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Objectives  Neurosurgical patients often receive 0.9% normal saline (NS) during the perioperative period. Theoretically, a balanced salt solution (BSS) is better than 0.9% saline. We compared the effects of two different fluids on acid-base balance, renal function, and neurological outcome in patients who underwent clipping following subarachnoid hemorrhage from a ruptured intracranial aneurysm. Materials and Methods  Patients in group NS ( n  = 30) received 0.9% saline and group BSS ( N  = 30) received BSS (Plasmalyte-A) in the perioperative period for 48 hours. Comparison of arterial pH, bicarbonate, and base deficit measured preoperatively, intraoperatively (first and second hour), and postoperatively (at 24 and 48 hours) was the primary outcome of the study. The secondary outcome compared serum electrolytes, renal function tests, urine neutrophil gelatinase-associated lipocalin (NGAL), serum cystatin C, and the neurological outcome using modified Rankin score (MRS) at discharge, 1, and 3 months. Results  In group NS, significantly low pH at 1-hour intraoperative period was seen compared with group BSS (7.37 ± 0.06 vs. 7.40 ± 0.05, p  = 0.024). The bicarbonate level in group NS was significantly lower and the base deficit was higher at second intraoperative hour (bicarbonate: 17.49 vs. 21.99 mEq/L, p  = 0.001; base deficit: 6.41 mmol/L vs. 1.89 mmol/L, p  = 0.003) and at 24 hours post-surgery (bicarbonate: 20.38 vs. 21.96 mEq/L, p  = 0.012; base deficit: 3.56 mmol/L vs. 2.12 mmol/L, p  = 0.034)). Serum creatinine was higher in group NS at 24 hours (0.66 vs. 0.52 mg/dL, p  = 0.013) and 48 hours (0.62 vs. 0.53 mg/dL, p  = 0.047). Serum urea, electrolytes, cystatin, urine NGAL, and MRS were comparable. Conclusion  In neurosurgical patients undergoing clipping for ruptured intracranial aneurysm, using a BSS during the perioperative period is associated with a better acid-base and renal profile. However, the biomarkers of kidney injury and long-term outcomes were comparable., Competing Interests: Conflict of Interest None declared., (Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background and Aims: Post-discharge nausea and vomiting (PDNV) is a pertinent problem in patients undergoing ambulatory surgery. The objective of this study was to assess the efficacy of the novel drug olanzapine, which has proved its efficiency in patients undergoing highly emetogenic chemotherapy for PDNV prevention., Methods: This randomised controlled trial recruited 106 adult patients (18-65 years) undergoing highly emetogenic daycare surgeries with propofol-based general anaesthesia (GA). Group O received preoperative oral olanzapine 10 mg, and Group C, acting as a control, received 8 mg of intravenous dexamethasone and 4 mg of ondansetron intraoperatively. The primary outcome was nausea (numeric rating scale >3) and/or vomiting 24 h after discharge. Secondary outcomes included nausea and vomiting in the post-anaesthesia care unit (PACU), severe nausea, vomiting and side effects. Normality was assessed using the Shapiro-Wilk test, and the independent samples t -test or the Mann-Whitney U test was used to compare continuous variables. Fisher's exact test was used to assess any non-random associations between the categorical variables., Results: The incidence and severity of postoperative nausea and vomiting were similar in both groups within PACU (four patients experienced nausea and vomiting, three had severe symptoms in Group O, P = 0.057) and in the post-discharge period (three patients in Group O had nausea and vomiting compared to five patients in Group C, of which four were severe, P = 0.484). The side effects (sedation, dizziness, and light-headedness) were comparable between the two groups., Conclusion: A single preoperative oral olanzapine can be an effective alternative to standard antiemetic prophylaxis involving dexamethasone and ondansetron for preventing PDNV in highly emetogenic daycare surgeries with propofol-based GA., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Anaesthesia.)

Background: efficacy of therapeutic cholecalciferol supplementation for severe COVID-19 is sparingly studied., Objective: effect of single high-dose cholecalciferol supplementation on sequential organ failure assessment (SOFA) score in moderate-to-severe COVID-19., Methods: participants with moderate to severe COVID-19 with PaO2/FiO2 ratio < 200 were randomized to 0.6 million IU cholecalciferol oral (intervention) or placebo., Outcomes: primary outcome was change in Day 7 SOFA score and pre-specified secondary outcomes were SOFA and 28-day all-cause mortality., Results: in all, 90 patients (45 each group) were included for intention-to-treat analysis. 25(OH)D3 levels were 12 (10-16) and 13 (12-18) ng/ml (P = 0.06) at baseline; and 60 (55-65) ng/ml and 4 (1-7) ng/ml by Day 7 in vitamin D and placebo groups, respectively. The SOFA score on Day 7 was better in the vitamin D group [3 (95% CI, 2-5) versus 5 (95% CI, 3-7), P = 0.01, intergroup difference - 2 (95% CI, -4 to -0.01); r = 0.4]. A lower all-cause 28-day mortality [24% compared to 44% (P = 0.046)] was observed with vitamin D., Conclusions: single high-dose oral cholecalciferol supplementation on ICU admission can improve SOFA score at Day 7 and reduce in-hospital mortality in vitamin D-deficient COVID-19. ClinicalTrials.gov  id: NCT04952857 registered dated 7 July 2021. What is already known on this topic-vitamin D has immunomodulatory role. Observational and isolated intervention studies show some benefit in COVID-19. Targeted therapeutic vitamin D supplementation improve outcomes in severe COVID-19 is not studied in RCTs. What this study adds-high-dose vitamin D supplementation (0.6 Million IU) to increase 25(OH)D > 50 ng/ml is safe and reduces sequential organ failure assessment score, in-hospital mortality in moderate to severe COVID-19. How this study might affect research, practice or policy-vitamin D supplementation in vitamin D-deficient patients with severe COVID-19 is useful may be practiced., (© The Author(s) 2024. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Anemia is a common complication of aneurysmal subarachnoid hemorrhage and is associated with unfavorable outcomes. Whether the physiological benefits of transfusion for anemia surpass the risk of blood transfusion remains to be determined., Objectives: The primary outcome was to evaluate the impact of peri-operative blood transfusion on the long-term neurological outcome, assessed by Glasgow Outcome Scale Extended at 3 months. The secondary outcomes included the impact of transfusion on the short-term neurological outcome, assessed by Modified Rankin Score at discharge/7 days, and on the incidence of vasospasm, infarction, re-exploration, tracheostomy, and length of hospital stay., Material and Methods: This prospective observational study was conducted on 185 patients with aneurysmal subarachnoid hemorrhage undergoing clipping of the aneurysmal neck. In our study, blood transfusion was administered to keep the target Hb around 10 g/dL., Results: Unfavorable long-term outcome was found in 27/97 (28%) of patients who received a blood transfusion as compared to 13/74 (18%) of patients who did not receive a transfusion (P = 0.116). Patients receiving transfusion had more chances of an unfavorable outcome at discharge/7 days as compared to those not transfused [44/103 (43%) versus 22/80 (27%)], P = 0.025. There were increased chances of vasospasm, infarction, re-exploration, tracheostomy, and increased length of hospital stay in patients receiving transfusion (P < 0.05)., Conclusions: The use of blood transfusion in patients with aneurysmal subarachnoid hemorrhage was associated with increased neurological complications and hence an unfavorable short-term outcome. However, when used judiciously as per the clinical requirements, blood transfusion did not have a significant effect on long-term neurological outcome., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Background: Postoperative nausea and vomiting (PONV) causes an unexpected prolonged hospital stay after ambulatory surgery. Novel measures such as preoperative loading of oral carbohydrates and postoperative chewing gum have recently gained momentum for postoperative recovery. This study evaluated the effects of preoperative carbohydrate loading and postoperative chewing gum (CG) on PONV after daycare laparoscopic cholecystectomy (LC)., Methods: A total of 100 patients were randomized to group A (preoperative carbohydrate loading with 200 ml of water with 25 g of carbohydrate and postoperative chewing gum (CG) when the patient responded to his/her name) and group B (standard care). The incidence of PONV and pain was assessed by using visual analogue scale. Quality of recovery (QoR-15) was assessed by using QoR15 questionnaire at 6 h, 24 h and 48 h after surgery., Results: The incidence of PONV and pain was lower in group A; however, it was not significant (p > 0.05). The severity of PONV, pain and the need for rescue antiemetic was significantly lower in group A (p < 0.05). The episodes of PONV and required dose of antiemetic were less in group A. Group A also had a significantly higher QoR-15 score at all time points (p < 0.001). Preoperative dyspepsia was also noticed as a significant confounding predictor for postoperative vomiting., Conclusion: Preoperative carbohydrate drinks and early postoperative CG reduces the severity of PONV and requirement of antiemetics in patients undergoing LC. Hence, these simple measures can be used as a standard of care to optimize perioperative care in patients undergoing daycare surgery., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24 h, day 3, and day 7. The primary outcome was an improvement in encephalopathy by ≥ 1 grade at 72 h., Patients and Methods: European association for study of liver (EASL) defined ACLF patients with overt HE were assessed and randomized into the experimental arm (IV-BCAA - 500 mL/day for 3 days + Lactulose; n = 39) and the comparator arm (Lactulose alone; n = 37). Six patients developed COVID-19 after randomization and were excluded (4-experimental arm and 2-comparator arm)., Results: Of 222 screened patients, 70 (35 in each arm) were included in the analysis. Baseline characteristics, including HE grade (2.9 ± 0.7 vs 2.8 ± 0.7; P  = 0.86) and (chronic liver failure) CLIF-C ACLF score (54.2 ± 5.6 vs 54.8 ± 5.7; P  = 0.65), were similar. Overall survival was 40% at 28 days (48.5% vs 31.4%; P  = 0.14). Improvement in hepatic encephalopathy scoring algorithm (HESA) by ≥ 1 grade at 24 h occurred in 14 patients (40%) in the BCAA arm and 6 patients (17.1%) in the control group ( P  = 0.03) which translated to a shorter intensive care unit (ICU) stay. The median change in HESA at 24 h was greater in the BCAA arm than the control arm ( P  = 0.006), which was not sustained at days 3 or 7. Ammonia levels did not correlate with the grade of HE (Spearman's correlation coefficient (ρ) = - 0.0843; P  = 0.29)., Conclusion: Intravenous BCAA does not lead to a sustained improvement in HE grade in ACLF., Trial Registration No: NCT04238416 (clinicaltrials.gov)., (© 2023 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: Studies have evaluated the effects of volatile and intravenous anesthetic agents on the cerebral vasculature with inconsistent results. We used digital subtraction angiography to compare the effects of propofol and sevoflurane on the luminal diameter of cerebral vessels and on cerebral transit time in patients with aneurysmal subarachnoid hemorrhage (aSAH)., Methods: This prospective preliminary study included adult patients with good-grade aSAH scheduled for endovascular coil embolization; patients were randomized to receive propofol or sevoflurane anesthesia during endovascular coiling. The primary outcome was the luminal diameter of 7 cerebral vessel segments measured on the diseased and nondiseased sides of the brain at 3 time points: awake, postinduction of anesthesia, and postcoiling. Cerebral transit time was also measured as a surrogate for cerebral blood flow., Results: Eighteen patients were included in the analysis (9 per group). Baseline and intraoperative parameters were similar between the groups. Propofol increased the diameter of 1 vessel segment at postinduction and postcoiling on the diseased side and in 1 segment at postcoiling on the nondiseased side of the brain ( P <0.05). Sevoflurane increased vessel diameter in 3 segments at postinduction and in 2 segments at postcoiling on the diseased side, and in 4 segments at postcoiling on the nondiseased side ( P <0.05). Cerebral transit time did not change compared with baseline awake state in either group and was not different between the groups., Conclusions: Sevoflurane has cerebral vasodilating properties compared with propofol in patients with good-grade aSAH. However, sevoflurane affects cerebral transit time comparably to propofol., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To analyze the relationship between eccentric downward eye movement/eccentric downward eye-positioning (EDEM/EDEP) encountered in patients undergoing ophthalmic surgeries and its return to a centralized position under general anesthesia (GA) with the depth of anesthesia (DOA)., Methods: Patients undergoing ophthalmic surgeries (6 months-12 years) under sevoflurane anesthesia without non-depolarizing muscle relaxant (NDMR) who witnessed a sudden tonic EDEM/EDEP were both retrospectively (R-group) and prospectively (P-group) enrolled (ambispective study). R-group included data-points after induction (AI) till the time surgery lasted while P-group compiled data both during induction (DI) and AI. DOA in terms of MAC (minimum alveolar concentration) at the time of EDEM/EDEP and centralization of eyeball and their timings were noted and compared for both AI and DI data-points. Also, vertical eccentric eye positions were scored and correlated with MAC., Results: AI data included 22 (14R+8P) events and their mean MAC of EDEM/EDEP and centralization were 1.60 ± 0.25 and 1.18 ± 0.17 respectively ( p = 0.000). DI data included 62 (P) cases and its mean MAC of EDEM/EDEP and centralization was 2.19 ± 0.43 and 1.39 ± 0.26 respectively ( p = 0.000). Median (IQR) eye positions during down-positioning in 84 events was -3 (-3.9 to -2.5). It was preceded by an eccentric upward drift of eyes in 10/22 (6R+4P) AI cases. A strong negative correlation was seen between DOA and eccentric eye positions ( r = -0.77, p = 0.000)., Conclusions: Tonic down-rolling of eyes is not uncommon in children seen without NDMR with higher depths of sevoflurane anesthesia compared to point of centralization and fluctuations in DOA should be avoided to circumvent inadvertent complications during ocular surgery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Chaurasia, Soni, Ganesh, Ram, Sukhija, Chaurasia and Takkar.)

This study evaluated the efficacy of intraperitoneal magnesium sulfate (MgSO 4 ) in preventing postoperative pain after elective laparoscopic cholecystectomy (LC). It is a prospective, double-blinded, placebo-controlled, randomized trial which included 64 patients who underwent LC. Patients were equally randomized into Groups A and B. MgSO 4 and normal saline were instilled in subdiaphragmatic space in Groups A and B, respectively, after creating pneumoperitoneum and before starting dissection. The Visual analogue Scale (VAS) was used to determine postoperative pain. Patients who received intraperitoneal MgSO 4 had lower average VAS scores for the first 6 h postoperatively, and also, the time for the requirement of first analgesic was longer (3.6 ± 0.4 vs. 2.3 ± 1.0 h). The incidence of vomiting and the requirement for rescue antiemetic was also lower in Group A. Intraperitoneal instillation of MgSO 4 reduces postoperative pain and vomiting following elective LC without incurring additional side effects., Competing Interests: None

Background: Series on radiotherapy (RT) practice in pediatric malignancies are limited in India as only a few centers practice pediatric RT, particularly under anesthesia. We aimed to study the clinical profile of pediatric cancer patients treated with RT and to analyze various challenges in pediatric RT under anesthesia., Materials and Methods: The data were prospectively maintained in Microsoft Excel spreadsheets. Pediatric cancer patients aged 0-14 years, registered in the RT department between February 1, 2019 and July 30, 2021were analyzed., Results: A total of 193 pediatric cancer patients (noncentral nervous system) received RT during the said period. Median age at presentation was 5.2 years (range: 9 months to 14 years) with a male-to-female ratio of 1.8:1. The majority of the patients were in the age group of 0-4 years (52.8%) followed by 5-9 years (29.5%) and ≥10 years (17.6%). Most common indications for RT included bone and soft-tissue tumors, retinoblastoma, Wilms tumor, neuroblastoma, and hematological malignancies. One hundred and seventy-nine (92.7%) patients received RT with curative intent, while 14 (7.3%) patients received palliative RT. Thirty (15.5%) patients needed anesthesia for RT. Ten (5.18%) patients required RT interruption due to toxicities with a median gap of 3 days., Conclusions: RT is challenging yet an important aspect of multidisciplinary care in paediatric cancers. Estimating the burden of pediatric patients in the RT department may help in assessing unmet needs, resource development, and prioritization, which may improve the cure rates.

Objective: Surgery of eloquent area gliomas is challenging and requires monitoring of the nearby white fiber tracts. In the present study, we analyzed 102 patients with eloquent region gliomas and discussed the concept of intraoperative dynamic white fiber tract navigation and monitoring., Methods: A total of 102 patients with an eloquent area glioma (52 insular, 29 motor area, 21 temporoparietal) were evaluated. The position of the white fiber tracts (corticospinal tract [or motor fiber; CST], inferior fronto-occipital fasciculus [ventral language fiber; IFOF], superior longitudinal fasciculus [SLF], and arcuate fasciculus [dorsal language fiber; AF) was recorded. Awake mapping of the cortical and subcortical eloquent structures was performed for all 102 patients. The suction stimulator was coregistered and used as a dynamic stimulator navigator., Results: Of the 102 patients, 60 were men and 42 were women, with an average age of 39.8 years. Most of the white fiber tracts were normal (CST, 31.3%; IFOF, 39.2%; SLF/AF, 40.19%) or displaced (CST, 59.8%; IFOF, 47.05%; AF/SLF, 44.11%). A few were disrupted (CST, 8.8%; IFOF, 13.7%; SLF/AF, 15.7%). The extent of tumor resection was 82.8%, 86.5%, and 94% for those with insular glioma, motor area glioma, and temporoparietal glioma, respectively. Of the 102 patients, 18 had developed transient speech and language disturbances with improvement, and 14 had developed motor deficits, of whom, all except for 2, had shown gradual improvement. When the dynamic suction stimulator navigator was used, the extent of resection was 96.5%, without any added deficits., Conclusions: The use of intraoperative neuronavigation and neurophysiological assessment can help achieve maximal tumor resection of eloquent area gliomas. Use of the integrated suction stimulator navigator provided dynamic navigation and mapping of the peritumoral eloquent fibers., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Transurethral resection of bladder tumors (TURBT) surgeries requires post-resection catheterization for continuous irrigation of the bladder. This indwelling catheter is associated with distressing catheter-related bladder discomfort (CRBD) and increases postoperative pain and agitation., Objectives: To prove the hypothesis that transurethral 100 mg lidocaine irrigation at the end of TURBT can reduce the frequency of moderate-to-severe postoperative CRBD., Methods: 116 patients scheduled for TURBT were screened, 94 were recruited and completed the study. American Society of Anesthesiologists Physical Status I-II adult patients, 20-75 years of age undergoing elective TURBT surgery under general anesthesia were included. Transurethral normal saline with 0.01% lidocaine (100 mg in 1 L NS) was used for irrigation 30 min before the completion of surgery in group L, while only normal saline was used for transurethral irrigation in group N. The main outcomes were frequency of CRBD, pain and patient satisfaction at 0, 1, 2, and 6 h postoperatively., Results: A total of 94 patients were analyzed in the study. The incidence of moderate-severe CRBD was significantly lower in group L as compared to group C at 0, 1, and 2 h (65.9% vs. 31.9%, p = 0.01; 31.9% vs. 10.6%, p = 0.012; 21.3% vs. 2.1%, p = 0.004, respectively). At the 6-h mark, the incidence of CRBD was lower in group L, although this did not achieve statistical significance (6.38% vs. 2.1%; p = 0.613)., Conclusion: Irrigation with 0.01% lidocaine (100 mg) towards the end of TURBT reduces the incidence of moderate-severe CRBD by 52% and increases patient satisfaction., (© 2022 The Japanese Urological Association.)

Competing Interests: There are no conflicts of interest.

Background: Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes. We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOT-VTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysm clipping in aneurysmal subarachnoid hemorrhage patients., Methods: Fifty adults scheduled for urgent craniotomy for aneurysm clipping were randomly allocated to 2 groups: group G (n=25) received GDFT guided by LVOT-VTI and group C (n=25) received CVP-guided fluid management. The primary outcome was intraoperative mean arterial pressure (MAP). Secondary outcomes included volume of fluid administered and several other intraoperative and postoperative variables, including neurological outcome at hospital discharge and at 30 and 90 days., Results: There was no difference in MAP between the 2 groups despite patients in group G receiving lower volumes of fluid compared with patients in group C (2503.6±534.3 vs. 3732.8±676.5 mL, respectively; P <0.0001). Heart rate and diastolic blood pressure were also comparable between groups, whereas systolic blood pressure was higher in group G than in group C at several intraoperative time points. Other intraoperative variables, including blood loss, urine output, and lactate levels were not different between the 2 groups. Postoperative variables, including creatinine, duration of postoperative mechanical ventilation, length of intensive care unit and hospital stay, and incidence of acute kidney injury, pneumonitis, and vasospasm were also comparable between groups. There was no difference in neurological outcome at hospital discharge (modified Rankin scale) and at 30 and 90 days (Extended Glasgow Outcome Scale) between the 2 groups., Conclusion: Compared with CVP-guided fluid therapy, transesophageal echocardiography-guided GDFT maintains MAP with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Low-dose dexmedetomidine may be a suitable alternative to opioids for pediatric ambulatory procedures under general anesthesia (GA). However, the recovery profile remains unclear. Herein, we aimed to evaluate the effects of low-dose dexmedetomidine on the recovery profile of children., Methods: Seventy-two children undergoing ambulatory oral rehabilitation under GA were randomly and equally distributed into two groups (D and F). Group D received an infusion of dexmedetomidine 0.25 µg/kg for 4 min for induction, followed by maintenance of 0.4 µg/kg/h. Group F received an infusion of fentanyl 1 µg/kg over 4 min for induction, followed by maintenance at 1 µg/kg/h. The primary outcome was the extubation time. The secondary outcomes were awakening time, end-tidal sevoflurane (ET-Sevo) requirement, change in hemodynamic parameters, Richmond Agitation-Sedation Scale (RASS), Children's Hospital of Eastern Ontario pain scale (CHEOPS) score, length of PACU stay, and incidence of adverse events., Results: Statistically significant differences were observed in the recovery profile between the groups: the median time for extubation was 3.65 (3.44-6.2) vs. 6.25 (4.21-7) minutes in groups D vs. F (P = 0.001), respectively, while the corresponding awakening times were 19 (18.75-21) and 22.5 (22-24) minutes, respectively (P < 0.001). The mean ET-Sevo was low in group D (1.1 vs. 1.2; P < 0.001). The heart rate was significantly low across all time points in group D, without resulting in bradycardia. The median RASS and CHEOPS scores were also significantly lower in group D. No significant differences were observed in the mean arterial pressure, incidence of adverse events, or length of PACU stay., Conclusion: Low-dose dexmedetomidine was more effective than fentanyl as an opioid substitute at providing a better recovery profile in pediatric ambulatory oral rehabilitation under GA. Dexmedetomidine also significantly reduced sevoflurane consumption without causing adverse events or prolonging hospital stay., Competing Interests: CONFLICTS OF INTEREST: The authors have no potential conflicts of interest (financial or nonfinancial) to declare., (Copyright © 2022 Journal of Dental Anesthesia and Pain Medicine.)

Background: The use of nonsteroidal anti-inflammatory drugs in neurosurgery remains controversial because of potential risk of hematoma formation secondary to platelet dysfunction. This study aimed to investigate the efficacy and safety of diclofenac compared with paracetamol for the management of postcraniotomy pain., Methods: In all, 110 adult patients undergoing craniotomy for supratentorial tumors were randomized to receive either intravenous paracetamol (15 mg/kg) or intravenous diclofenac sodium (1.5 mg/kg) 30 minutes before the end of surgery and postoperatively at 12-hour intervals up to 48 hours. The analgesic efficacy of diclofenac and paracetamol was assessed using the Numerical Rating Scale (NRS) score at 12, 24, and 48 hours after surgery. We also examined the need for rescue analgesia, coagulation profiles using a Sonoclot analyzer, and incidence of intracranial hematoma formation., Results: At 24 hours postsurgery, NRS scores were lower in group D than in group P; median (interquartile range) and mean rank NRS score in group D was 3.00 (1.0), 43.71, respectively, compared with 3.00 (1.0), 59.29 in group P (P=0.004). Patients in group P received more rescue analgesia than those in group D. Coagulation profiles were similar between groups at 24 hours. Activated clotting time was longer in group D (128.76±12.61 s) than in group P (123.84±09.77 s; P=0.03) at 48 hours, although remained within normal limits in both groups; clot rate and platelet function were similar at 48 hours. There was no difference in the incidence of postoperative tumor bed hematoma., Conclusion: Compared with paracetamol, diclofenac sodium provided more effective postoperative analgesia at 24 hours with no evidence of adverse effects on coagulation profiles in patients undergoing craniotomy for supratentorial tumors., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Patients with liver disease often have alteration of neurological status which requires admission to an intensive care unit. Patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and rarely cirrhosis are at risk of cerebral edema. These patients require prompt assessment of neurological status including assessment of intra-cranial pressure (ICP) and monitoring metabolic parameters like arterial/venous ammonia levels, serum creatinine and serum electrolytes so that timely specific therapy for raised ICP can be instituted to prevent permanent neurological dysfunction. The overall aims of neuromonitoring and sedation protocols in a liver intensive care unit are to identify the level of multifactorial metabolic encephalopathy, individualize sedation and analgesia requirements for patients on mechanical ventilation, institute specific therapy to correct the neurological insult in ALF and ACLF, provide clear physiological data for guided therapy of drugs like muscle relaxants, antiepileptics, and cerebral edema reducing agents, and assist with overall prognostication. In this review article we will outline the clinical scenarios related to liver disease requiring intensive care and neuromonitoring, current techniques of neurological assessment, sedation protocols and point of care tests which enable the treating physician and intensivist guide therapy for raised ICP., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Failure to secure the airway after administration of induction agent in a postmandibulectomy patient can lead to life-threatening complications; hence, recognising a difficult airway is of immense importance. Preoperative airway evaluation includes, but is not limited to, inter-incisor gap, modified Mallampati grading, neck movement, neck circumference, thyromental distance, sterno-mental distance, upper lip bite test and dental status. This case signifies the challenge encountered in securing the airway and the importance of thorough preoperative airway evaluation and preparedness before induction of anaesthesia in a postmandibulectomy patient for carcinoma of the buccal mucosa., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background & Objectives: The high mortality associated with the thrombotic events in hospitalized COVID-19 patients resulted in the usage of anticoagulants in varying doses. Whether high-dose anticoagulants have led to better outcomes or higher incidence of clinically significant bleeding events is debatable. Thus, this study was conducted to find the incidence of clinically significant bleeding events in moderate-to-severe COVID-19 ARDS (acute respiratory distress syndrome) patients on therapeutic anticoagulation and their outcomes., Methods: In this retrospective, single-centre study of 155 critically ill COVID-19 patients, the incidence of clinically significant bleeding was observed. Multivariate regression models were used to evaluate the association between anticoagulant regimen, coagulation and inflammatory markers with the incidence of bleeding and thrombotic events., Results: The incidence of clinically relevant non-major bleeding was 33.54 per cent (26.17-41.46%) and major bleeding was 9.03 per cent (5.02-14.69%). The anticoagulation intensity at baseline had a high odds of major bleeding when enoxaparin and dual antiplatelet therapy were used together [adjusted odds ratio OR of 434.09 (3.81-49502.95), P<0.05]. At admission, bleeders had a poorer PaO 2 /FiO 2 ratio with more patients on invasive ventilation. At the time of bleeding, the bleeders had a higher D-dimer, ferritin, C-reactive protein and procalcitonin compared to non-bleeders. The subhazard ratio for death in bleeders was 3.35 (95% confidence interval, 1.97-5.65; P<0.001)., Interpretation & Conclusions: The incidence of bleeding in critically ill COVID-19 patients on therapeutic anticoagulation may increase with the severity of the disease as well as with concurrent use of dual antiplatelets. Major bleeding may also contribute to higher mortality.

Background: Characteristics of laboratory findings of COVID-19 patients are of great significance for diagnosis and treatment. Studies that have analysed the variations in hepatic profile in correlation with the inflammatory markers in SARS-CoV-2 are limited., Methods: We retrospectively analysed liver function tests and inflammatory markers of 170 admitted patients with confirmed COVID-19 in the tertiary care centre, Post Graduate Institute of Medical Education and Research (PGIMER), India, using Roche Cobas Autoanalyzer., Results: Number of patients with normal liver enzyme levels were 63 (41.5%), while with raised levels of any of the liver enzymes were 89 (58.5%), out of which 43 (48.31%) had liver injury which manifested as increased severity in terms of intensive care unit (ICU) requirement (p=0.0005). Significantly raised levels of liver enzymes and liver injury were observed with age (p<0.0001) and in males (p=0.004). Significantly decreased levels of albumin and total proteins and increased levels of total bilirubin (p<0.0001) were seen in patients with abnormal liver enzyme levels and liver injury as compared to patients with normal levels. Significant increase in the levels of alanine transaminase and gamma-glutamyl transferase was seen on the 7th day, CRP and ferritin (p<0.0001) peaks were observed on 2nd and 3rd day respectively. A significant positive correlation was found between the levels of these inflammatory markers and liver function parameters., Conclusions: More than half of patients admitted to the hospital with SARS-CoV-2 infection had an abnormal liver function which was found to be associated with raised levels of inflammatory markers. Significantly higher proportions of patients with abnormal liver function were elderly and males and were at higher risk of progressing to severe disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background & Objectives: The safety of the ChAdOx1 nCoV-19 vaccine is a cause of concern for many who have been vaccinated. The people have multiple concerns and fear regarding the adverse events of the vaccine. Thus, this study was undertaken to establish the safety profile of ChAdOx1 nCoV-19 Corona Virus Vaccine (Recombinant) among the healthcare professionals., Methods: This was a descriptive cross-sectional survey. After taking clearance from the institutional ethics committee 1500 healthcare professionals, who had their vaccination in the past two weeks were selected. They were provided with an online survey proforma regarding adverse events following immunization (AEFIs) of COVID-19 vaccine developed using google forms with an informed consent form affixed to it., Results: A total of 1036 individuals participated in the study. The mean and median (inter quartile range) age of the participants was 37.7 ±11.25 and 35 (29-46) yr, respectively. Of these, 52.1 per cent were female, 29.3 per cent were doctors, 33.4 per cent were nurses and 9.5 per cent were paramedical staff. Forty six per cent participants experienced one or more minor AEFIs such as pain, tenderness, redness, etc. at the injection site. Fatigue (31.75%), generalized feeling of unwell (28.57%), muscle pain (23.16%) and fever (21.71%) were the most commonly reported systemic AEFIs followed by headache (20.07%), dizziness (10.03%) and joint pains (15.25%). Most of them experienced these AEFIs within 24 h of the first dose of administration. About 42 per cent of the participants took oral antipyretics/analgesics for managing the AEFIs., Interpretation & Conclusions: ChAdOx1 nCoV-19 Corona Virus Vaccine was found to be associated with mild local and systemic AEFIs that were more common after the first dose as compared to the second dose. There adverse events could be dealt with oral over-the-counter medications, with no requirement of hospitalization.

Background and objectives Recent randomized controlled trials (RCTs) have indicated potential therapeutic benefits with high-dose dexamethasone (HDD) or tocilizumab (TCZ) plus standard care in moderate to severe coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome (ARDS). No study has compared these two against each other. We aimed to compare the efficacy and safety of HDD against TCZ in moderate to severe COVID-ARDS. Methods Patients admitted with moderate to severe COVID-19 ARDS with clinical worsening within 48 hours of standard care were randomly assigned to receive either HDD or TCZ plus standard care. The primary outcome was ventilator-free days (VFDs) at 28 days. The main secondary outcomes were 28-day all-cause mortality and the incidence of adverse events. Our initial plan was to perform an interim analysis of the first 42 patients. Results VFDs were significantly lower in the HDD arm (median difference: 28 days; 95% confidence interval (CI): 19.35-36.65; Cohen's d = 1.14;p   < 0.001). We stopped the trial at the first interim analysis due to high 28-day mortality in the HDD arm (relative risk (RR) of death: 6.5;   p = 0.007; NNT (harm) = 1.91). The incidence of secondary infections was also significantly high in the HDD arm (RR: 5.5; p = 0.015; NNT (harm) = 2.33). Conclusions In our study population, HDD was associated with a very high rate of mortality and adverse events. We would not recommend HDD to mitigate the cytokine storm in moderate to severe COVID-19 ARDS. TCZ appears to be a much better and safer alternative., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Naik et al.)

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a global health problem, India being the second most affected country. The kinetics of antibody response to SARS-CoV-2 in Indian population is not studied yet. To understand serological response in relation to age, gender, time period and severity of disease, Roche Elecsys anti-SARS-CoV-2 test was used which analysed both IgM and IgG. One hundred and three COVID-19 patients were enrolled. Seropositivity was seen in 64% of patients, with 33% at ≤ 7 days, 62% between 8 and 15 days and 81% at ≥ 16 days from the time of admission. Men (65%) showed higher antibody response than women (59%), whereas no difference was observed in seropositivity with respect to age of the patients. Dynamics of antibody responses revealed individual variations. Patients in ICU had higher antibody reactivity with 67% positivity as compared to 60% positivity in non-ICU patients. Kinetics of antibody response during COVID-19 disease varied in relation to gender, age, time period and severity and these factors might play an important role in treatment and control of COVID-19., Competing Interests: Conflicts of InterestThe Authors declares that they have no conflict of interest., (© Association of Clinical Biochemists of India 2021, corrected publication 2021.)

Background Very little has been reported about health care workers' (HCWs) adherence to the Centers for Disease Control and Prevention (CDC) guidelines of doffing personal protective equipment (PPE) amid the COVID-19 pandemic. Real-time remote audio-visual doffing surveillance (RADS) system for assisting doffing might reduce the risk of self-contamination. We used this system to determine the incidence of the breach in biosafety during doffing of PPE among HCWs involved in the care of Covid-19 patients. Methods A total of 100 HCWs were enrolled in this observational study who performed duties in the COVID intensive care unit (ICU) of our tertiary care centre. With a real-time RADS system, trained observers from remote locations assisted HCWs during doffing of PPE and noted breach at any step using the CDC doffing checklist. The breach was considered major if committed during removal of gloves/gown/N-95 or if ≥3 errors occurred in any other steps. Results Overall, 40% of the HCWs committed a breach during doffing at least one step. The majority of the errors were observed during hand hygiene (34%), followed by glove removal (12%) and N-95 removal (8%). Nineteen percent of HCWs committed the major breach, out of which 37.5% were done by house-keeping sanitation staff (p = 0.008 and RR 2.85; 95% CI of 1.313-6.19), followed by technicians (22.5%), nursing staff (16.7%) and resident doctors (6.5%). Conclusions Performing doffing using a real-time RADS system is associated with a relatively low incidence of a breach in biosafety compared with earlier studies using an onsite standard observer. Overall adherence of HCWs to the CDC guidelines of doffing PPE was satisfactory. This study highlights the importance of the RADS system during doffing of PPE in a health care setting amid the COVID-19 pandemic., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Naik B et al.)

Background Survivors of COVID-19 pneumonia may have residual lung injury and poor physical and mental health even after discharge. We hypothesized that COVID-19 severe acute respiratory distress syndrome (ARDS) patients needing mechanical ventilation may be at a greater risk of deterioration in pulmonary function, mental health, and quality of life (QOL). This study analyses the differences in pulmonary function, mental health, and QOL after recovery, in patients having received non-invasive oxygen therapy versus invasive mechanical ventilation during ICU stay. Methods Patients aged >18 years, who had completed 3 months post ICU discharge, with moderate to severe COVID-19 ARDS, were consecutively enrolled from May 1 to July 31, 2021. Patients were allocated into Group A - having required high flow nasal cannula (HFNC)/non-invasive ventilation (NIV) and Group B - having received invasive mechanical ventilation. Pulmonary function tests, 6-minute walk test (6-MWT), and health-related quality of life were compared. Results Of the 145 eligible patients, 31 were lost to follow-up and 21 died. Seventy-four patients were allocated into Groups A (57 patients) and B (17 patients). In Group A, abnormal forced expiratory volume in first second (FEV 1 ), forced vital capacity (FVC), forced expiratory flow in mid-half of FVC (FEF 25-75 ), and peak expiratory flow rate (PEFR) values were obtained in 27 (47.37%), 43 (75.44%), 11 (19.3%), and 25 (43.86%) patients, and in Group B, in 13 (76.47%), 17 (100%), 1 (5.88%), and 8 (47%) patients, respectively. No patient had abnormal FEV 1 /FVC. All Group B patients had a restrictive pattern in spirometry as compared to 77% in Group A. Group B had a lower arterial partial pressure of oxygen (PaO 2 ) (p=0.0019), % predicted FVC (p<0.0001), % predicted FEV 1  (p=0.001), and 6-MWT distance (p<0.001). The physical component score in the short-form survey 12 questionnaire was higher in group A, p<0.001, whereas the mental component score was comparable. Conclusions Patients requiring invasive mechanical ventilation (MV) have a greater risk of impaired pulmonary function and reduced QOL post-ICU discharge. This warrants a greater need for following these patients for better rehabilitation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Hazarika et al.)

Purpose: To compare serum total calcium and phosphate levels in patients with non-severe COVID-19 with age, sex, and serum 25-hydroxyvitamin D level matched healthy adult cohort. Methods: In this retrospective case-control study, medical records of patients (≥18 years) diagnosed as non-severe COVID-19 admitted at and discharged from our tertiary care institution during the period from April 10, 2020 and June 20, 2020 were retrieved. Baseline investigations, notably, serum calcium, phosphate, albumin, magnesium, 25-hydroxyvitamin D, and C-reactive protein (CRP), were performed at admission before any form of calcium or vitamin D supplementation were considered. The biochemical parameters were compared with age, sex, and 25-hydroxyvitamin D matched healthy adult controls (1:1 ratio) derived from the Chandigarh Urban Bone Epidemiological Study (CUBES). Results: After exclusion, 72 patients with non-severe COVID-19 (63 mild and 9 moderate disease) and an equal number of healthy controls were included in the final analysis. Age, sex, serum 25-hydroxyvitamin D, and albumin levels were matched between the 2 groups. Hypovitaminosis D and hypocalcemia were seen in 97 and 67% of the patients, respectively. The patients had lower serum calcium ( P value <0.001) and phosphate ( P = 0.007) compared with the controls. There was no statistically significant correlation between serum calcium and CRP. Conclusions: Hypocalcemia is highly prevalent even in COVID-19 patients with non-severe disease probably implying that hypocalcemia is intrinsic to the disease. Prospective studies with larger number of patients are required to prove this hypothesis and unravel the underlying pathophysiological mechanisms., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Pal, Ram, Zohmangaihi, Biswas, Suri, Yaddanapudi, Malhotra, Soni, Puri, Bhalla and Bhadada.)

Background & Objectives: The COVID-19 pandemic emerged as a major public health emergency affecting the healthcare services all over the world. It is essential to analyze the epidemiological and clinical characteristics of patients with COVID-19 in different parts of our country. This study highlights clinical experience in managing patients with COVID-19 at a tertiary care centre in northern India., Methods: Clinical characteristics and outcomes of consecutive adults patients admitted to a tertiary care hospital at Chandigarh, India, from April 1 to May 25, 2020 were studied. The diagnosis of SARS-CoV-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat and/or nasopharyngeal swabs. All patients were managed according to the institute's consensus protocol and in accordance with Indian Council of Medical Research guidelines., Results: During the study period, 114 patients with SARS-CoV-2 infection were admitted. The history of contact with COVID-19-affected individuals was available in 75 (65.8%) patients. The median age of the patients was 33.5 yr (13-79 yr), and there were 66 (58%) males. Of the total enrolled patients, 48 (42%) were symptomatic. The common presenting complaints were fever (37, 77%), cough (26, 54%) and shortness of breath (10, 20.8%). Nineteen (17%) patients had hypoxia (SpO 2 <94%) at presentation and 36 (31%) had tachypnoea (RR >24). Thirty four (29.8%) patients had an accompanying comorbid illness. Age more than 60 yr and presence of diabetes and hypertension were significantly associated with severe COVID-19 disease. Admission to the intensive care unit (ICU) was needed in 18 patients (52%), with three (2.6%) patients requiring assisted ventilation. Mortality of 2.6 per cent (3 patients) was observed., Interpretation & Conclusions: Majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Fever was noted only in three-fourth of the patients and respiratory symptoms in half of them. Patients with comorbidities were more vulnerable to complications. Triaged classification of patients and protocol-based treatment resulted in good outcomes and low case fatality., Competing Interests: None

Background and Aims: Patients with diabetes mellitus (DM) often demonstrate impaired antibody response to influenza/hepatitis B vaccines. Hence, we compared anti-SARS-CoV-2 antibody response in non-severe COVID-19 patients with and without type 2 diabetes mellitus (T2DM)., Methods: Records of non-severe COVID-19 patients admitted at our institution between April 10, 2020 and May 20, 2020 were retrieved. Qualitative detection of total (IgG + IgM) anti-SARS-CoV-2 antibody was performed using electrochemiluminescence immunoassay in plasma samples collected at least 14 days post-polymerase chain reaction (PCR) confirmation of diagnosis., Results: Thirty-one non-severe COVID-19 patients were included. Nine patients (29%) had T2DM with mean HbA 1c at admission of 8.3 ± 1.0%. Anti-SARS-CoV-2 antibody was estimated at a median of 16 (14-17) days post-PCR confirmation of COVID-19 diagnosis. Only three patients (10%) were seronegative, and all had T2DM. Patients with T2DM were more likely to have non-detectable anti-SARS-CoV-2 antibodies than those without DM (p = 0.019)., Conclusions: COVID-19 patients with T2DM may not undergo seroconversion even after two weeks of diagnosis. Impaired seroconversion could theoretically increase the risk of reinfections in patients with DM. However, the finding requires validation in large-scale studies involving serial estimations of anti-SARS-CoV-2 antibodies in patients with and without DM., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare.

Background: Traumatic brain injury (TBI) induces major insult to the normal cerebral physiology. The anesthetic agents may infrequently produce deleterious effects and further aggravate damage to the injured brain. This study was conducted to evaluate the effects of propofol and sevoflurane on cerebral oxygenation, brain relaxation, systemic hemodynamic parameters and levels of interleukin-6 (IL-6) in patients with severe TBI undergoing decompressive craniectomy., Methods: A prospective randomized comparative study was conducted on 42 patients undergoing surgery for severe TBI. Patients were randomized into two groups, Group P received propofol and Group S received sevoflurane for maintenance of anesthesia. All patients were induced with fentanyl, propofol, and vecuronium. The effect of these agents on cerebral oxygenation was assessed by jugular venous oxygen saturation (SjVO 2 ). Hemodynamic changes and quality of intraoperative brain relaxation were also assessed. The serum levels of IL-6 were quantitated using enzyme-linked immunosorbent assay technique., Results: SjVO 2 values were comparable and mean arterial pressure (MAP) was found to be significantly lower in Group P as compared to those in Group S ( P < 0.05). Brain relaxation scores were comparable between the groups. The level of IL-6 decreased significantly at the end of surgery compared to baseline in patients receiving sevoflurane ( P = 0.040)., Conclusions: Cerebral oxygenation measured by SjVO 2 was comparable when anesthesia was maintained with propofol or sevoflurane. However, significant reduction in MAP by propofol needs attention in patients with severe TBI. The decrease in IL-6 level reflects anti-inflammatory effect and probable neuroprotective potential of propofol and sevoflurane., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Asian Journal of Neurosurgery.)

COVID-19 pandemic is an emerging, rapidly evolving public health emergency where a nation's health-care system can face a marked surge in demand for intensive care unit (ICU) beds and organ support. In regions with insufficient medical resources, it may further aggravate the existing shortage, limiting an ICU's ability to provide the normal standard of care. It can present ethically or legally demanding questions about how to prioritize the allocation of life-saving medical resources. In developing countries like India, still many hospitals are challenged by competing priorities and remain underprepared. In the wake of COVID-19 pandemic, to guide the intensive care disaster planners in regions with low resources and to ensure ICU readiness, this review shares our experience and strategies for preparing ICU with existing and alternative resources, focusing on space, equipment, and health-care workers' safety and training., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Anesthesia: Essays and Researches.)

Background  The intracranial pressure (ICP) is measured through various noninvasive methods to overcome complications of invasive ICP monitoring. In this study, transcranial Doppler was used to measure pulsatility index (PI) and resistive index (RI) that were correlated with opening intraventricular ICP. The opening intraventricular ICP was measured with the placement of intraventricular catheter in lateral ventricle without loss of cerebrospinal fluid. Methods  The prospective, observational study was conducted on 40 patients with clinical and radiological features of raised ICP who underwent either endoscopic third ventriculostomy or ventriculoperitoneal shunt surgery. The PI and RI were measured simultaneously with opening ICP measurements under general anesthesia. Both PI and RI were correlated with ICP by using Pearson correlation coefficient. The receiver operating characteristic (ROC) curve was used to get the optimal values of PI ad RI for corresponding ICP values. Results  The mean PI was 1.01 ± 0.41 and mean RI was 0.59 ± 0.32. The mean opening ICP value was 21.81 ± 8.68 mm Hg. The correlation between PI and RI with ICP was a statistically significant with correlation coefficient of 0.697 and 0.503, respectively. The ROC curve shown statistically significant association between PI and ICP from 15 to 40 mm Hg, whereas the association between RI and ICP was from 15 to 25 mm Hg, with various sensitivity and specificity. Conclusion  The opening intraventricular ICP correlated better with PI than RI in patients with features of raised ICP., Competing Interests: NoteAuthors’ ContributionsConflict of Interest Oral paper presentation at 17th Annual conference of Indian Society of Neuroanaesthesiology and Critical Care from 05 to 07 February, 2016 at National Institute of Mental Health and Neurosciences (NIMHANS) convention center, Bengaluru, India. N. K. was awarded the 2nd best paper presentation for the same. Dr. Narender Kaloria helped in writing, draft, data acquisition, and data analysis. Dr. Nidhi Bidyut Panda helped in concept and design of the manuscript, and drafting and editing the manuscript. Dr. Hemant Bhagat helped in the definition of intellectual content and review of the manuscript. Dr. Neha helped in draft, data analysis, and statistical analysis. Dr. Shiv Lal Soni helped in critical revision of the manuscript. Dr. Rajeev Chauhan helped data acquisition. Dr. Rajesh Chhabra helped in literature search and conduct of the study. Dr. Kiran Jangra helped in literature search and critical revision. The article has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work from inception to published article. The corresponding contributor is designated as “guarantor” for above research work authenticity. None declared.

Introduction: Hyperosmotic agents are used to decrease intracranial pressure (ICP). We aim to compare the effect of euvolemic solutions of 3% hypertonic saline (HTS) and 20% mannitol on intraoperative brain relaxation in patients with clinical or radiological evidence of raised ICP undergoing surgery for supratentorial tumors., Materials and Methods: A., prospective double-blind study was conducted on 30 patients randomized into two equal groups. Each patient was administered 5 ml/kg of either 20% mannitol or 3% HTS over 15 minutes (min) after skin incision. Hemodynamic data, brain relaxation and serum electrolyte levels were recorded., Results: Intraoperative brain relaxation was comparable between the two groups. There was a statistically significant difference in the mean arterial pressures (MAPs) between the two groups after one minutes (min) with a greater degree of decrease in blood pressure recorded in the mannitol group (P = 0.041). MAP with mannitol was significantly lower than the preinduction value after 75 min of administration of drug (P = 0.003). Urine output was significantly higher in the mannitol group (P = 0.00). Administration of HTS was associated with a transient increase in serum sodium concentrations, which was statistically significant but returned to normal within 48 h (P < 0.001)., Conclusions: Both mannitol and HTS provided adequate intraoperative brain relaxation. On the contrary, there was no statistically significant fall in blood pressure with HTS. Thus, we advocate the use of HTS over mannitol as it maintains better hemodynamic stability., Competing Interests: None

Context: Postoperative sore throat (POST) is a frequent and undesirable complication after general anesthesia with endotracheal intubation. Various pharmacological and non-pharmacological methods with variable success rate are used for attenuating POST. However, no single drug has been universally accepted., Aims: To compare the effect of betamethasone gel, ketamine gargles and intravenous dexamethasone on the incidence and severity of POST., Settings and Design: Prospective randomized controlled single-blinded trial conducted at a tertiary care centre., Materials and Methods: A total of 100 patients of age 18 to 70 yr, ASA class I and II, scheduled for elective surgeries under general anaesthesia were included and divided randomly in betamethasone, dexamethasone, ketamine and control groups. Endotracheal tubes were lubricated with 0.05% betamethasone gel in betamethasone group, 0.2 mg/kg of dexamethasone was administered intravenously before induction of anaesthesia in dexamethasone group, 40 mg of ketamine gargles mixed with 30 ml of saline was given 5 minutes prior to induction in ketamine group. In the control group, none of the above agents were used. During the 24 hr after the operation, we noted the occurrence and severity of POST, cough and hoarseness., Statistical Analysis Used: The demographic data, surgical time and intubation among the groups were analyzed using one-way analysis of variance. Incidence and severity of POST, cough and hoarseness of voice among the groups were analyzed utilizing Chi-square test., Results: Incidence of POST at one hour was found to be significantly less in betamethasone group (16%) and dexamethasone group (20%) in comparison to the control group (48%). The incidence of POST at 4 hours and 24 hours were found to be comparable. The frequency of hoarseness and cough at 1 hour, 4 hour and 24 hours were similar in all the groups., Conclusions: Prophylactic betamethasone gel application and intravenous dexamethasone administration before induction of anaesthesia resulted in clinically important and statistically significant decreases in the incidence of POST only in early postoperative period., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Anesthesia: Essays and Researches.)

Background: Laparoscopic cholecystectomy (LC) is associated with high risk of postoperative nausea and vomiting (PONV) if no prophylactic antiemetic is used., Aims: The study compared prophylactic palonosetron and dexamethasone with ondansetron and dexamethasone in patients undergoing LC., Setting and Design: This prospective, double-blinded, randomized, controlled study was conducted at a tertiary care center., Materials and Methods: The study was carried out in 86 patients who underwent LC. The patients were randomly assigned to following study groups: Group 1 who received palonosetron (0.75 mg) with dexamethasone (8 mg) and Group II who received ondansetron (4 mg) with dexamethasone (8 mg). Patients were observed for nausea with visual analog scale and vomiting episode during 48 h postoperative follow-up., Statistical Analysis Used: Data were analyzed as mean, standard deviation, percentage, and number. The following statistical tests were used: paired or unpaired t -test, Mann-Whitney test, Chi-square test, and repeated ANOVA test., Results: There was no statistically significant difference in heart rate, mean arterial pressure, and oxygen saturation from baseline. During 48 h follow-up, the incidence of nausea, vomiting, and PONV was higher in Group II, but the difference was not statistically significant. The total dose of rescue antiemetic was 2.14 ± 4.15 mg in Group I and 5.00 ± 8.62 mg in Group II patients ( P = 0.058). Headache was present in three patients in Group I and two patients of Group II., Conclusion: The palonosetron with dexamethasone is comparable to ondansetron with dexamethasone in the prevention of PONV in patients undergoing LC., Competing Interests: There are no conflicts of interest.

Vegetable oils are found suitable alternate of diesel fuel as per the results of short-run studies. Long-run studies with vegetable oil as a fuel pointed out the problems related to wear and maintenance of the engine. A single cylinder, variable compression ratio diesel engine was tested for 512 h (32 cycles of 16 h per day) to investigate longevity implications of fueling Thumba vegetable oil. Results of the study revealed that a very little damage was observed over the running surface of the cylinder liner, piston rings, valves, and valve seats. Wear in the piston outer diameter was observed to be 13 to 30 microns. Cylinder wear was about 80 microns. The closed gap in the oil piston ring increased up to 200 microns. Heavy carbon deposition was found on different internal parts of the engine, which indicates poor combustion of fuel. Amount of copper (66 mg/kg) and silicon (112 mg/kg) dissolved in the lubricating oil was found more than permissible limits (Cu 50 mg/kg, Si 25 mg/kg), after 450-h engine test run. But all the dissolve materials remain in allowable limits when the durability test conducted with diesel. Smoke, CO, HC, and NO X emissions were found to increase initially then decrease in the further engine running hours. But these emissions were found inferior to the engine emissions fueled with diesel in all the running hours. CO2 emissions were found superior throughout the test with the preheated T20 Thumba oil blend than diesel. The maximum reduction in the viscosity of the lubricating oil, during endurance testing, was found 60 centipoises but it was found 25 centipoises when the test conducted with diesel.

Increasing environmental concern, human health and the continuous upgradation in the stringent standards of vehicular emissions have shown much interest in cleaner diesel fuels. Out of various strategies to mitigate the diesel engine emissions, use of water blended diesel in the form of emulsion has grabbed sufficient attention of the fuel research community. Various researches have shown that water-emulsified diesel has sufficient potential to improve the engine performance simultaneously with a significant reduction in the levels of nitrogen oxides (NO x ) and particulate matter (PM) emissions. Micro-explosion phenomenon of combustion in emulsion fuel helps to provide efficient and complete combustion which in turn improves brake thermal efficiency. The current study presents a comprehensive review of the usage of water-emulsified diesel fuel in CI engines. Focusing on the performance, combustion, and emission analysis, it also talks in detail about the principle and the chemistry involved in making of a stable and homogeneous water-diesel emulsion compatible for CI engine. The literature survey concludes two crucial points. First, the water-blended diesel emulsion serves as an economical, fuel efficient, and cleaner combustion technology. Second, the optimum blend ratio, emulsifier quantity, and proper process differs in almost all the research papers and hence needed to be standardized.

In this paper, the effect of injection pressure on the performance, emission, and combustion characteristics of a diesel-acetylene fuelled single cylinder, four-stroke, direct injection (DI) diesel engine with a rated power of 3.5 kW at a rated speed of 1500 rpm was studied. Experiments were performed in dual-fuel mode at four different injection pressures of 180, 190, 200, and 210 bar with a flow rate of 120 LPH of acetylene and results were compared with that of baseline diesel operation. Experimental results showed that highest brake thermal efficiency of 27.57% was achieved at injection pressure of 200 bar for diesel-acetylene dual-fuel mode which was much higher than 23.32% obtained for baseline diesel. Carbon monoxide, hydrocarbon, and smoke emissions were also measured and found to be lower, while the NO x emissions were higher at 200 bar in dual fuel mode as compared to those in other injection pressures in dual fuel mode and also for baseline diesel mode. Peak cylinder pressure, net heat release rate, and rate of pressure rise were also calculated and were higher at 200 bar injection pressure in dual fuel mode.

The continuous rise in the cost of fossil fuels as well as in environmental pollution has attracted research in the area of clean alternative fuels for improving the performance and emissions of internal combustion (IC) engines. In the present work, n-butanol is treated as a bio-fuel and investigations have been made to evaluate the feasibility of replacing diesel with a suitable n-butanol-diesel blend. In the current research, an experimental investigation was carried out on a variable compression ratio CI engine with n-butanol-diesel blends (10-25% by volume) to determine the optimum blending ratio and optimum operating parameters of the engine for reduced emissions. The best results of performance and emissions were observed for 20% n-butanol-diesel blend (B20) at a higher compression ratio as compared to diesel while keeping the other parameters unchanged. The observed deterioration in engine performance was within tolerable limits. The reductions in smoke, nitrogen oxides (NO x ), and carbon monoxide (CO) were observed up to 56.52, 17.19, and 30.43%, respectively, for B20 in comparison to diesel at rated power. However, carbon dioxide (CO 2 ) and hydrocarbons (HC) were found to be higher by 17.58 and 15.78%, respectively, for B20. It is concluded that n-butanol-diesel blend would be a potential fuel to control emissions from diesel engines. Graphical abstract ᅟ.