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Renal cell carcinoma (RCC) frequently presents with osseous metastasis, predominantly lytic and prone to pathological fracture. The metastatic lesion in the extremity presents with local swelling, pain and immobility due to pathological fracture. The solitary or oligometastatic lesions should be treated with curative intent, which can help the patient to lead a more prolonged and disability-free life. The RCCs and their metastases are hypervascular with an exuberant arterial supply. Surgery can lead to uncontrolled life-threatening haemorrhage. Preoperative transarterial embolisation reduces tumour vascularity significantly and reduces intraoperative blood loss. We present a 46-year-old male patient with solitary hypervascular metastatic recurrence of RCC with a pathological femoral fracture with an infeasible initial surgery due to profuse haemorrhage. He was successfully treated by preoperative transarterial embolisation, followed by surgical resection and implantation of a megaprosthesis. Multidisciplinary management reduces patient morbidity and mortality with successful treatment in solitary hypervascular metastasis from RCC.

Study objective To evaluate the efficacy of ultrasound-guided single-shot quadratus lumborum block (QLB) for postoperative analgesia in adults following total hip arthroplasty (THA). Design Systematic review and meta-analysis. Setting Perioperative period. Patients Adult patients undergoing THA. Methods Studies were identified by performing searches in the following electronic databases, PubMed (Medline), Cochrane Central Registry of Trials (CENTRAL), and Google Scholar. We sought studies in adult patients undergoing THA, comparing QLB with a control group (no block, sham block or any other ultrasound guided regional nerve blocks). A total of 774 patients from 10 studies (7 randomized controlled, one controlled clinical and two retrospective study) were included in this meta-analysis. Main results The 24 hour opioid consumption was similar in both the groups (WMD −4.09; 95% CI [−9.00, 0.83]; P = 0.10; I2 = 95%). The pain scores at rest at 24 hours was significantly less in QLB group (WMD −0.62; 95% CI [−1.15, −0.10]; P = 0.02; I2 = 75%). The difference in pain scores was however not clinically significant. The pain scores on movement at 24 hours, time to first analgesic request, and time to discharge from hospital were similar in both the groups. Conclusions QLB as part of multimodal analgesia did not result in any significant analgesic benefits in patients undergoing hip arthroplasty in terms of either postoperative opioid consumption or pain scores at rest and on movement. Overall, the level of certainty is low. Further, well-designed trials are required to verify the results.

Background Endotracheal intubation by direct laryngoscopy is a widely performed lifesaving technique. Although there are guidelines for optimal size and depth of insertion of an endotracheal tube (ETT) for successful intubation, there is no consensus on the point at which it should be held along its length. This will arguably affect the time, ease, and success of the technique due to a difference in visualization and torque applied to the ETT after glottic visualization. We aim to compare the effect of 2 different sites of holding the ETT on time to intubation (TTI), intubation difficulty scale (IDS), and complications. Methods ASA 1–2 patients (>18 years) posted for surgery under general anesthesia, undergoing supervised intubation by anesthesia trainees (experience < 18 months), will be included. Patients with an anticipated difficult airway or unanticipated difficulty—CL grade 3 or 4 requiring the use of airway adjuncts—will be excluded. Patients will be randomized by a computer-generated number list, and allocation concealed with opaque sealed envelopes. The two sites for holding the ETT will be group 1 at 19 cm and group 2 at 24 cm. ETT marked at the selected site will be handed by the technician once the optimum position of the table, patient, and laryngoscopic view is confirmed by the intubator. The entire procedure will be video recorded. Two blinded assessors will independently review the videos to document the time to intubation and intubation difficulty score. A postoperative sore throat will be recorded. Sample size To detect a 20% difference in time to intubation between groups with a significance level of 5% and power of 85%, we will need a total of 298 patients. Accounting for data loss, we plan to recruit 180 patients in each group. Discussion This will be the first study to assess whether the site of holding the tube has any impact on the ease and time taken for intubation. The findings of this study will provide scientific evidence for suggesting an appropriate place for holding the ETT during direct laryngoscopy procedures. Trial registration Clinical Trials Registry India CTRI/2019/09/021201

Brain tumors are the second most common malignancy in childhood and the surgical excision remains the cornerstone of management. The objective of this study was to analyze the factors associated with the length of intensive care unit (ICU) and hospital stay, and postoperative outcome in such children.Three years of data were collected, retrospectively, by detailed review of medical records pertaining to pre-anesthetic evaluation and perioperative course of children less than 16 years of age who underwent excision of intracranial tumors.One hundred sixty-eight medical records were analyzed. One third of the children were found to have developed various intraoperative adverse events; the most common were hemodynamic changes following brainstem handling and brain swelling. 58% of children required postoperative mechanical ventilation. 82.7% of patients had favorable neurologic outcome which was comparable between the two tumor locations (supratentorial vs infratentorial). On multivariate analysis, re-exploration surgery and electrolyte disturbances, such as serum sodium, were found to be the independent risk factors affecting hospital stay. The amount of intraoperative blood loss and postoperative pulmonary complications (POPCs) were independent risk factors affecting the neurologic outcome.Adverse events are fairly common after excision of brain tumors in children. Intraoperative complications did not affect the ICU stay or neurological outcome; however, the postoperative complications increased length of ICU and hospital stays. POPC was the single most important factor responsible for poor neurologic outcome and was more so in children who underwent infratentorial surgery, prolonged mechanical ventilation, and who had a lower cranial nerve palsy.

Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors.Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals.The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups.This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores.CTRI/2016/10/007350.

Background and Objectives Suboptimal management of postcraniotomy pain causes sympathetic and hemodynamic perturbations, leading to deleterious effects on the neurological system and overall patient outcome. Opioids are the mainstay of postoperative pain management but have various problems when given in high doses, or for prolonged durations in neurosurgical patients. The ideal method of pain control following craniotomy generally relies on a combination of various drugs. Oral pregabalin may be an attractive alternative in these patients. Materials and Methods Sixty, American Society of Anesthesiologists class I and II patients posted for elective supratentorial craniotomy, aged 18 and 60 years, were randomly assigned into three groups of 20 each to receive oral placebo (Group A), pregabalin 75 mg (Group B), or pregabalin 150 mg (Group C) before the induction of anesthesia. At the end of the surgery, patient-controlled analgesia was started with intravenous fentanyl. Visual analog scale (VAS) score was recorded every 2 hours for 24 hours, along with total postoperative fentanyl requirement. Results There were no differences in sex, duration of surgery or anesthesia and total intraoperative fentanyl administered among the three groups. The median postoperative VAS score (Group A—18.0, Group B—20, and Group C—22.0; p = 0.63) was similar in all the groups. However, postoperative fentanyl requirement over 24 hours was least in the group that received 150 mg pregabalin (Group A—190 μg, Group B—240 μg, and Group C—100 μg; p = 0.03). Conclusions Even though pain scores were not significantly different, patients receiving 150 mg oral pregabalin required the least amount of postoperative opioids.

Background: Laryngoscopic endotracheal intubation (LEI) is a widely performed lifesaving technique. There are evidence and guidelines to help decide the optimal sized endotracheal tube (ET), laryngoscope, depth of insertion, and patient position for successful endotracheal intubation. We hypothesize that after glottic visualization, the point at which the ET is held will affect the time, ease, and success of the technique due to a difference in visualization and torque. We aim to compare two sites of holding the ET after optimal laryngeal-inlet visualization: time to intubation, rate of success of first pass intubation, intubation difficulty and complications.Methods: Supervised intubations on ASA 1-2 patients (>18 years) posted for surgery under general anesthesia performed by anesthesia trainees (experience three or requiring the use of airway adjuncts will be excluded. A computer-generated numbers list will randomize patients; allocation concealed with opaque sealed envelopes. ET marked at the selected site will be handed to the intubator by the theatre-technician once she/he confirms the optimum laryngoscopic view. The entire procedure will be video recorded. Two blinded assessors will independently review the videos to document the time to intubation (TTI defined as the time from holding the ET to the removal of laryngoscope from the mouth after successful intubation) and intubation difficulty score. Postoperative sore throat and hoarseness will be recorded.Sample size: 54 experienced anesthetists were video-recorded during intubating. The site of holding ET and TTI were analyzed. The mean site was 3 SD 2.5 cm from the tip, yielding two sites for the study- 19 cm (Gr 1) and 24 cm (Gr 2). To detect a 20% difference in intubation time between groups, the confidence of 95%, and power 85%, we will need 298 patients: 180 per group after accounting for data loss.Discussion: This will be the first study to assess whether holding the tube at a particular site has any impact on the ease and time taken for intubation. This study's findings will provide the first scientific evidence for an appropriate place for holding the ET during LEI, which we feel will help trainees improve their LEI technique.Trial registration: CTRI/2019/09/021201, Clinical Trials Registry India. http://ctri.nic.in/Clinicaltrials/advsearch.php. Registered 12th September 2019

Awake craniotomy is a well-accepted neurosurgical procedure in adult patients that helps resection of lesions on or close to the eloquent cortex when surgery is carried out in its vicinity. In the pediatric population, extraoperative mapping with strip or grid electrodes or intraoperative neurophysiologic monitoring (IONM) under general anesthesia (GA) is commonly preferred for brain mapping. As the GA is known to suppress the cortical responses, the brain mapping requires the patient to remain awake. The noninvasive functional mapping may also guide the resection of lesions around the eloquent cortex. Diagnostic modalities such as positron emission tomography (PET), functional magnetic resonance imaging (fMRI), and magnetoencephalography are utilized, preoperatively, to localize sensory, motor, and language functions. However, in children, these techniques have limitations in identifying the ictal foci; hence, they may have limited utility when the surgery is carried out near the critical cortex. Moreover, the fMRI identifies a specific cortical area during a definite task rather than the area critical to these functions. Hence, there is a possibility of overestimation of a functional cortex amounting to inaccuracies during resections of the lesions. Therefore, the procedure of awake craniotomy may be preferred in children, as in adults with similar indications, to overcome these inadequacies.

Generalized tonic–clonic seizures (GTCS) result in diverse physiological alterations that are mostly short-lived and rarely lead to immediate serious consequences. Some early serious complications reported are head trauma and aspiration. While most cases of seizures are diagnosed readily from clinical history, some cases remain indolent and present later. A brain hemorrhage can have varied manifestations that warrant every clinician to be vigilant in diagnosis and management to prevent life-threatening complications. Furthermore, many reports have described seizures in patients operated for subdural hematoma (SDH), but to the best of our knowledge, none reveals SDH after the seizure. We encountered an unexpected incident of severe SDH in a 32-year-old adult following witnessed GTCS. How to cite this article Singh S, Kaushal A, Datta R, Unnithan RR, Mishra N. A Rare Case of Epileptic Seizure After-effect Resulting in Nontraumatic Spontaneous Subdural Hemorrhage. Indian J Crit Care Med 2020;24(8):722–723.

Multiple sclerosis (MS) is the most prevalent chronic inflammatory disease of the central nervous system (CNS), affecting more than 2 million people worldwide [1]. It is punctuated by fully or partially reversible episodes of neurologic disability, usually lasting for days or weeks. The typical syndrome at presentation include, but is not limited to, monocular visual loss due to optic neuritis, limb weakness or sensory loss due to transverse myelitis, double vision due to brain-stem dysfunction, or ataxia due to a cerebellar lesion [2]. The association of TGN and multiple sclerosis (MS) has been well-known since the end of the nineteenth century [3]; a strong association has been suggested with a 20-fold higher prevalence of TGN in this group compared to the general population [4]. A systematic review [5] suggested a prevalence of 3.8% of TGN in patients with MS. Patients of TGN due to MS have been found to have a mean age 5.5 year less than those suffering from idiopathic TGN [6].