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Author(s): Rajesh S. Rautela [1]; Michell Gulabani [1]; Pramod Kumar (corresponding author) [1]; Rashmi Salhotra [1]; Medha Mohta [1]; Kshitiz Verma [1] INTRODUCTION Etomidate is a favoured intravenous (IV) induction [...], Background and Aims: Etomidate is a popular induction agent, but its use is associated with myoclonus in 50-80 of non-premedicated patients. This study aims to compare dexmedetomidine and butorphanol for their relative efficacy in preventing etomidate-induced myoclonus. Methods: This randomised study was conducted after obtaining institutional ethical committee clearance and written informed consent from sixty American Society of Anesthesiologists (ASA) I or II consenting patients between 18 and 60 years of age of either sex who had been scheduled for elective surgeries under general anaesthesia. Patients were randomly allocated to dexmedetomidine 0.5 μg/kg (Group D) or butorphanol 0.015 mg/kg (Group B). Both the drugs were given as an infusion over a period of 10 min before induction of anaesthesia. The primary outcome was the incidence of myoclonic movements after etomidate, and the secondary outcomes were the severity of myoclonus, changes in the haemodynamic parameters and incidence of airway complications. Normally distributed variables were compared using Student's t-test, and non-normally distributed variables were compared using Mann-Whitney U test. Qualitative data were analysed using Chi-square/Fisher's exact test. A P-value Results: The incidence of etomidate-induced myoclonus was significantly higher in group B compared to group D (P = 0.035). The median (interquartile range [IQR]) of myoclonus grade in patients of group D was 0.00 (0.00-3.00), and group B was 2.50 (0.00-3.00) (P = 0.035). Haemodynamics and airway-related complications were comparable between the groups. Conclusion: Dexmedetomidine was more effective than butorphanol in preventing etomidate-induced myoclonus. Keywords: Anaesthesia, butorphanol, dexmedetomidine, etomidate, myoclonus

Background: Percutaneous nephrolithotomy (PCNL) surgery may be associated with postoperative Acute Kidney Injury (AKI). Commonest intraoperative risk factors for postoperative AKI include hypotension and hypoperfusion. Intravenous fluids are administered during surgery to optimize intravascular status and thus prevent hypotension. Conventionally, intravenous fluids are administered during surgery using pre-calculated volumes based on maintenance needs. Alternatively, goal-directed fluid therapy using Stroke Volume Variation (SVV) can be used to decide the volume of intravenous fluids. We compared early postoperative AKI following intraoperative use of conventional (group C, n=15) versus SVV directed fluid therapy (group S, n = 17) in patients undergoing PCNL surgery. Methods: This double-blinded pilot study involved 32 adult patients, randomised to two groups according to type of intraoperative fluid therapy (group C or group S). Postoperative AKI was diagnosed as per KDIGO guidelines. Results: Incidence of early postoperative AKI was clinically higher for group S, though statistically similar, as compared to group C (47.1% versus 26.7%) (P = 0.234). Postoperative increase in eGFR, and 24-hour urine output were clinically greater for group S (P > 0.05). Volume of intraoperative fluids infused was significantly lesser for group S (P = 0.000). The incidence of hypotension and requirement of vasopressor to maintain blood pressure was clinically lesser, though statistically similar for group S as compared to group C (P = 0.659). Conclusions: There appears to be a clinical trend of greater incidence of AKI with use of SVV guided therapy despite better intraoperative hemodynamic stability and greater improvement in postoperative urine output and eGFR in the first postoperative day. Keywords: Percutaneous nephrolithotomy, Acute kidney injury, Fluid therapy, General anesthesia, Blood pressure

Objectives: Increase in Intra-Abdominal Pressure (IAP) is commonly accepted as a cause for intrathecal dose sparing and consequently higher level of sensory block during pregnancy. There is however very little actual data evaluating the relationship. Thus, we aimed to evaluate association between IAP and maximum level of sensory block following intrathecal injection of hyperbaric bupivacaine as well as plain levobupivacaine for cesarean section. Methods: Preliminary randomized controlled blinded trial included females aged 18-40 years, scheduled for elective cesarean section under single-shot subarachnoid block. After randomization, they received either intrathecal hyperbaric bupivacaine (group H) or plain (isobaric) levobupivacaine (group P) in a dose of 12.5 mg (n = 40 each). IAP was measured before and after the spinal block, using the recommended intravesical technique. The maximum level of sensory block and the IAPs were measured in each patient. Results: There was no significant correlation of IAPprespinal with maximum level of sensory block for group H (P = 0.334; rs = -0.157) or group P (P = 0.637; rs = -0.078). Similarly, there was no significant correlation of the IAPpostspinal: group H (P = 0.370; rs = -0.145); and group P (P = 0.714; rs = -0.061). Both group H and group P had similar IAPprespinal (15.9 [14.3-18.2] and 15.3 [14.3-17.4] mmHg, respectively) (P = 0.474); as well as IAPpostspinal (15.2 [13.8-17.2] and 14.6 [13.4-16.0] mmH, g respectively) (P = 0.239). Among ancillary observations, duration of sensory block was significantly longer for group P versus group H (133.6 ± 24.2 and 103 ± 23.4 mins; P < 0.000). However, the maximum levels of sensory and motor block, respective times required to achieve them, as well as incidences of intraoperative hypotension and bradycardia were statistically similar between group H and group P (P > 0.05). Conclusions: The IAP was raised to the level of conventionally defined intra-abdominal hypertension (>12 mmHg) in patients scheduled for elective cesarean section. However, despite being increased, the IAPprespinal or IAPpostspinal did not show any significant association with the maximum level of sensory block (P > 0.05).

Background The patient partnership is desirable for the optimal management of comorbidities. This became significant more so during the coronavirus disease 2019 (COVID-19) crisis wherein health infrastructure was overburdened. Objectives The aim of this study was to estimate the clinicoepidemiological profile, health literacy regarding predisposing risk factors, and disease management in patients with COVID-19-associated mucormycosis (CAMCR). Materials and Methods A structured questionnaire-based study on randomly chosen 100 microbiologically proven patients of CAMCR, consisting of 38 multiple choice questions, was designed with each answer having a patient and assessor response to it. Results A male predilection was seen (68%) with rhino-orbital (73%) being the commonest anatomic site. Forty-nine percent of the study participants had pre-existing diabetes of which 62% did not carry out regular blood sugar monitoring and in 18%, blood sugars were controlled prior to COVID-19. Thirty-five percent of patients with mild COVID-19 illness were treated with unwarranted steroids and 56% of patients had fluctuating blood sugar levels, during COVID-19 illness. Seventy-nine percent of patients were not vaccinated against COVID-19, 16% only partially vaccinated. Seventy-one percent of patients were not aware of red flag signs and of mucormycosis with 8% presenting early, on noticing nasal symptoms. Conclusion This study observed diabetes as the most common comorbidity in patients with CAMCR. A lacuna in the health literacy of diabetics presenting with CAMCR was found. Additionally, knowledge regarding glycemic control during COVID-19 illness with or without the use of steroids and awareness of the “red flag” signs of CAMCR were mostly lacking. Interventions to improve awareness amongst patients with diabetes should help in optimal glycemic control, and avoid potential complications like severe COVID-19 illness, and mucormycosis.

Background: Etomidate is a popular induction agent, due to its several advantages for example, an extremely stable hemodynamic profile with no effects on sympathetic nervous system and baroreceptors, minimal effect on respiration and also prevents histamine release in healthy patients or in those with reactive airway disease. It, however, may be associated with myoclonus whose incidence has been reported as 50%–80% in nonpremedicated patients. Ideally, a pretreatment drug for preventing myoclonic movements should be short acting, not have significant effects on respiration and hemodynamics, and not prolong recovery from anesthesia. Midazolam has been used as a pretreatment to attenuate myoclonus in different doses with varied results, but the optimal dose has not been established. The present study was planned to compare the effect of three doses of midazolam, i.e., 0.015 mg/kg, 0.03 mg/kg, and 0.05 mg/kg in preventing etomidate-induced myoclonus. Materials and Methods: This study comprised 164 American Society of Anesthesiologists I/II consenting patients between 18 and 60 years. They were randomly divided into four groups after which pretreatment with normal saline in group M0, midazolam 0.015 mg/kg in group M0.015, 0.03 mg/kg in group M0.03, and 0.05 mg/kg in group M0.05 was administered. The primary outcome was the incidence of myoclonus after etomidate. The secondary outcome measures included severity of myoclonus and changes in hemodynamic parameters. One-way analysis of variance with Bonferroni's correction was used to compare quantitative data. Chi-square test was applied for qualitative data. Further, as there were four groups with multiple comparisons, Bonferroni's correction was applied and P < 0.01 was considered statistically significant. Results: We observed a significant reduction in the incidence of myoclonus of group M0.015 as compared to group M0 (P < 0.001). A significant reduction in severity of myoclonus was observed in all the three midazolam groups compared to the control group (P < 0.001) without any significance among the patients receiving different doses of midazolam. Conclusion: We recommend using midazolam pretreatment in a dose of 0.015 mg/kg for prevention of etomidate-induced myoclonus.

Introduction: Mucormycosis, an aggressive fungal infection may result in a difficult airway owing to its inflammation. King Vision Video Laryngoscope (KVVL) is a useful addition to a difficult airway armamentarium. McCoy laryngoscope with hinged tip is well-known equipment of difficult airway cart. Conventional Macintosh laryngoscope dominates in anaesthesia practice. Standard, existing and contemporary devices were compared in difficult airways resulting from mucormycosis. Aim: To compare the relative performance of KVVL, McCoy, and Macintosh laryngoscopes based on the ease of intubation and haemodynamic response in patients with mucormycosis. Materials and Methods: The present study was a randomised clinical trial, conducted in a tertiary care government hospital, during June-August 2021 on 90 consenting patients of 18-65 years age, belonging to either sex with microbiologically confirmed mucormycosis undergoing debridement surgery. Group A was intubated with a non channeled KVVL, while group B had McCoy and group C had Macintosh laryngoscope. Primary outcome parameters were Cormack Lehane (CL) grade, time from laryngoscopy to successful intubation, number of attempts, any adjuncts or optimisation maneuvers, and any mucosal injury. Secondary outcome parameters were Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Blood Pressure (MBP) measured on arrival, before induction, after induction, and at 1, 2, 3, 5, and 7 minutes after intubation. Comparison of quantitative variables not normally distributed were analysed using Kruskal-Wallis test. Post-hoc analysis by Dunn’s multiple pairwise comparison test. Friedman test followed by pairwise comparison was done to compare haemodynamic parameters within each group. Chi-square test was used for qualitative variables. The p-value ≤0.05 was considered to be statistically significant. Results: The CL grade was lowest in group B (1.83±0.38) against group A (1.93±0.25), group C (2.13±0.35) with p-value of 0.029. Time from laryngoscopy to successful intubation was the least in group B (19.5±3.98 seconds) against group A (26.07±9.8 seconds), group C (21.33±3.74 seconds) with p-value of 0.002. No significant difference was there in the number of attempts, airway adjuncts/optimisation maneuvers, mucosal injury. Haemodynamic variables were comparable. Conclusion: McCoy laryngoscope was found to perform best in difficult airways resulting from mucormycosis. It was most effective for glottic visualisation, with the shortest time to successful intubation and, haemodynamic parameters were comparable to KVVL and macintosh laryngoscopes.

Management of a difficult airway can be a nightmare for even an experienced anaesthesiologist. Video laryngoscopes have been mentioned in the difficult airway cart as a requisite equipment according to 2016 All India difficult airway guidelines. Ambuscope is a recently introduced flexible videoscope which is portable, light weight and single use device. This was a case of 25-year-old male who presented with loss of vision in both eyes and diffuse swelling of the face in the Ophthalmology Department. A diagnosis of post Coronavirus Disease-19 (COVID-19), Rhino-orbito-cerebral mucormycosis was made. Further patient was scheduled for emergency surgical debridement and bilateral orbital exentration under general anaesthesia. Airway assessment revealed mouth opening of one finger, Mallampati (MPG) score of 4, thyromental distance of 4.5 cm and a receding mandible with normal neck flexion and extension. Ambuscope™ 3 was employed for facilitating endotracheal intubation after anaesthesia induction. Ambuscope is a useful aid in confirming the position of endotracheal tubes and tracheostomy tubes in the operating room and intensive care unit. They are a disposable, convenient and practical alternative to fibreoptic bronchoscopes in patients of difficult airway. AmbuscopeTM 3 has tip movements with 150° up and 130° down. These unique features make this equipment user-friendly in anticipated and unanticipated difficult airway scenarios. Flexible endoscopes have carved a niche for themselves in the armamentarium of the anaesthesiologist airway cart to be equipped for any challenge.

Background and Aims: Swapping of the endotracheal tube with laryngeal mask airway (LMA) before emergence from anaesthesia is one of the methods employed for attenuation of pressor response at extubation. We decided to compare the placement of ProSeal ™ LMA (PLMA) before endotracheal extubation versus conventional endotracheal extubation in controlled hypertensive patients scheduled for elective surgeries under general anaesthesia. Methods: Sixty consenting adult patients were randomly allocated to two groups of thirty each; Group E in whom extubation was performed using standard technique and Group P in whom PLMA was inserted before endotracheal extubation (Bailey manoeuvre). The primary outcome parameter was heart rate (HR). The secondary outcomes were systolic, diastolic and mean blood pressure (MBP), electrocardiogram, oxygen saturation and end-tidal carbon dioxide. Two-tailed paired Student's t-test was used for comparison between the two study groups. The value of P< 0.05 was considered as statistically significant. Results: The patient characteristics, demographic data and surgical procedures were comparable in the two groups. A statistically significant decrease was observed in HR in Group P as compared to Group E. Secondary outcomes such as systolic, diastolic and MBP depicted a statistically insignificant difference. Conclusion: Bailey manoeuvre was not effective method to be completely relied upon during extubation when compared to standard extubation.

An 11-year-old male child, known case of down’s syndrome with congenital oesophageal stricture was posted for oesophageal dilatation. Preoperative airway assessment revealed a high arched palate, receding mandible and Mallampati Score of 2. During surgery, after loss of consciousness which was described as loss of eyelash reflex and adequate jaw relaxation, direct laryngoscopy and endotracheal intubation was attempted with a cuffed endotracheal tube number 5.0mm ID (internal diameter). The endotracheal tube could not be negotiated smoothly, so 5.0mm ID uncuffed endotracheal tube was used which passed through easily, but on auscultation revealed a significant leak. Later, intubation via a Micro Laryngeal Surgery (MLS) cuffed tube 4.0mm ID was attempted. The MLS tube advanced smoothly and there was no associated leak on positive pressure ventilation. Thus by innovative thinking and avant-garde reasoning, a definitive airway device could be positioned with no other suitable alternative at hand.

Background and Aim : Patients with complete dentures more occasionally neglect their denture and oral health by improper maintenance of dentures, resulting in bad oral and denture hygiene. This may lead to a host of multiple local and systemic problems such as stomatitis, bacterial and fungal infections, reservoirs for distant infections, denture stains and bad breath. Most denture wearers maintain their dentures with simple manual cleansing methods, which are not adequate to effectively sanitize the reservoir of microorganisms inhabiting the denture surfaces. The aim of this study was to compare the efficacy of the use of a denture cleanser and compare it with an adjunct use of chlorhexidine mouth rinse along with the denture cleanser and possibly suggest it as a suitable protocol. Materials and Methods : Two groups of complete denture patients were selected for the study. The total number of patients in each group was 12 and the total period of the study was 21 days. Three sets of microbiological samples were collected from each patient: before the start of the study, on day 8 and on day 21 of the study. The first sample was collected after an initial washover period (7 days) with plain water before the start of the study and the second set after 1 week of study initiation, where group-1 followed protocol-I (denture cleanser only) and group-2 followed protocol-II (denture cleanser and mouth rinse). A second washout period of 7 days followed and a crossover of the protocol was performed for the groups and followed for 1 week. Then, a third set of samples were collected. The colony-forming units were calculated for each patient for each sample and statistically analyzed. Friedman test for non-parametric analysis was employed for the comparison within the groups and a Mann-Whitney test was used for the statistical comparison between the groups. Results : There was a definite reduction in the bacterial numbers and a significant statistical difference after administering the protocols in both the groups (P < 0.001). However, there was little significance on comparing the samples between the groups (P=0.026) in the initial study period, and there was no statistical significance when comparing the groups after the crossover (P=0.140). Conclusion : The use of denture cleansers definitely reduced the microbial numbers as compared to plain manual cleansing methods in complete dentures. Although there was a substantial decrease in the bacterial colonies after the use of the mouthwash, it was not statistically significant.