relationship between ETT CP and postoperative extubation failure.Settings and Design: Single-center quality improvement project.Subjects and Methods: ETT CP was measured with a manometer following intubation and again after TEE insertion. Tracheal perfusion pressure was then calculated and postoperative extubation failures were recorded.Statistical Analysis: Chi-square testing, Fisher's-exact testing, one-way analysis of variance testing or Kruskal-Wallis testing with Dunn's pairwise, and student's t-test or Wilcoxon rank-sum testing were used to analyze the data.Results: Median ETT CP increased significantly after TEE insertion in each age group, with infants showing a smaller magnitude of increase (+2 [1-6] cm H2O, P < 0.001) than adults (+12 [8-14] cm H2O, P = 0.008) (intergroup comparison P = 0.002). Five patients (9%) failed extubation, all of which were infants. Within the infant subgroup, no significant difference existed between failed vs successful extubation regarding ETT CP during bypass (15 ± 1 vs 16 ± 2 mmHg, P = 0.206) or tracheal perfusion pressure pre-bypass (34 ± 9 vs 38 ± 11 mmHg, P = 0.518), during bypass (20 ± 9 vs 22 ± 6 mmHg, P = 0.697), or post-bypass (42 ± 9 vs 41 ± 9 mmHg, P = 0.923). There was a significant difference in cardiopulmonary bypass duration (151 ± 29 vs 85 ± 32 min, P < 0.001).Conclusion: Factors beyond intraoperative ETT CP likely play a larger role in postoperative extubation failure. [ABSTRACT FROM AUTHOR]

Background: Emergence agitation for pediatric patients after general anesthesia is one of the postoperative complications. The relationship between consciousness at tracheal extubation and emergence agitation is not clear.Aim: The aim of the present study was to determine whether tracheal extubation of anesthetized pediatric patients with heart disease by propofol decreases the incidence of emergence agitation.Settings and Design: This was a retrospective case-control study conducted at a children's hospital. Materials and Methods: Pediatric patients with heart disease aged 0-14 years who underwent cardiac catheterization under general anesthesia by propofol between October 2014 and September 2018 were enrolled. The incidence of emergence agitation by anesthetized extubation was compared with that by awake extubation.Statistical Analysis Used: Logistic regression analysis was performed.Results: Anesthetized extubation was performed in 202 patients and awake extubation was performed in 56 patients. The incidence of emergence agitation was significantly lower in patients who underwent anesthetized extubation than in patients who underwent awake extubation (25.2% vs. 69.6%, P = 0.000). In logistic regression analysis, anesthetized extubation [odds ratio (OR): 0.075, 95% confidence interval (CI): 0.034-0.165, P = 0.000] and older age (OR: 0.808, 95% CI: 0.728-0.897, P = 0.000) were associated with a decreased incidence of emergence agitation, and preoperative anxiety (OR: 2.220, 95% CI: 1.060-4.660, P = 0.03) was associated with an increased incidence of emergence agitation.Conclusions: Tracheal extubation under anesthesia by propofol decreases the incidence of emergence agitation in pediatric patients with heart disease. [ABSTRACT FROM AUTHOR]

Background: Protocolized ventilator weaning (PW) strategies utilizing spontaneous breathing trials (SBTs) result in shorter intubation duration and intensive care unit (ICU) length of stay (LOS). We compared respiratory therapy (RT)-driven PW versus usual care (UC) as it pertains to physiologic respiratory parameters, intubation duration, extubation success/reintubation rates, and ICU LOS. Methods: prospective, multicentric, randomized controlled trial was performed in closed medical and surgical ICUs with 24/7 in-house intensivist coverage at six academic medical centers in a resource-limited setting from October 18, 2007, to May 03, 2014. Extubation readiness was determined by the attending physician (UC) or the respiratory therapist (PW) using predefined criteria and SBT. Physiologic variables, serial blood gas measurements, and weaning indices were assessed including the Rapid Shallow Breathing Index (RSBI), negative inspiratory force (NIF), occlusion pressure (P0.1), and dynamic and static compliance (Cdyn and Cs). Results: total of 5502 patients were randomized (PW 2787; UC 2715), of which 167 patients died without ventilator weaning (PW 90; UC 77) and 645 patients were excluded (PW 365; UC 280). Finally, a total of 4200 patients were analyzed (PW 2075; UC 2125). The PW group displayed improvements in minute ventilation (P < 0.001), Cs and Cdyn (both P < 0.05), P0.1 (P < 0.001), NIF (P < 0.001), and RSBI (P < 0.001). Early re-intubation (≤48 h) rates were lower in the PW group (16.7% vs. 24.8%; P < 0.0001), as were late re-intubation rates (5.2% vs. 25.8%; P < 0.0001). Intubation duration was longer in the PW group (P < 0.001), however, hospital LOS was shorter (P < 0.001). Mortality was unchanged (P = 0.19). Conclusion: PW with RT-driven extubation decisions is safe, effective, and associated with decreased re-intubation (early and late), shorter hospital stays, increased intubation duration (statistically but not clinically significant), and unchanged in-patient mortality. [ABSTRACT FROM AUTHOR]

Background: Surgeries in prone position expose a patient to multitude of complications including laryngeal edema which may be related to the volume of fluid administered. Administering larger volumes of fluid intraoperatively may contribute to significant tissue edema, leading many anesthesiologists to practice a restrictive fluid infusion strategy. Although previous studies have compared fluid infusion strategies, changes in airway dimensions leading to airway edema have not been extensively investigated. Here, we compared two fluid infusion regimens in patients undergoing spine surgery in the prone position, and assessed their association with airway edema by means of the cuff leak test (CLT). Aims: The aim of this study was to test the hypothesis whether a larger volume of crystalloid administration in spine surgeries performed in prone position would result in greater chances of airway edema, than would a restricted infusion policy, utilizing the CLT. Materials and Methods: After ethical committee approval, thirty patients, aged 21–60 years, American Society of Anesthesiologists Status I or II, scheduled for elective spine surgery in the prone position, were selected. Group 1 (restrictive group) received 3 mL.kg− 1.h− 1, whereas Group 2 (permissive group) received 5 mL.kg− 1.h− 1 of crystalloids plus urine output replacement. The airway edema was assessed by CLT which was performed soon after intubation (T1) and before extubation (T2). Cuff leak volume (CLV) was calculated from the difference in tidal volumes before (VTi) and after cuff deflation (VTe). Airway edema was evaluated by calculating the differences in the CLV at T1 and T2 (ΔCLV); the more the value of Δ CLV which means greater difference between these two points, the more the decrease in laryngeal lumen, signifying an increased risk of airway edema. Results: Decrease in laryngeal lumen was observed in patients who received permissive fluid regimen than that of the restrictive group, signifying more chances of airway edema in the former group. In addition, a poor correlation was found between the duration of anesthesia and development of airway edema in our study group. Conclusions: Because surgeries in the prone position are at risk of airway edema, restrictive fluid regimen strategy should be preferred over the liberal one as there are more chances of reduction in laryngeal lumen dimensions with permissive fluid infusions. [ABSTRACT FROM AUTHOR]

Background: Failed extubation and subsequent re-intubation in ventilated patients can lead to many adverse consequences, including organizational and personal expenditures. Extubation decisions based on subjective methods are a major contributor to extubation failure. This study compared the effect of cough peak expiratory flow (PEF) measurement and cough strength measurement using the white card test (WCT) on extubation success. Materials and Methods: This randomized clinical trial was conducted in two groups in 2018 on 88 ventilated patients in intensive care units of Imam Reza Hospital in Mashhad, Iran. Ninety patients were divided into two groups of 45, but two were excluded from the white card group. The criteria established for extubation included PEF ≥60 L/ min during coughing in the cough PEF group and noticing card humidity in the WCT group. In both groups, extubation success was determined as the sole outcome and was compared with the standard PEF and cough strength. The researcher who assessed the outcome and statistician were blinded about group allocation. Results: Extubation success was measured as 97.8% in the cough PEF group and 76.7% in the WCT group (P = 0.003) during the first 24 h. In the second 24 h, however, successful extubation was reported as 90.9% in the cough PEF group and 60.6% in the WCT group (P = 0.002). Conclusion: Using the cough PEF rate increases the likelihood of extubation success and reduces adverse effects, and is recommended to be used for extubation decision-making. [ABSTRACT FROM AUTHOR]

Background: Myocardial damage due to ischemia and reperfusion is still unavoidable during coronary surgery. Anesthetic agents have myocardial preconditioning effect. Ketamine has sympathomimetic effect, while dexmedetomidine has a sympatholytic effect in addition to anesthetic, analgesic, and anti-inflammatory properties of both the drugs. This study was carried out to compare ketamine–dexmedetomidine (KD) combination with fentanyl–propofol (FP) combination on the release of cardiac troponin T (cTnT) and outcome after coronary artery bypass graft. Patients and Methods: Ninety adult patients who underwent coronary artery bypass grafting (CABG) were assigned to receive either KD base anesthesia (KD group) or FP anesthesia (FP group). Trends of high-sensitive cTnT, CK-MB, and serum cortisol were followed in the first postoperative 24 h. Other outcomes were vital signs, weaning from cardiopulmonary bypass, tracheal extubation time, and echocardiographic findings. Results: There was a significant lower release of cTnT in KD group than FP group during its peak values at 6 h after aortic unclamping (92.01 ± 7.332 in KD versus 96.73 ± 12.532 ng.L−1 P = 0.032). significant lower levels of serum cortisol levels were noted KD group than in FP group at 6 and 12 h after aortic unclamping P < 0.001. As regard tracheal extubation time, patients assigned to KD group extubated earlier than whom in FP group 202.22 ± 28.674 versus 304.67 ± 40.598 min respectively P < 0.001. Conclusion: The use of KD during on-pump CABG confers better myocardial protective and anti-inflammatory effect than fentanyl propofol. [ABSTRACT FROM AUTHOR]

Background: Upper thoracic epidural analgesia (TEA) is compared with lower thoracic epidural analgesia for the perioperative pain management and fast tracking in patients undergoing off pump coronary artery bypass grafting (OPCAB) surgery for the intraoperative hemodynamic, quality of analgesia, incentive spirometry, time to awakening & extubation and intensive care unit (ICU) duration.Materials and Methods: A prospective, randomized comparative clinical study was conducted with total of 60 patients randomized to either Group U: Upper TEA (n = 30) or Group L: Lower TEA (n = 30). Visual analog scale (VAS) was recorded in both the groups during rest and deep breathing at the various time intervals postextubation. Both the groups were also compared for intraoperative hemodynamics, incentive spirometry, time to awakening, and extubation and ICU duration. Statistical analysis was performed using the independent Student's t-test. A value of P < 0.05 was considered statistically significant.Results: Postextubation VAS score at rest and deep breathing at 0, 3, 6, 12, 24, 36, and 48 h were statistically significant in both groups (P ≤ 0.05). Incentive spirometry, time to awakening and extubation and duration of ICU stay were also statistically significant (P ≤ 0.05) between the groups.Conclusion: Lower thoracic epidural was better than upper thoracic epidural in perioperative pain management and fast tracking in OPCAB surgery. [ABSTRACT FROM AUTHOR]

Background: Myocardial protection in cardiac surgeries is a must and requires multimodal approaches in perioperative period to decrease and prevent the increase of myocardial oxygen demand and consumption that lead to postoperative cardiac complications including myocardial ischemia, dysfunction, and heart failure.Study Design: Prospective, controlled, randomized, double-blinded study.Aims: This study aims to study the effect of propofol-dexmedetomidine continuous infusion cardioprotection during open-heart surgery in adult patients.Materials and Methods: Sixty adult patients of both sexes aged from 30 to 60 years old belonging to the American Society of Anesthesiologists III or IV undergoing open-heart surgery were randomly divided into two equal groups: Group P (control group) received continuous infusion of propofol at a rate of 2 mg/kg/h and 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 μg/kg/h (used as a placebo) and Group PD received continuous infusion of propofol at a rate of 2 mg/kg/h and dexmedetomidine 200 μg diluted in 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 μg/kg/h. Infusion for all patients started immediately preoperative till skin closure. Hemodynamic measurements of heart rate (HR), invasive mean arterial pressure, and oxygen saturation were recorded at baseline before induction of anesthesia, immediately after intubation, at skin incision, at sternotomy and every 15 min in the 1st h then every 30 min during the prebypass period then every 15 min in the 1st h then every 30 min after weaning from CPB till the end of the surgery. Serum biomarkers; cardiac troponin (cTnI) and creatine kinase-myocardial bound (CK-MB) samples were measured basally (T1), 15 min after unclamping of the aorta (T2), immediate postoperative (T3), and 24 h postoperative (T4). Intraoperative data were also recorded including the number of coronary grafts, aortic cross-clamping duration, duration of cardiopulmonary bypass (CPB), duration of surgery, and rhythm of reperfusion. Fentanyl requirement, extubation time, and length of intensive care unit (ICU) stay were also recorded for every case.Results: There was no statistically significant differences as regard to demographic data between the studied two groups. HR and blood pressure recorded was lower in the PD group than the control group, and this difference was noted to be statistically significant. Furthermore, the PD group showed lower levels of myocardial enzymes (cTnI and CK-MB), decreased total fentanyl requirement, earlier postoperative extubation, and shorter ICU stay than the P(control) group.Conclusion: The use of propofol-dexmedetomidine in CPB surgeries offers more cardioprotective effects than the use of propofol alone. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is associated with pneumoperitoneum and hemodynamic disturbances. Pregabalin and Clonidine have been used for anesthetic effects, but a better drug for controlling hemodynamic parameters is being investigated. Aims: The study was done to assess and compare the efficacy of preoperative single oral dose of pregabalin and clonidine in maintaining the hemodynamic parameters in the LC. Settings and Design: The prospective, interventional, randomized, comparative, single-blinded study was conducted in the department of anesthesia and surgery from January 2015 to September 2016 after taking approval from the institutional ethical committee. Materials and Methods: The study included a total of 90 patients, aged between 18 and 56 years of both sexes scheduled for elective LC. Patients were randomized into three groups of 30 each who received oral pregabalin 150 mg, clonidine 200 ug, and placebo. The hemodynamic parameters were recorded at various time intervals along with any adverse events. Statistical Analysis: Quantitative variables were compared using unpaired t-test (when the data sets were not normally distributed) between the two groups. Qualitative variables were compared using Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: There was a significant increase in the heart rate (HR) and systolic, diastolic, and mean blood pressure during laryngoscopy and pneumoperitoneum in the control group as compared to both pregabalin and clonidine. HR was significantly lower in clonidine group after extubation and in postoperative period than both control group and pregabalin group. There was no major difference in the incidence of side effects. Conclusion: Both pregabalin (150 mg) and clonidine (200 ug) were effective in controlling the hemodynamic parameters during LC, with clonidine providing better hemodynamic stability than Pregabalin. [ABSTRACT FROM AUTHOR]

Healthcare workers (HCW's) are at increased risk of corona virus disease (COVID-19) infection during aerosol generating activities. The aerosol box has been used during intubation and extubation to prevent transmission of infection to HCWs. Isolation room with negative pressure has been advocated for COVID-19 patients. The described containment box has been designed to be useful in COVID intensive care unit (ICU) as a multipurpose box which is a cost effective and readily available resource. This innovation combines the containment box with negative pressure generation using central vacuum [ABSTRACT FROM AUTHOR]

Background: The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management. Aims and Objectives: The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery. Materials and Methods: Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test. Results: A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K. Conclusion: Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects. [ABSTRACT FROM AUTHOR]

Background/aims: Methadone may offer advantages in facilitating early extubation after cardiac surgery, but very few data are available in the pediatric population.Setting/design: Community tertiary children's hospital, retrospective case series.Materials and Methods: We performed a retrospective analysis of all pediatric cardiac surgical patients for whom early extubation was intended. A multimodal analgesic regimen was used for all patients, consisting of methadone (0.2-0.3 mg/kg), ketamine (0.5 mg/kg plus 0.25 mg/kg/h), lidocaine (1 mg/kg plus 1.5 mg/kg/h), acetaminophen (15 mg/kg), and parasternal ropivacaine (0.5 mL/kg of 0.2%). Outcome variables were collected with descriptive statistics.Results: A total of 24 children [median = 7 (interquartile range = 3.75-13.75) years old, 23.7 (14.8-53.4) kg] were included in the study; 22 (92%) had procedures performed on bypass and 11 (46%) involved a reentry sternotomy. Methadone dosing was 0.26 (0.23-0.29) mg/kg. None of the children required intraoperative supplemental opioids; 23 (96%) were extubated in the operating room. The first paCO2 on pediatric intensive care unit admission was 51 (45-58) mmHg. Time to first supplemental opioid administration was 5.1 (3.5-9.5) h. Cumulative total supplemental opioids (in intravenous morphine equivalents) at 24 and 72 h were 0.2 (0.09-0.32) and 0.42 (0.27-0.68) mg/kg. One child required postoperative bilevel positive airway pressure support, but none required reintubation. None had pruritus; three (13%) experienced nausea.Conclusion: A methadone-based multimodal regimen facilitated early extubation without appreciable adverse events. Further investigations are needed to confirm efficacy of this regimen and to assess whether the excellent safety profile seen here holds in the hands of multiple providers caring for a larger, more heterogeneous population. [ABSTRACT FROM AUTHOR]

Background: Self-extubation is a common clinical problem associated with mechanical ventilation in trauma patients worldwide. Objectives: This study aimed to evaluate the predisposing factors, complications, and outcomes of self-extubation in patients with head injury. Methods: This was a retrospective cohort study. Settings: The study was conducted in a trauma intensive care unit (TICU). Patients: All intubated patients with head injury admitted to TICU between 2013 and 2015 were included in the study. Interventions: Planned compared to selfextubation during weaning from sedation. Measurements: Risk, predictors, and outcomes of self-extubation were measured. Main Results: A total of 321 patients with head injury required mechanical ventilation, of which 39 (12%) had self-extubation and 12 (30.7%) had reintubation. The median Glasgow Coma Scale, head abbreviated injury score, and injury severity score were 9, 3, and 27, respectively. The incidence of self-extubation was 0.92/100 ventilated days. Self-extubated patients were more likely to be older, develop agitation (P = 0.001), and require restraints (P = 0.001) than those who had planned extubation. Furthermore, self-extubation was associated with more use of propofol (P = 0.002) and tramadol (P = 0.001). Patients with self-extubation had higher Ramsay sedation score (P = 0.01), had prolonged hospital length of stay (P = 0.03), and were more likely to develop sepsis (P = 0.003) when compared to the planned extubation group. The overall in-hospital mortality was significantly higher in the planned extubation group (P = 0.001). Age-adjusted predictors of self-extubation were sedation use (adjusted odds ratio [aOR]: 0.06; P = 0.001), restraint use (aOR: 10.4; P = 0.001), and tramadol use (aOR: 7.21; P = 0.01). Conclusions: More than one-tenth of patients with traumatic head injury develop self-extubation; this group of patients is more likely to have prescribed tramadol, develop agitation, and have longer hospital length of stay and less sedation use. Further prospective studies are needed to assess the predictors of self-extubation in TICU. [ABSTRACT FROM AUTHOR]

Background: Creation of pneumoperitoneum in laparoscopic surgeries with carbondioxide to intra-abdominal pressures higher than 10 mmHg induces significant alterations of hemodynamics. To counteract, propofol or dexmedetomidine was compared and postoperative recovery assessed. Aims: The aim of this study was to compare the efficacy of standard dose of propofol versus low-dose dexmedetomidine as infusions to limit hemodynamic instability with pneumoperitoneum and facilitate recovery. Settings and Design: This was a prospective, randomized, single-blind, comparative study. Materials and Methods: Seventy patients between 18 and 60 years belonging to the American Society of Anesthesiologists Physical Status Class 1 and 2 scheduled for laparoscopic surgeries were randomly divided – Group D: To receive dexmedetomidine 1 μg/kg over 10 min before and 0.2 μg/kg/h infusion after intubation till the end of pneumoperitoneum and Group P: To receive propofol 100 μg/kg/min after intubation till the end of pneumoperitoneum. Variables such as heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded at baseline, preinduction, after loading dose of dexmedetomidine, postinduction, postintubation, at pneumoperitoneum, every 15 min till the end of surgery, at extubation, and postoperatively for 2 h monitored with Ramsay Sedation Scale and modified Aldrete's score. Results: Hemodynamic stability was better maintained in Group D than Group P with significant attenuation of hemodynamic stress response to pneumoperitoneum in terms of HR (3% decrease vs. 18% increase), SBP (5% decrease vs. 12% increase), DBP (2%increase vs. 16% increase), and MAP (4% decrease vs. 7% increase). Postoperatively, significant sedation was noted till 90 min in Group D and recovery was better in Group P. Conclusion: With doses of test drug infusion used, there is better attenuation of hemodynamic stress response to pneumoperitoneum with dexmedetomidine and faster recovery with propofol. [ABSTRACT FROM AUTHOR]

Background and Aims: Early extubation in neurocritical patients has several potential benefits. Glasgow Coma Scale (GCS) is a crude measure of neurologic function in these patients and a low GCS score does not necessarily mean contraindication for extubation. Data on patients with neurosurgical or neurological pathology undergoing early extubation utilizing the airway score criteria is limited. Hence, this study was conceived to assess the usefulness of modified airway care score (ACS) as a criterion for successful extubation of neurocritical patients whilst comparing various outcomes. Material and Methods: One hundred and twenty four patient who underwent endotracheal intubation in the neurocritical care unit were enrolled in this prospective observational study over a period of 12 months. Patients were randomly enrolled into either the study group patients (S), who were extubated immediately after a successful spontaneous breathing trial (SBT) and an ACS ≤7 or into the control group (N), wherein patients were extubated/tracheostomized at discretion of the attending neurointensivist. Both groups were observed for comparison of preset outcomes and analyzed statistically. Results: Patients of study group experienced a statistically significant shorter extubation delay (3.28 h vs 25.41 h) compared to the control group. Successful extubation rate was significantly higher and reintubation rate was significantly lower in study group (6.6% vs 29.3%). Incidence of nosocomial pneumonia, duration of ICU stay and overall duration of mechanical ventilation were significantly lower in the study group. ACS and GCS had a negative correlation at the time of extubation. Conclusion: ACS can be used as a criterion for successful early extubation of neurocritical patients. [ABSTRACT FROM AUTHOR]

Background and Aims: General anesthesia using agents like Desflurane or Sevoflurane are beneficial for early recovery especially for ambulatory procedures. The aim of this randomised controlled double-blind study was to compare the early recovery profiles of sevoflurane and desflurane in patients undergoing laparoscopic cholecystectomy. Material and Methods: ASA I, II patients, undergoing laparoscopic cholecystectomy were randomly assigned to receive desflurane (n = 30) or sevoflurane (n = 30), using Bispectral Index System (BIS) to determine the depth of anaesthesia. An independent adjudicator, who was blinded to the agent used, recorded the events during the recovery phase. The time required for extubation, eye opening, verbal response and achievement of a modified Aldrete score of 9 were recorded. Results: The time required for extubation and for eye opening was significantly shorter in the Desflurane group as compared to the Sevoflurane group [9.1 min ± 5.0 versus 12.5 min ± 7.1, P = 0.049 and 10.1 min ± 5.2 versus 6.3 min ± 4.0, P = 0.008]. Verbal Response also occurred significantly faster in the Desflurane group [12.7 min ± 5.4 versus 8.7 min ± 4.7, P = 0.002]. A significantly higher mean modified Aldrete score was seen at extubation [7.1 ± 0.6 vs 6.0 ± 0.8, P < 0.001] in the Desflurane group, which also achieved a modified Aldrete score of ≥9 significantly sooner [11.1 min ± 4.6 versus 17.8 min ± 6.9, P < 0.001] than the Sevoflurane group. The frequency of adverse effects was not significantly different in either of the groups. Conclusion: The time required for early recovery from anaesthesia, was significantly shorter in the Desflurane group compared to the Sevoflurane group. [ABSTRACT FROM AUTHOR]

Background: Application of transannular patch (TAP) during the repair of tetralogy of Fallot (TOF) leads to the development of pulmonary regurgitation (PR). This PR is known to cause right ventricular (RV) volume overload and dysfunction which in turn leads to increase in both morbidity and mortality both in immediate and long-term periods. Here, we sought to analyze the effects of polytetrafluoroethylene (PTFE) pulmonary bicuspid valve on the early outcome of patients with TOF repair where TAP is needed. Subjects and Methods: This is a retroprospective, observational study where PTFE bicuspid pulmonary valve was incorporated in all consecutive patients undergoing repair of TOF involving the application of TAP. Postoperative inhospital course was assessed, and patients were followed till 6 months for the status of PR and peak RV outflow tract (RVOT) gradient. Results: 38 patients were enrolled in the study. The mean age of participants was 53.66 ± 78.67 months. Extubation in operating room was done in 31 (81.58%) patients. Duration of ventilator support was 10.48 ± 24.22 h, and duration of hospital stay was 7.95 ± 3.08 days. These data were compared with three recent studies where only TAP was applied. Extubation in operating room, mechanical ventilation time, and hospital stay were significantly improved in the present study. Out of 37 live patients, four (10.81%) patients had no PR, 28 (75%) had mild, 1 (2.7) had moderate, and 4 (10.81%) had severe PR. Average RVOT peak gradient was 18.8 ± 8.1 mmHg. Conclusion: Incorporation of PTFE bicuspid pulmonary valve during the repair of TOF appears to facilitate early extubation and thus reduces ventilator-associated comorbidities. Study needs further long-term follow-up to look for behavior of PTFE bicuspid valve. [ABSTRACT FROM AUTHOR]

This case report reviews the hospital course of a 15-month-old girl admitted to the PICU for acute respiratory failure due to enterovirus infection; who subsequently had multiple extubation failures secondary to acute transverse myelitis. This rare presentation highlights the importance of assessing the neurological status in a patient with rhino-enteroviral respiratory infection and of considering acute transverse myelitis as an etiology for difficulty with extubation. [ABSTRACT FROM AUTHOR]