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Hydrocephalus is a disorder of abnormal accumulation of cerebrospinal fluid (CSF) in the ventricular system. Accumulation of CSF occurs due to an imbalance between CSF production and absorption. In the new-born and infants, hydrocephalus almost entirely presents as an enlarged head resulting from the separation of cranial bone plates, so any new-born or infant with an enlarged head should undergo evaluation. We report the case of a gross hydrocephalus in a 9-month-old infant (head circumference 55 cm) posted for ventriculoperitoneal shunt surgery with anaesthetic consideration of difficult intubation because of such a large head size, positioning, age-related pathophysiology and temperature regulation. The case was managed successfully with an uneventful hospital stay, and a significant decrease in head size was noted.

Background and Aims: Despite advances in minimally invasive surgery, postoperative pain remains a concern after laparoscopic cholecystectomy. This study aims to compare the effect of intraperitoneal instillation of bupivacaine with alpha-2 agonists (dexmedetomidine and clonidine) for postoperative analgesia. Methods: One hundred and eight patients scheduled for elective laparoscopic cholecystectomy were randomised to receive either 20 mL of 0.5% bupivacaine (Group B), 20 mL of 0.5% bupivacaine with dexmedetomidine 1 μg/kg (Group BD) or 20 mL of 0.5% bupivacaine with clonidine 1 μg/kg (Group BC). Study drug made to equal volume (40 mL) was instilled before the removal of trocar at the end of surgery. Standard general endotracheal anaesthesia with intra-abdominal pressure of 12–14 mm Hg during laparoscopy was followed uniformly. The primary objective of our study was the magnitude of pain. One way analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical variables was used. Results: The Numerical Rating Scale (NRS) scores for pain intensity did not show any statistical significance at any of the pre-defined time points. Time to first request for analgesia was shortest in group BC (64.0 ± 60.6 min) when compared to the other groups (B, 78.8 ± 83.4 min; BD, 112.2 ± 93.4 min; P < 0.05). Total amount of rescue fentanyl given in groups BD (16.8 ± 29.0 μg) and BC (15 ± 26.4 μg) was significantly less than B (35.7 ± 40.0 μg); P < 0.05). Conclusion: The addition of alpha-2 agonists to bupivacaine reduces the post-operative opioid consumption, and dexmedetomidine appears to be superior to clonidine in prolonging time to first analgesic request.

Background: A ten-point surgical APGAR score (SAS) has been previously developed and validated that provides surgeons with a simple, objective and direct rating of operative performance and risk. This score has been evaluated in different types of surgeries till date. We validated SAS in both elective and emergency abdominal surgeries separately which was not done previously. Methods: In this prospective, observational and longitudinal study, 105 surgical cases undergoing open abdominal surgeries were studied. The SAS was calculated for all patients, patients were followed up for the occurrence of any major complications or mortality during hospital stay after surgery. All the patients were divided into three groups based on their SAS score (high risk: SAS 0–4, moderate risk: SAS 5–7 and low risk: SAS 8–10) using a threshold that has been previously established. Results: The occurrence of major complications was significantly higher in high-risk SAS group (12%) than in the moderate risk group (5%). In the low-risk SAS group, the occurrence of major complications was low (1%). The mortality rate in high-risk SAS was more than that in low-risk SAS group with statistical significance both in elective and emergency cases. Conclusions: In our study, we found that patients who belong to high-risk SAS group were significantly associated with post-operative major complications and mortality in both elective and emergency surgeries. A patient with low intraoperative SAS should be considered at risk and monitored meticulously. Trial Registration: Clinical Trials Registry-India (CTRI) identifier No. CTRI/2019/02/017567.

Background: Various adjuvants were combined with local anaesthetic agents, either intrathecally or epidurally, to prolong the duration of a denser neuraxial block and achieve adequate intraoperative conditions. Methods: In this prospective randomised double-blind placebo-controlled study, 90 patients were randomly allocated into three groups of 30 each depending upon the intrathecal adjuvant used. Standardised anaesthetic technique and monitoring for subarachnoid block (and epidural catheter placement) with 3 mL of 0.5% hyperbaric bupivacaine was followed. In addition, Group K (n = 30) received 0.3 mg/kg of preservative-free ketamine, Group F (n = 30) received 25 μg (0.5 mL) of fentanyl and Group C (control group, placebo, n = 30) received 0.5 mL normal saline. Time of onset and duration of sensory and motor block and duration of analgesia, haemodynamic parameters, sedation scores intra-operatively and post-operatively and side effects were recorded and analysed. Results: The mean time (sec) to onset of sensory (P = 0.04) and motor (P = 0.02) blockade was prolonged, and the duration (min) of sensory (P = 0.003) and motor (P = 0.009) block and the duration of analgesia (min) (P = 0.022) were shorter in the Group K compared to other two groups. Fentanyl showed shorter onset time, longer duration of sensory and motor block and duration of analgesia in contrast to ketamine and placebo. Conclusions: Fentanyl (25 μg) was superior to 0.3 mg/kg of ketamine and placebo as an intrathecal adjuvant with minimal side effects.

Background: Following general anaesthesia, post-operative shivering, apart from its physiological and haemodynamic effects, has been described as even worse than surgical pain. Methods: After ethical committee approval and informed consent, ninety patients were subjected to study. They were randomly divided into three groups. Just after intrathecal bupivacaine injection, all patients received prophylactically intravenous drug as normal saline (Group C, n = 30) or ketamine 0.5 mg/kg (Group K, n = 30) or tramadol 2 mg/kg (Group T, no = 30) for shivering. The incidence and degree of shivering and the effectiveness and side effects of ketamine and tramadol in preventing shivering during the post-operative period were recorded. Results: We compared the efficacy of tramadol and ketamine in the prevention of post-anaesthetic shivering in patients undergoing surgery under GA. The incidence of post-anaesthetic shivering was significantly less with tramadol and ketamine as compared to that of the control group (P < 0.01). Tramadol and ketamine were equally effective in controlling the severity of shivering as compared to that of the control group (P = NS). The prevention of shivering was comparable in the tramadol and ketamine groups (P > 0.05). Patients in the ketamine group had statistically significant sedation at 20 and 30 min compared to the tramadol and control groups (P < 0.05). In this study, we can assume that both intravenous tramadol 2 mg/kg and intravenous ketamine 0.5 mg/kg are highly effective and comparable in the prevention of post-anaesthetic shivering and the possible mechanisms is by lowering of shivering threshold.

Background: Laryngoscopy and tracheal intubation (LTI) is associated with undesirable haemodynamic (HD) responses. Both clonidine and dexmedetomidine have been tried to attenuate this HD response. The present study was to assess whether single pre-induction dose of intravenous clonidine (2 μg/Kg) or dexmedetomidine (1 μg/Kg) is more efficient to attenuate the HD response to LTI. Methods: Sixty patients belonging to American Society of Anesthesiologists Grade I and II were randomly divided into two groups: group C (clonidine 2 μg/Kg) and Group D (dexmedetomidine 1 μg/Kg). Study drug was given as an infusion over 10 Min before induction of anaesthesia followed by standardised anaesthetic technique. Heart rate (HR) and blood pressure (BP) were studied at baseline, before study drug infusion (BSD), after study drug infusion, before LTI and at 1, 2, 3, 5 and 10 m in after intubation. Sedation score was analysed BSD, after study drug infusion and at the end of surgery Results: This study revealed suppression of HR and BP at all time points in both the groups without any significant difference in suppression of HR between the groups. The magnitude of fall in BP in the clonidine group is more compared to the dexmedetomidine group before LTI and at 3, 5, and 10 min after tracheal intubation. The patients in the dexmedetomidine group were more sedated than in the clonidine group at the end of the study drug infusion. Conclusions: Both clonidine and dexmedetomidine were effective in attenuating HD response to LTI. Dexmedetomidine appears to be superior to clonidine in maintaining stable HD.

Background: Complications associated with central venous catheter central line central line-associated bloodstream infections (CLABSIs). Methods: We prospective by studied the microbiological profile and antimicrobial susceptibility patterns of isolated bacteria from CLABSIs in respiratory intensive care unit at our a tertiary care teaching hospital in Tirupati, Andhra Pradesh. Results: Colonisers were isolated from 110 of the 288 samples without any growth in blood cultures from among 288 samples that were submitted with a clinical suspicion of sepsis from patients with eligible central line. Among these, Staphylococcus aureus was the predominant coloniser. Seventy-four were blood culture positive, of which 36 showed other sources of infection. In our study, CLABSI rate was 12.9/1000 catheterised days. Among these culture positives, predominant isolate was S. aureus, followed by Staphylococcus hominis, Acinetobacter, Klebsiella and Escherichia coli. All the S. aureus strains were sensitive to linezolid, tetracycline and vancomycin. Among Gram-negative organisms, Acinetobacter baumannii and E. coli strains were 100% sensitive to polymyxin B and tigecycline. In our study, we have observed carbapenem resistance in E. coli and A. baumannii, which is alarming. Methicillin-resistant S. aureus accounted for 71.4% of S. aureus CLABSIs. All A. baumannii (n = 6), Klebsiella (n = 4) and E. coli (n = 4) isolates were extended spectrum beta-lactamase producers. Conclusions: Strict implementation of insertion and maintenance bundle care of the central lines is mandatory to prevent colonisation.

Background: The aim of the present prospective randomised double-blind clinical study was to compare the incidence of pain-free injection following the use of this new formulation (propofol with medium-chain triglycerides [MCT] and long-chain triglycerides [LCT]) with propofol dissolved in LCT with added 2% lignocaine in patients undergoing various surgical procedures under general anaesthesia. Methods: Sixty adult patients (age range 18–50 years) were randomised to receive either 20 mL propofol dissolved in a mixture of MCT–LCT [Group L (n = 30)] or 18 mL propofol dissolved in LCT with added 2 mL 2% lignocaine [Group S (n = 30)]. A specially trained clinical research investigator assessed the occurrence of injection pain using a four-graded pain scale. Results: There was no significant difference in propofol injection pain among patients who received either LCT propofol with added lidocaine, (Group S) (33.3%) or new formulation propofol (Group L) (30.0%) (P = 0.993). Conclusions: The newer formulation, MCT–LCT propofol, is equally effective vis-à-vis the conventional propofol with added lignocaine to reduce the incidence of pain, thereby eliminating the need for addition of another drug, lignocaine.

Background and Aims: Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic consumption effectively but the timing of instillation remains debatable. This study aims at comparing pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic cholecystectomy. Methods: Ninety patients belonging to American Society of Anesthesiologists physical status I or II were randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1, 2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data were compared using analysis of variance, Kruskal-Wallis or Chi-square test. Results: For all predefined time points, VAS in group PE was significantly lower than that in groups C (P < 0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain discharge criteria was not statistically different among groups. Conclusion: Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and early resumption of normal activity in comparison to post surgery IPLAI and control.

Background: Pain on injection with propofol is a well recognized problem sometimes very distressing to patient. Current study compared the effectiveness of intravenous dexmedetomidine and lignocaine pretreatment for the prevention of propofol pain during induction of general anaesthesia. Methods: Ninety, American Society of Anesthesiologists (ASA) grade I and II patients were randomised into three groups of 30 each, Group D, Group L and Group N. Group D, patients received dexmedetomidine 0.2 μg/kg diluted to 5 ml of normal saline, group L, patients received 0.5 mg/kg preservative free lignocaine diluted to 5 ml of normal saline and group N, patients received 5 ml of normal saline. Intravenous access was secured with 20 G cannula and venous occlusion was applied to forearm using a pneumatic tourniquet inflated to 90 mm of Hg for 1 minute. The study drugs were injected over 5 seconds and after 1 minute venous occlusion was released and 25% of total calculated dose of propofol (2 mg/kg) was given intravenously over a period of 60 seconds. Severity of pain was evaluated using McCrirrick and Hunter scale at 0 seconds, 30 seconds and 60 seconds respectively and then remaining propofol and neuromuscular blocking agent was given. Results: The groups were comparable demographically. There was significant difference in pain scores assessed at 0 seconds, 30 seconds and at 60 seconds between the three groups. Conclusions: Dexmedetomidine in a dose of 0.2 μg/kg before applying venous occlusion by tourniquet for one minute in the same vein before inducing the patient with propofol was effective in decreasing the propofol injection pain when compared to lignocaine in a dosage of 0.5 mg/kg and placebo.

Background: Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications. Aim: This study was designed to test the effect of pre-induction administration of clonidine, given as a single intravenous dose, on post-operative pain scores and fentanyl consumption in patients after thoracic surgery. Setting and Design: Tertiary referral centre. Prospective, randomised, double-blind, placebo-controlled trial. Methods: Sixty patients were randomly allocated to receive clonidine (3 mcg/kg) or saline pre-operatively before induction of anaesthesia. The primary endpoint was pain on coughing (visual analogue scale (VAS) 0-100 mm) 120 min after surgery, time to first analgesic injection in the post-anaesthesia care unit (PACU) and 24-h fentanyl consumption. Statistical Analysis: For between-group comparisons, t-test and U-test were used as appropriate after checking normality of distribution. The incidence of complications between the groups was compared by Fisher′s exact test. Results: The post-operative VAS for the first 120 min and the fentanyl consumption at 24 h was significantly greater in the placebo group compared with the clonidine group (P

We aimed to show that a single preprocedural dose of either dexmedetomidine or fentanyl reduces procedural pain and discomfort and provides clinically acceptable sedation. In this prospective, double-blind study, sixty patients scheduled for elective surgery and requiring planned central venous catheter insertion were randomized to receive dexmedetomidine (1 μg/kg), fentanyl (1 μg/kg), or 0.9% normal saline intravenously over ten minutes followed by local anesthetic field infiltration before attempting central venous catheterization. The primary outcome measures are assessment and analysis of pain, discomfort, and sedation level before, during, and after the central venous catheter insertion at five time points. The median (IQR) pain score is worst for normal saline group at local anaesthetic injection [6 (4–6.7)] which was significantly attenuated by addition of fentanyl [3 (2–4)] and dexmedetomidine [4 (3–5)] in the immediate postprocedural period (P=0.001). However, the procedure related discomfort was significantly lower in dexmedetomidine group compared to fentanyl group in the first 10 min of procedure after local anaesthetic Injection (P=0.001). Fentanyl is more analgesically efficient for central venous catheter insertion along with local anaesthetic injection. However, dexmedetomidine has the potential to be superior to fentanyl and placebo in terms of providing comfort to the patients during the procedure.

Background and Aims: A major limitation to providing oxygen therapy by high flow nasal oxygen (HFNO) delivery devices is its availability and therefore as an alternative many clinicians use a standard non rebreathing face mask (NRBM) in order to oxygenate their patients where low-flow nasal oxygen or simple facemask oxygen is not providing adequate respiratory support to achieve the target peripheral oxygen saturation (SpO[sub.2]). We aimed to determine the clinical effectiveness of HFNO versus NRBM in terms of improving patient outcome among patients admitted to our intensive care unit (ICU) during coronavirus disease-2019 (COVID-19) outbreak. Methods: In this prospective open labelled study, 122 COVID-19 patients presenting with acute hypoxaemic respiratory failure (AHRF) were randomised to receive either HFNO or NRBM to achieve the target SpO[sub.2]. The primary clinical outcome measured was device failure rate and secondary outcome was all-cause 28-day mortality rate. Results: The device failure rate was significantly higher in HFNO group (39 versus 21, P = 0.030). Oxygen support with NRBM resulted in a reduced all mortality rate over HFNO (26.2 versus 45) but the mortality rate after treatment failure in either group (HFNO or NRBM) remained high (91 versus 92). Conclusion: Oxygen support with NRBM results in both reduced device failure rate and higher survival among patients of COVID-19 with AHRF. Keywords: Acute hypoxaemic respiratory failure, COVID-19, high flow nasal oxygen, mortality, non-rebreathing mask, treatment failure, Author(s): Bhargavi Thota [1]; Aloka Samantaray (corresponding author) [1]; Vengamma B [2]; Hanumantha Rao Mangu [1]; Mohan Alladi [3]; Usha Kalawat [4] INTRODUCTION High flow nasal oxygen (HFNO) delivery devices [...]

Background and Aims: Skull pin head holder application is intensely painful and is accompanied with abrupt increase in heart rate and arterial blood pressure. We aimed to determine the effects of adding dexmedetomidine to ropivacaine scalp block in attenuating the haemodynamic response to skull pin insertion in neurosurgical procedures. Methods: Sixty patients were randomly allocated to receive scalp block with 25 ml of 0.5 ropivacaine added with either normal saline (control group) or dexmedetomidine (1 μg/kg) after anesthesia induction. A standard uniform general endotracheal anaesthesia protocol was followed in all study subjects. Heart rate and blood pressure measurements were made at baseline, 1, 3, 5, 10, and 15 min following skull pin placement. Student's independent t-test, Chi-square test and repeated measure analysis of variance were used to analyse the obtained data. Results: There was no significant attenuation of heart rate (P = 0.418), systolic (P = 0.542), diastolic (P = 0.793) and mean blood pressure (P = 0.478) with addition of dexmedetomidine to ropivacaine. Conclusions: The addition of dexmedetomidine (1 μg/kg) to 25 ml of 0.5 ropivacaine offers no additional benefit over 25 ml of 0.5 ropivacaine alone scalp block in attenuating the haemodynamic response to skull pin placement in neurosurgical procedures. Keywords: Blood pressure, dexmedetomidine, heart rate, nerve block, ropivacaine, Author(s): B. N Sahana [1]; Radhapuram Sri Devi [1]; Aloka Samantaray (corresponding author) [1]; Natham Hemanth [1]; Hemalatha Pasupuleti [1]; Hanumantha Rao Mangu [1] INTRODUCTION The use of skull pin [...]

Background: Multimodal therapy can be used for obtundation of the haemodynamic response to laryngoscopy and tracheal intubation. The current study was undertaken to compare the haemodynamic response to laryngoscopy and tracheal intubation after administration of 0.2 mg/kg morphine or 2 μg/kg fentanyl with 2% end tidal sevoflurane during induction of anaesthesia. Methods: Sixty patients were randomised into two equal groups to receive either 2% end tidal sevoflurane + fentanyl 2 μg/kg (Group SF) or 2% end tidal sevoflurane + morphine 0.2 mg/kg (Group SM). General anaesthesia technique was standardised for both the groups. Haemodynamic parameters heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded for 15 min. Results: The maximum increase in HR compared to baseline was statistically significant in Group SM (16.5%, P = 0.0002) which occurred at one min after tracheal intubation. The maximum increases in SBP, DBP and MAP compared to baseline occurred at one min after tracheal intubation in both the groups, Group SF (7.04%, 6.5% and 7.9% respectively) and Group SM (6.2%, 8.2% and 8.1% respectively) which was not statistically significant. The attenuation of haemodynamic response between the two groups was not statistically significant (for HR P = 0.1428, for SBP P = 0.8558, for DBP P = 0.1958 and for MAP P = 0.5303). Conclusions: With 2% end tidal sevoflurane during induction of anaesthesia, both 0.2 mg/kg morphine and 2 μg/kg fentanyl were equally effective in attenuating haemodynamic response to laryngoscopy and tracheal intubation. However morphine appeared to be less effective in attenuating the chronotropic response resulting in a greater increase in heart rate from baseline. [ABSTRACT FROM AUTHOR]

Background: Multimodal therapy can be used for obtundation of the haemodynamic response to laryngoscopy and tracheal intubation. The current study was undertaken to compare the haemodynamic response to laryngoscopy and tracheal intubation after administration of 0.2 mg/kg morphine or 2 µg/kg fentanyl with 2% end tidal sevoflurane during induction of anaesthesia. Methods: Sixty patients were randomised into two equal groups to receive either 2% end tidal sevoflurane + fentanyl 2 µg/kg (Group SF) or 2% end tidal sevoflurane + morphine 0.2 mg/kg (Group SM). General anaesthesia technique was standardised for both the groups. Haemodynamic parameters heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded for 15 min. Results: The maximum increase in HR compared to baseline was statistically significant in Group SM (16.5%, P = 0.0002) which occurred at one min after tracheal intubation. The maximum increases in SBP, DBP and MAP compared to baseline occurred at one min after tracheal intubation in both the groups, Group SF (7.04%, 6.5% and 7.9% respectively) and Group SM (6.2%, 8.2% and 8.1% respectively) which was not statistically significant. The attenuation of haemodynamic response between the two groups was not statistically significant (for HR P = 0.1428, for SBP P = 0.8558, for DBP P = 0.1958 and for MAP P = 0.5303). Conclusions: With 2% end tidal sevoflurane during induction of anaesthesia, both 0.2 mg/kg morphine and 2 µg/kg fentanyl were equally effective in attenuating haemodynamic response to laryngoscopy and tracheal intubation. However morphine appeared to be less effective in attenuating the chronotropic response resulting in a greater increase in heart rate from baseline. [ABSTRACT FROM AUTHOR]

The primary reasons for blood transfusion in cardiac surgery are to correct anaemia and to improve tissue oxygen delivery. However, there is a considerable debate regarding the actual transfusion trigger at which the benefits of transfusion overweight the risk. The association between extreme haemodilution, transfusion and adverse outcome after cardio pulmonary bypass (CPB) is not clear and the current available literature is not sufficient to provide a strong recommendation regarding the safe haematocrit range during CPB. There is no quality evidence to support use of fresh red blood cell except during massive transfusion or exchange transfusion in neonate. Overall concern regarding the safety of allogeneic blood transfusion resulted in the search for autologous blood transfusion and perioperative blood salvage. The aim of this review is to provide cardiac surgery specific clinically useful guidelines pertaining to transfusion triggers, optimal haemodilution during CPB, autologous blood transfusion and role of perioperative blood salvage based on available evidence. [ABSTRACT FROM AUTHOR]