Archives of Anesthesiology and Critical Care
Volume:9 Issue: 4, Autumn 2024

Bedside lung ultrasound (LUS) is increasingly being used in diagnosing various lung pathologies. Acute respiratory distress syndrome (ARDS), one of such lung pathology, is a major underlying cause of mortality in critically ill patients. Early diagnosis of ARDS can improve the outcome in such patients. The primary objective of this study is to explore application of B-lines in LUS for early detection of developing ARDS in susceptible patients.

This is a prospective cohort study. This study enrolled patients admitted in intensive care unit. Daily clinical evaluation, bedside chest x ray and bedside lung ultrasound done to diagnose ARDS. Mean days of diagnosing ARDS by chest x ray and LUS were compared using t-test. Area under the Receiver Operating Curves Characteristics was calculated with a 95% confidence interval to determine the prognostic value of LUS.

Out of a total of 100 participants, 28 patients developed ARDS. Lung ultrasound was found to diagnose ARDS significantly earlier then chest x ray (p=0.001).

Results in this study showed that B-line score in patients susceptible to develop ARDS can help in early diagnosis of the same.

Ventilator-associated pneumonia (VAP) is a consequence of mechanical ventilation, which can be fatal. Several markers are available to predict outcomes related to VAP. Choosing a predictor that is inexpensive, affordable, and accurate is advantageous. This study aimed to examine red cell distribution width (RDW) as a predictor of mortality in patients with VAP.

This prospective cohort study was conducted among 49 patients in the intensive care unit (ICU) of Valiasr Hospital in Tehran. A researcher-made checklist was used to collect RDW and other marker data, as well as mortality outcomes and length of stay (LOS) in the ICU. The Pearson correlation coefficient in the SPSS software and the regression model in the Eviews software were used to examine the relationship between markers and different outcomes.

Of a total of 49 patients (57.1% male; mean age = 54 ± 16), the length of ICU stays ranged from 7 to 14 days. According to the Pearson correlation coefficient, a significant association between RDW and mortality (P =.009) was noted. But no significant relationship between RDW and length of stay in the ICU (P =.81) was noted. Additionally, the regression model showed a positive relationship between RDW and white blood cells (WBC), lactate, and sequential organ failure assessment (SOFA).

Our study showed a positive but weak correlation between RDW and ICU mortality in patients with VAP. Due to its availability and low cost of measurement, RDW is an appropriate option for predicting mortality risk in patients who are admitted to the ICU and develop VAP.

The objective of the present study was to identify prognostic factors associated with mortality and transfer to intensive care units (ICUs) in hospitalized COVID-19 patients using random forest (RF). Also, its performance was compared with logistic regression (LR).

In this retrospective cohort study, information of 329 COVID-19 patients were analyzed. These patients were hospitalized in Besat hospital in Hamadan province, the west of Iran. The RF and LR models were used for predicting mortality and transfer to ICUs. These models' performance was assessed using area under the receiver operating characteristic curve (AUC) and accuracy.

Of the 329 COVID-19 patients, 57 (15.5%) patients died and 106 (32.2%) patients were transferred to ICUs. Based on multiple LR model, there was a significant association between age (OR=1.02; 95% CI=1.00-1.05), cough (OR=0.24; 95% CI=0.10-0.56), and ICUs (OR=7.20; 95% CI=3.30-15.69) with death. Also, a significant association was found between kidney disease (OR=3.90; 95% CI=1.04-14.63), decreased sense of smell (OR=0.28; 95% CI=0.10-0.73), Kaletra (OR=2.53; 95% CI=1.39-4.59), and intubation (OR=8.32; 95% CI=3.80-18.24) with transfer to ICUs. RF showed that the order of variable importance has belonged to age, ICUs, and cough for predicting mortality; and age, intubation, and Kaletra for predicting transfer to ICUs.

This study showed that the performance of RF provided better results compared to LR for predicting mortality and ICUs transfer in hospitalized COVID-19 patients.

Intravenous (IV) sedation is often used to relieve anxiety or stress during surgery under regional anesthesia. Subarachnoid block is a widely followed regional anaesthesia technique, especially in lower abdominal and lower limb surgeries. Intense sensory and motor block, continuous supine position and the inability to move the body also brings a feeling of discomfort and phobia in many patients. Sedation has been shown to increase patient satisfaction during regional anaesthesia. Dexmedetomidine is well suited for conscious sedation as patient can be quickly aroused and oriented on demand. Aim of this study was to compare infusion doses of 0.3μg/kg/hr and 0.5μg/kg/hr, after loading dose of 1μg/kg of injection (inj).dexmedetomidine in order to obtain a better regimen for patients undergoing procedures under spinal anaesthesia in terms of sedation and hemodynamic stability.

To compare efficacy of dexmedetomidine for intraoperative sedation and hemodynamic stability at doses of 0.3μg/kg/hr and 0.5μg/kg/hr after loading dose of 1 μg/kg in patients operated under spinal anaesthesia.

Adult 80 Patients were randomly divided into two groups, (Group D-0.3) and (Group D-0.5). They were given spinal anaesthesia with 0.5% hyperbaric bupivacaine and initial dose of inj.dexmedetomidine 1 μg/kg was infused over 10 minutes. Group D-0.3 received maintenance dose of inj.dexmedetomidine of 0.3μg/kg/hr and Group D-0.5 received maintenance dose of 0.5μg/kg/hr. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), respiratory rate (RR), spO2 and sedation using observer’s assessment of alertness/sedation (OASS) were recorded at baseline, after loading dose, before spinal anesthesia, after spinal anesthesia at every 5 minutes upto 30 minutes, followed by every 15 minutes till the end of surgery and every 5 minutes upto 15 minutes after surgery. Data were compared using chi-square and unpaired t test.

The mean age for Group D-0.3 is 43.9+11 and for Group D-0.5 is 35.3+20. There is no statistically significant difference in demographic profile between two groups. It was also observed that there is no statistically significant difference in HR, SBP, DBP, MAP, RR and SpO2 in all point of time (p>0.05). According to sedation score in group D-0.3 72% patients were sleeping comfortably but easily arousable and 8% patients were in deep sleep, while in group D-0.5 70% were sleeping comfortably but easily arousable and 15% in deep sleep.

After a loading dose of 1 μg/kg intravenously, an iv infusion of dexmedetomidine at a lower rate, i.e. 0.3μg/kg/hr is equally effective in providing sedation for patients undergoing surgeries under spinal anesthesia as 0.5μg/kg/hr.

Covid-19 has been associated with more than 330 million cases and 5.5 million deaths since December 2019 with many countries witnessing two or three waves of covid -19 cases. In our study we retrospectively analysed data of patients admitted to Intensive Care Unit of a tertiary care hospital in India with moderate to severe disease for association of mortality with comorbidities, gender and age of patients.

Data of patients admitted to Intensive care unit of our hospital from march 2021 to august 2021 with moderate to severe covid infection was retrospectively collected, patients with incomplete data in records were excluded and data of total of 415 patients was analysed for association of comorbidities (Diabetes, CKD, CAD, Hypertension, Chronic respiratory illness), gender and age for any association with mortality by multivariate binary logistic analysis and chi square test.

There was significant association of increased mortality with age more than 50 yrs having an odds ratio of 1.5 and age more than 70 yrs having odds ratio of 2.46(p= 0.027). There was also significant association between CKD and mortality with odds ratio of 3.117. (p =0.050). No association between Diabetes, CAD, Hypertension, Chronic respiratory illness and gender was found in our study.

The novel coronavirus infection (COVID-19) has significantly increased mortality in patients of age more than 50 yrs, the risk increases further if age is more than 70 yrs. We also found increased mortality in patients with chronic kidney disease.

Pnuemoperitonium in laparoscopy is associated with cardiorespiratory changes. Combination of epidural with General anaesthesia (GA) will offer benefit of hemodynamic control and perioperative analgesia. We aimed to study the efficacy of Combined Epidural- General Anaesthesia (CEGA) with pre-emptive activation over general anaesthesia in laparoscopic cholecystectomies.

In this prospective double blind –randomised study, 90 surgical inpatients were studied in two study groups. Group GE-(n=45) received Lumbar Epidural analgesia with ropivacaine 0.2% along with GA and Group G (n=45) received only GA. Heart rate (HR), Mean arterial Pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), Capnogram (ETCO2), saturation (spo2), VAS score, Ramsay sedation score, requirement of propofol, muscle relaxants and analgesics were studied.

Statistical analysis was carried out with SPSS version 20. Statistical value of p<0.05 was considered significant. We noted significant difference in MAP, SBP, DBP, muscle relaxants, Propofol, Fentanyl and lesser pain scores in Group GE than Group G i.e (p<0.001).

Combination of epidural and general anaesthesia technique with pre emptive activation has the benefit of better control of hemodynamics .It reduced requirements of analgesics and anaesthetic drugs and had faster recovery with less post operative pain in laparoscopic cholecystectomies.

Spinal anaesthesia is the most common technique used for lower abdominal surgeries. Spinal anaesthesia using plain hyperbaric bupivacaine has disadvantages like delayed onset, shorter duration etc. Adding adjuvants like fentanyl, dexmedetomidine has overcome these disadvantages and improve post operative analgesia and stable hemodynamic condition with minimal side effects. Aim of the study was to determine the time of onset and duration of sensory and motor block, sedation score and postoperative analgesic efficacy of Fentanyl and Dexmedetomidine as adjuvant to bupivacaine in lower abdominal surgeries.

This prospective, double blind, randomized study included total 100 patient-divided equally in 2 groups (group F-fentanyl and group D-dexmedetomidine) after matching the inclusion and exclusion criteria. Group F received 3ml of 0.5 % injection Hyperbaric Bupivacaine + 25 mcg Fentanyl and Group D received 3ml of 0.5 % injection Hyperbaric Bupivacaine + 5mcg Dexmedetomidine intrathecally. The onset and duration of sensory and motor block, sedation score, duration of postoperative analgesia and need of rescue analgesia along with haemodynamic parameters were recorded.

The mean time for onset of sensory block in group D was (3.5 ± 0.88 mins) significantly lower than group F (4.4 ± 1.2 mins) (p=0.001). And the mean time of onset of motor block in group D (3.23 ± 1.0mins) was significantly lower than in group F (4.3 ± 1.1 mins). Duration of sensory and motor block was significantly higher in group D as compared to group F. The mean analgesic dose in group D was 1.4 ± 0.78 and in group F was 3.6 ± 0.73(p<0.005).

From our study we concluded that Dexmedetomidine is a better adjuvant than Fentanyl as it provides rapid onset and prolonged sensory and motor block, hemodynamic stability with excellent post operative analgesia.

The improved consciousness level reflects the patient’s recovery following acute brain injury. The medications that can regulate neurotransmitter levels, neural synaptic plasticity, and functional connectivity of consciousness networks might play a crucial role in improving the consciousness status of the patients. Thus, this study aims to evaluate the effectiveness of amantadine in improving consciousness in acute brain injury patients.

The present quasi-experimental study was performed from 2021 to 2022 after obtaining the necessary permissions from Zahedan University of Medical Sciences, Iran. Eighty patients with acute brain injury who met the study inclusion criteria were recruited and randomized into amantadine and placebo groups. The amantadine group was given a daily dose of 100 mg amantadine tablets, while the placebo group received a gavage of amantadine-like placebo tablets twice daily for 14 days. The consciousness level of patients was measured daily until the outcome (ICU discharge or expiration) was established. Eventually, a comparative data analysis was conducted to determine amantadine's efficacy in enhancing consciousness, reducing mechanical ventilation time, and improving patient outcomes.

The mean GCS score in the amantadine group was 5.5±1.4 on admission and 11.9±3.7 at the end of the study, compared to 6.6±1.5 on admission and 11.8±3 at the end of the study, for the placebo group (p=0.154 and p=0.211, respectively). The mean duration of mechanical was 28.87±11.34 days in the amantadine group and 24.13±14.93 days in the placebo group (P=0.329). Twenty-four patients in the amantadine group were discharged from ICU, and 16 were expired. For the placebo group, 21 patients were discharged from ICU, while 16 were expired (p=0.221). No statistically significant difference was found in any of the measured variables between the two groups.

The results demonstrate that amantadine administration had no statistically significant impact on improving consciousness status and clinical outcomes and reducing mechanical ventilation time in acute brain injury patients.

Spinal Anesthesia Induced Hypotension(SAIH) continues to be the troublesome complication for obstetric patients undergoing cesarean section under subarachnoid block. Vasopressors are emerging as the cornerstone of treating SAIH in cesarean section patients with the evolving evidence of arterial vasodilatation as the primary cause of hypotension. This study was hypothesized to compare the efficacy of norepinephrine and ephedrine boluses to maintain hemodynamics in cesarean section.

After approval from institutional ethics committee and registration in Clinical Trials Registry India(CTRI ) and informed consent, study was conducted in 110 healthy parturients aged 18-40 years, belonging to ASA physical status I and II, posted for elective cesarean section under spinal anesthesia, were randomly allocated into group N(n=55) and group E(n=55),who received intravenous boluses of norepinephrine 6 g and ephedrine 10mg respectively as prophylaxis(one dose soon after induction) and in treatment of SAIH. The number of vasopressor boluses were recorded as primary objective and hemodynamics, APGAR scores, adverse events were noted.

The number of boluses of vasopressor used was 1.9±1.2 for Ephedrine and 4.72±2.9 for Norepinephrine. At 30,40,50 and 60 minutes after anesthesia, there was significant fall in mean arterial pressure in the norepinephrine group compared to ephedrine group. The incidence of tachycardia was more in ephedrine group and incidence of bradycardia was more in norepinephrine group.

Both the study drugs, ephedrine and norepinephrine are comparably effective in preventing SAIH after prophylactic bolus and effective in maintaining blood pressure intraoperatively, more number of boluses of norepinephrine was required compared to ephedrine.

In patients undergoing lower limb orthopaedic surgery, unrelieved post-operative pain not only results in discomfort to the patients but also predispose to the development of chronic pain syndromes. The dawn of ultrasonographic-guided techniques has led to increased interest in femoro-sciatic nerve block (FSNB) for lower limb orthopaedic surgeries. Efficacy of various adjuvants have been studied to prolong the block and analgesia. In recent years, there is growing interest in magnesium sulphate (MgSO4) and dexamethasone as adjuvants to local anaesthetics in nerve blocks. Duration of post-operative analgesia was the primary outcome of our study, whereas the rescue analgesics requirement, VAS scores and haemodynamic parameters and time required for toe movement were the secondary outcomes.

Sixty-patients scheduled to undergo below knee orthopaedic surgeries under subarachnoid block were divided into 2 groups: Group RM(n=30) patients received 38 mL of 0.375% Ropivacaine with MgSO4 150 mg in 2 mL NS and Group RD(n=30) patients received 38 mL of 0.375% Ropivacaine with Dexamethasone 8 mg(2mL) to make total drug volume of 40 mL. In all patients, 20 mL of LA solution was injected around femoral nerve and 20 mL around sciatic nerve. The primary outcome was duration of post-op analgesia and secondary being requirement of rescue analgesia and time for toe movement. Mean variables were analysed and compared with unpaired t-test. Proportions were compared with Chi-square test and Fischer-exact test.

Duration of analgesia was prolonged with Dexamethasone (18.8 ± 7.8) as compared to MgSO4 (8.8 ± 4.2). In regards to early ambulation, MgSO4(6.78 ± 2.25) was a cut above Dexamethasone (16.43 ± 4.56).

Both MgSO4 or Dexamethasone added to Ropivacaine prolonged the duration of analgesia, decreased requirement of rescue analgesia. Dexamethasone delays requirement of rescue analgesics with better pain scores as compared to MgSO4.

Metabolic acidosis (MA) is a common pathologic process with fatal consequences in critically ill (CI) patients. The more the severity of acidosis the more mortality rate is expected. To evaluate the relationship of hospital mortality with MA severity in CI patients admitted to emergency department (ED).

In this prospective cohort study, we enrolled CI patients (based on physician clinical assumption), most at level 1 or 2 emergency severity index triage system. Patients were followed and evaluated in 2 parallel groups, one with and the other without MA. The severity of acidosis, chief complaints, final diagnosis, demographic data, acute physiologic assessment and chronic health evaluation II (APACHE II) score, serum lactate and bicarbonate level, need for intubation and mechanical ventilation, admission ward, hospital length of stay and in hospital mortality were compared between the 2 groups.

A total of 1811 CI patients including 60.2% males and 39.8% females with and without MA were evaluated. The most common age range was 65-55 years old (31.7%) with the meanSD of 61.348.23. The most common complaints and diagnoses were weakness (40.5%) and pneumosepsis (35.1%), respectively. Patients with severe acidosis had higher lactate level and APACHE II score (p<0.05). Mortality rate was 10.4%. Most of our cases had severe MA. Expired cases had higher lactate level and APACHE II score (p<0.05).

Lactate level, bicarbonate level and APACHE II score were all significant independent predictors of hospital mortality in CI patients.

Continuous monitoring of the cardiovascular system and control of the changes affecting it is a constant challenge for the surgical team. The need to control the condition of the heart and better understand its condition is raised in the topic of advanced hemodynamic monitoring, which is a set of different techniques for real-time monitoring of the cardiovascular condition and its influencing factors. Cardiac output, as the most important indicator of cardiac function, is an integral part of cardiac monitoring systems. The measurement of this index has witnessed extensive changes in the past few years, which clearly shows its importance. Cardiac surgery is one of the most serious cases that requires accurate assessment of cardiac output and advanced hemodynamic monitoring. Therefore, the present study examines the types of cardiac output in cardiac surgery.

Surgical resection is frequently the intervention required for post-tuberculous empyema or other sequels. However, pneumonectomy may not be feasible in some situations, and video-assisted thoracoscopic surgery (VATS) plays a role in such a scenario. Whether a patient undergoes open resection of VATS, isolation of infected lung is integral to one-lung ventilation and better access to the surgical field, and a double-lumen tube (DLT) remains the preferred choice. Difficulties in DLT placement after pneumonectomy are reported; however, failure to isolate a lung by appropriately placed DLT is scarce or absent. A 28-year cachectic gentleman with poor preoperative lung function was suffering from endobronchial tuberculosis. He also had one episode of tuberculosis twelve-year back. At presentation, he had a massive pneumothorax and stage-III empyema as a sequel, including a rare finding of plastered mediastinum mimicking vanishing lung syndrome. He underwent uniportal-VATS under general anesthesia using one-lung ventilation. Complete lung destruction from active tuberculosis and its sequel leading to the plastered mediastinum and deformed airway pose a significant lung isolation challenge. U-VATS can be considered for therapeutic purpose where standard thoracotomy and pneumonectomy is contra-indicated. However, lung isolation in such patients is tricky and poses a risk. The present case highlights the challenges faced with lung isolation using a DLT and discusses the probable remedy to these problems.

Erector spinae plane block is an interfascial plane block that is a novel analgesic technique which is easy to administer. It provides extensive multidermatomal sensory block. It is a simple and safe procedure and is a promise of the future. It has been used to multiple surgeries of the thoracic and abdominal regions like thoracotomy, mastectomy, fibroadenoma, percutaneous nephrolithotomy and so on. Here, we describe the case of a 40year old male patient with ischemic heart disease, posted for percutaneous nephrolithotomy under general anesthesia, supplemented with ultrasound guided erector spinae plane block, with intermittent boluses. The catheter was used for post-operative pain relief for upto 48 hours and later removed. Intraoperative hemodynamics were optimal and post-operative need for multimodal analgesics had reduced.

Parotid pleomorphic adenomas are benign salivary gland tumors, which predominantly affect the superficial lobe of the parotid gland. The “pleomorphic” nature of the tumor can be explained on the basis of its epithelial and connective tissue origin. Slowly progressing asymptomatic swelling is the usual presentation of the tumor. Surgical excision of the tumor mass forms the mainstay of treatment, with utmost care taken to preserve the facial nerve. We describe here, a case of an obese male patient who was posted for parotid tumor resection under general anesthesia supplemented with superficial cervical plexus block whilst monitoring both muscle relaxation and nerve integrity.

Hot water Epilepsy (HWE) is a type of epilepsy which occurs when hot water is poured over the body. Patient undergoing implant exit removal of tibia was intra operatively managed who has the history of corrected VSD and hot water epilepsy.

Propofol is a commonly used medication for sedation during surgery; however, it must be used with precaution in neurologic patients because of the subsequent adverse effects of cardiovascular and neurologic. An 83-year-old male patient with acute subdural hemorrhage was referred with a two-year history of falling and a recent occurrence of imbalance; the patient underwent urgent surgery under general anesthesia, using 100 μg fentanyl for premedication, 50 mg Propofol for induction, and Isoflurane gas and fentanyl drip for maintenance. During transmission of the patient for postsurgical computed tomography, two ccs Propofol 1% were mistakenly injected into the patient's radial artery and managed appropriately by the master. Following this management, the patient represented no alteration in his vital signs and was discharged in a favorable condition. Here, we report how this case could be managed successfully. Robust data regarding the complications of accidental administration of Propofol through an artery are lacking, and the presented results remain controversial. The authors have herby drawn attention to the unique management of an accidental intra-arterial injection of Propofol. Further studies are warranted to establish definite conclusions.