The COVID-19 pandemic has hit the electroconvulsive therapy (ECT) services hard worldwide as it is considered an elective procedure and hence has been given less importance. Other reasons include the risk of transmission of infections, lack of resources, and the scarcity of anesthesiologists due to their diversion to intensive care units to manage COVID-19 patients. However, ECT is an urgent and life-saving measure for patients diagnosed with depression and other severe mental illnesses who have suicidality, catatonia, or require a rapid therapeutic response. COVID-19 pandemic is a significant source of stress for individuals due to its impact on health, employment, and social support resulting in new-onset psychiatric illnesses and the worsening of a pre-existing disorder. Hence, a continuation of the ECT services during the COVID-19 pandemic is of paramount importance. In this narrative review, the authors from India have compiled the literature on the ECT practice during the COVID-19 pandemic related to the screening and testing protocol, necessity of personal protective equipment, modification in ECT Suite, electrical stmulus settings, and anesthesia technique modification. The authors have also shared their experiences with the ECT services provided at their institute during this pandemic. This description will help other institutes to manage the ECT services uninterruptedly and make ECT a safe procedure during the current pandemic.

The COVID-19 pandemic has hit the electroconvulsive therapy (ECT) services hard worldwide as it is considered an elective procedure and hence has been given less importance. Other reasons include the risk of transmission of infections, lack of resources, and the scarcity of anesthesiologists due to their diversion to intensive care units to manage COVID-19 patients. However, ECT is an urgent and life-saving measure for patients diagnosed with depression and other severe mental illnesses who have suicidality, catatonia, or require a rapid therapeutic response. COVID-19 pandemic is a significant source of stress for individuals due to its impact on health, employment, and social support resulting in new-onset psychiatric illnesses and the worsening of a pre-existing disorder. Hence, a continuation of the ECT services during the COVID-19 pandemic is of paramount importance. In this narrative review, the authors from India have compiled the literature on the ECT practice during the COVID-19 pandemic related to the screening and testing protocol, necessity of personal protective equipment, modification in ECT Suite, electrical stmulus settings, and anesthesia technique modification. The authors have also shared their experiences with the ECT services provided at their institute during this pandemic. This description will help other institutes to manage the ECT services uninterruptedly and make ECT a safe procedure during the current pandemic.

Ebstein's anomaly is a rare congenital cardiac disease with dysplastic tricuspid valves, resulting in a wide spectrum of clinical manifestations, ranging from asymptomatic state to severe congestive cardiac failure (CCF).[1] This report describes such a patient who underwent endovascular coiling of an intracranial cerebral aneurysm under general anesthesia. Written informed consent was obtained from the patient before writing this manuscript. A 40-year-old female patient, weighing 50 kg, presented with a history of right-sided frontal headache and left upper limb weakness of 20 days duration. She was diagnosed to have systemic hypertension and Ebstein's anomaly and was on treatment with calcium channel blockers, beta-blockers, antiplatelet, and anticoagulant for the past 10 years. She had no symptoms of chest pain, palpitations, breathlessness, cyanotic spells, or easy fatiguability during the current visit. Diagnostic workup for her presenting symptoms included digital subtraction angiography of the cerebral vessels that revealed a right middle cerebral artery aneurysm measuring 5× 2.5 × 2.78 mm. Systemic examination was unremarkable except for a low baseline peripheral arterial oxygen saturation (SpO2) of 88% at room air and pansystolic murmur of Levine grade 3 on auscultation in tricuspid area, with no signs suggestive of CCF. Her investigations were unremarkable except for electrocardiogram (ECG) that showed tall broad P waves in all leads. Transthoracic echocardiogram showed severe tricuspid regurgitation (TR), dilated right atrium, and atrialized right ventricle. Patent foramen ovale (PFO) with right to left shunt was present with good biventricular function and pulmonary arterial systolic pressure of 25 mm Hg.

Proximal balloon occlusion prior to carotid artery stenting is considered a relatively safe practice during endovascular treatment of carotid artery stenosis. Transient neurological deterioration affecting the ipsilateral hemisphere is seen soon after balloon inflation, when placed proximal to the stenotic segment. This occurs in cases of bilateral carotid disease due to insufficient collateral blood flow from the contralateral side. Near infrared spectroscopy cerebral oximetry (NIRS) is a valuable tool in detecting hypoperfusion- induced cerebral tissue desaturation (rSO2) during these procedures. This helps the interventional radiologist to deflate the balloon at the earliest to re-establish the cerebral blood flow. The non-invasive nature and continuous real-time interpretation make NIRS an attractive adjunct in the neuroanesthesiolgist's armamentarium for monitoring cerebral ischemia. However, significant contribution from chromophores in the extra-cerebral tissues and external carotid artery circulation can limit its sensitivity during occlusion of the internal carotid artery. In our case, it did not reflect brain ischemia during hypotension and when the neurologic symptoms were obvious. Commonly available cerebral oximetry sensors placed over the frontal region do not cover the parietal lobe where ischemia is likely to occur during occlusion of the carotid artery. In such scenarios, it has been shown that multi-channel NIRS has a better sensitivity in detecting cerebral ischemia. This case report highlights the importance of frequent neurological examination during carotid stenting as rSO2 values might not always suggest cerebral ischemia.

power in left upper limb.Histopathology report confirmed it to be a schwannoma. Conclusion:Intraoperative neurophysiological monitoring and nerve stimulation is important tool in complete surgical excision of peripheral nerve tumors and preserving nerve function.

Aim: To study changes in cerebral hemodynamics following augmentation of blood pressure (BP) and cardiac output in patients of traumatic brain injury.Methodology/Description: After institutional ethics committee clearance and informed consent, this prospective and observational study was performed on 30 adult traumatic brain injury patients admitted to ICU and requiring pharmacological support to manage BP.Cardiac hemodynamic parameters were recorded by a noninvasive cardiac monitor (NICOM).MCA flow velocity was recorded on both sides using transcranial Doppler.Autoregulation was assessed bilaterally using THRR.BP augmentation was performed using noradrenaline infusion to achieve systolic arterial pressure augmentation of 20% and 40% of the baseline.All observations were repeated subsequently once target BP is achieved after initiation of vasopressor therapy.Linear mixed effect model was used for assessing the time course change between variables.Results: The hemodynamic variables (SBP, MAP, and HR), NICOM variables (CO, CI, and SVI) and TCD variables (mean flow velocity and pulsatility index) showed significant changes over all the time points (p < 0.001).Regression model showed a significant prediction of ipsilateral (estimate = 0.27) and contralateral mean flow velocity (estimate = 0.141) by MAP (p < 0.001 for both) and ipsilateral mean flow velocity (estimate = 1.5) by cardiac output (p < 0.008).Conclusion: Use of vasopressor therapy to improve systemic hemodynamics (BP and cardiac output) augmented cerebral blood flow when assessed with transcranial Doppler, in patients of traumatic brain injury irrespective of autoregulation status.

S106 Journal of Neuroanaesthesiology and Critical Care | Volume 4 • Supplement 1 • 2017 | neurophysiological monitoring, transcranial motorevoked potentials (MEPs), somatosensory-evoked potentials (SEPs) and electromyography (EMG). Methods: We conducted a prospective observational pilot study. High dose opioids, propofol and dexmedetomedine were administered for anaesthesia (BIS value of 45-55). Neuromuscular blockers, nitrous oxide, inhalational anesthetics were avoided and normothermia, euvolemia, normocapnia, mean arterial pressure >65 mm of Hg and hematocrit >21% were maintained. Cortical SSEP were recorded through monopolar needle electrodes placed on scalp. Changes were considered significant if the amplitude was decreased by more than 50% and/or the latency was increased by 10%. MEPs were elicited with electrodes inserted over motor cortex and recorded as compound muscle action potentials via surface electrodes placed in peripheral muscles. Results: Nine adolescents and 3 children underwent scoliotic corrective surgeries with Cobb’s angle of 40°-90°. Combined MEPs and SEPs monitoring was successful in all patients. No significant intraoperative evoked potential changes were seen in any patient which coincided with the absence of any neurological deficit postoperatively. One patient developed intraoperative bradycardia, one patient had excessive blood loss with intraoperative metabolic acidosis and one patient developed surgical site infection postoperatively. No patient needed postoperative mechanical ventilation. Conclusion: Intraoperative neurophysiological monitoring is a safe, reliable and sensitive method for detection of intraoperative injury to spinal cord and nerve root damage during scoliosis surgery. The anaesthetic drugs administered must be compatible with the neurophysiological monitoring. Maintenance of adequate depth of anaesthesia, hemodynamic and physiological stability of the patient and postoperative pain management are the major concerns for the anaesthesiologist.

BACKGROUND AND AIMS:Limited registry studies are available on the use of anesthetic agents. This registry was conducted to evaluate emergence outcomes in Indian adult patients undergoing surgery with desflurane anesthesia.MATERIAL AND METHODS:This multicenter, prospective, non-interventional, observational study (Registry in India on Suprane Emergence [RISE] registry) included adult inpatients who received desflurane as general anesthetic for surgical procedure of ≥2 h. Patients were stratified by age into three groups: ≥18-40 years, ≥41-65 years, and >65 years. Data on patients' demographics, practice, and usage pattern of medications were collected. The primary efficacy outcomes were time to extubation, time to response to verbal command, and time to orientation.RESULTS:Of 236 patients screened, 201 (≥18-40 years, n = 70; ≥41-65 years, n = 65; >65 years, n = 66) were enrolled in the study. Mean time to extubation observed in ≥18-40 years group was 7.2 ± 4.1 min, ≥41-65 years was 11.6 ± 8.99 min, and >65 years was 12.0 ± 10.5 min. Mean time to response to verbal command was 7.4 ± 4.3 min for ≥18-40 years, 10.9 ± 8.5 min for ≥41-65 years, and 10.0 ± 5.4 min for >65 years. Mean time to orientation was 13.0 ± 7.0 min for ≥18-40 years, 16.1 ± 12.0 min for ≥41-65 years, and 17.0 ± 8.6 min for >65 years. Incidence of nausea and retching/vomiting was observed in 8% of patients each in the postoperative period, and these complications were seen more in the >65 years age group. Overall, desflurane treatment maintained hemodynamic stability and no major airway events were reported.CONCLUSIONS:The RISE registry data suggest that desflurane-based anesthesia provides early recovery with stable hemodynamics without any airway adverse events, in a wide variety of surgical procedures.

Background: Myocardial dysfunction leading to circulatory instability (hypotension) during the perioperative period in traumatic brain injury (TBI). We intended to study myocardial dysfunction in TBI patients undergoing emergency surgical decompression and its association with neurological outcome. Methods: We recruited adult head injury patients undergoing surgery within 48 hours of insult. Preoperatively at bedside, ECG and Echocardiography were done. Postoperatively, patient was followed up for 48 hours with an ECG and an echocardiography. ECG was analyzed for heart rate, intervals (PR, QRS and QTc), morphologic end repolarization abnormalities (MERA), ST segment and T wave changes. Echocardiographic measurements collected were left ventricular ejection fraction (LVEF) and regional wall motion abnormalities (RWMA). GCS status at discharge was recorded. Results: Of 110 patients recruited before surgery: ECG abnormalities were sinus tachycardia (15%), prolonged QTc interval (42%), T wave abnormalities (42%), ST segment abnormalities (11%) and MERA (47%). Echocardiography showed LVEF <50% in 10% and RWMA in 10.8%. After surgery, ECG showed significant increase in sinus tachycardia and T-wave abnormalities, but reduction inprolonged QTc interval and MERA. Echocardiography showed significant decrease in LVEF <50% and RWMA. Presence of LV dysfunction were associated with lower GCS score at discharge. Independent predictors of LV dysfunction were poor GCS motor score and prolonged QTc interval. Conclusion: Left ventricular dysfunction improved following surgical decompression. Poor LV function was associated with poor admission GCS and prolonged QTc interval. Patients with poor LV function had lower GCS at discharge.

With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm.Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome.Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.

Introduction: Intraoperative blood loss during intracranial tumour surgery is a common and serious complication and predicting the same is challenging task for the anaesthesiologist. Although radiological scans can be used to qualitatively predict intraoperative blood loss, no current literature explores it systematically. This study is designed with the purpose of elucidating the magnetic resonance imaging (MRI) characteristics predictive of intraoperative bleeding. Methodology: Retrospective Observational Single centre study. E-hospital for haemoglobin (Hb) (pre-operative and post-operative) values and InstaRISPACS MRIs of intracranial tumour surgery patients was collected. Putative predictors of blood loss from MRIs were: (1) Size of tumour, (2) proximity to venous sinuses, (3) proximity to major intracranial arteries and first-degree branches, (4) pattern of contrast enhancement, (5) contrast enhancement ratio, (6) suspected histopathology of tumour, (7) percentage of areas of hypointensity (necrosis) within tumour, (8) average pixel intensity of susceptibility weighted images, (9) number of flow voids within tumour and (10) peritumoural oedema. The method utilised involved calculation of estimated blood loss from pre-operative and post-operative Hb values and intraoperative blood transfusion weight of patients. Formula used was (Hbpre − Hbpost)/Hbpre × estimated blood volume (EBV) + intraoperative BT volume administered. EBV = 70 × weight (females); 65 × weight (males). BT volume = packed cell volume (PCV) (0.6/0.35) = PCV × 1.714 or whole blood volume. A sample size of 100 patients was planned for producing a predictive model. Spearman’s correlation analysis was used for association between blood loss and MRI characteristics. Linear and logistic regression were used for identifying independent predictors of volume of intraoperative blood loss and predicting high blood loss (>25% of EBV). Results: Currently, 20 patients have been recruited. None of the above parameters appear to be significantly correlated with the calculated blood loss. Thus, none of the parameters were used for predictive modelling. Updated results will be discussed after complete data collection. Conclusion: The importance of quantitative prediction of expected blood loss in anaesthetic practice cannot be undermined in neurosurgeries. With no precedence of such study in known literature, we expect this study to be useful and hopefully lay background for future detailed research in this niche.

Introduction: Poor neurological status in traumatic brain injury (TBI) patients can be due to raised intracranial pressure or underlying brain parenchymal injury or a combination. Surgical decompression would improve the neurological condition of the former but not the later. The purpose of this study is to observe trends of intraoperative haemodynamics and bispectral index (BIS) in head injury cases. Methods: In this prospective study, 30 TBI (subdural haematoma or contusion) patients undergoing emergency cranial decompression were to be recruited. BIS electrode was placed in an alternate fashion on contralateral fronto-temporal region. Baseline haemodynamics and BIS were recorded. Further recordings were taken after anaesthesia induction, pre-craniotomy, post-craniotomy (5, 10, 15 min), post- durotomy (5, 10, 15 min) and 10 min at the end of surgery after discontinuation of anaesthetics. Glasgow coma scale before and after surgery, and Glasgow outcome scale (GOS) at hospital discharge were noted. Results: Currently, interim analysis of 20 patients showed significant changes between systolic blood pressure (SBP) (P = 0.002) and BIS (P = 0.007) during pre-craniotomy, 15 min post-craniotomy and 15 min post-durotomy [Figure 1]. SBP decreased marginally after craniotomy (P = 0.005) followed by a decrease after durotomy (P = 0.017). BIS showed significant increase post-craniotomy (P = 0.008) followed by a significant reduction after durotomy (P = 0.05). Mean changes in BIS and SBP after durotomy were 5.08 ± 1.8 and 18.92 ± 5.51 mmHg respectively. Heart rate (HR) and diastolic pressures showed no difference. On sub- classification of cases into good GOS (3, 4, 5) and poor GOS (1, 2), we noted no significant difference in trends of change of BIS (P = 0.104) and HR (P = 0.287) but a significant difference in SBP trends (P = 0.008) [Figure 2]. Discussion: The association between trends of SBP and BIS values indicates impaired cerebral autoregulation. BIS increases immediately after craniotomy and may or may not be related to blood pressures. The outcome of patients seems to be correlated with trends of change of SBP intraoperatively in the pericraniotomy period. Further updated results will be discussed after achieving higher sample size.

Background: Intraoperative hypotension is associated with worse outcomes in head injury patients. We intended to study the intraoperative haemodynamic changes in traumatic brain injury (TBI) patients undergoing emergency surgery. Methodology: Twenty adult patients undergoing surgery for TBI within 48 h of insult were recruited. Patients’ demographics and clinical findings were recorded. After induction, the radial arterial line was secured and cardiac output was monitored with FloTrac/EV1000 sensor to obtain cardiac index (CI), stroke volume index (SVI), pulse rate (PR) and mean arterial pressure (MAP). Systemic vascular resistance index (SVRI) was measured in patients who had central venous catheter in situ. Data were collected at following time points – incision, craniotomy beginning, end, durotomy and after decompression. Results: CI decreased during craniotomy and increased after durotomy significantly. Stroke volume variation (SVV) increased during craniotomy and decreased after durotomy significantly. MAP increased at beginning of craniotomy and decreased significantly after durotomy. SVRI and SVI decreased, PR increased during craniotomy but was not statistically significant. Discussion: Decrease in CI, increase in SVV and SVRI, not associated with change in PR or MAP occurred in the pericraniotomy period due to blood loss during craniotomy. The increase in CI and fall in SVRI and MAP after durotomy may be the result of loss of sympathetic tone. Advanced haemodynamic monitoring might be useful and provide better understanding of pressure and flow changes in patients undergoing surgery for head injury.

Systemic complications following liquid glue embolisation of intracranial pial arteriovenous fistulae (AVF) are uncommonly reported. We report a patient who had a pulmonary embolism of a liquid glue during endovascular treatment of a pial AVF. The patient had haemodynamic instability, pulmonary hypertension, increased alveolar dead space and increased brain natriuretic peptide levels. In addition to other supportive measures, her pulmonary hypertension was controlled with sildenafil. Ten months after the event, the patient had a considerable improvement of the clinical and laboratory variables and a significant radiographic resolution of the glue from the pulmonary circulation.

Hypertensive, hypervolumic, and hemodilution therapy (triple-H therapy) is administered to patients with symptomatic cerebral vasospasm after intracranial aneurysm clipping. This therapy can sometimes result in cardiac dysfunction because of pharmacologically induced hyperadrenergic state. The diagnosis may be missed if blood pressure alone is monitored to guide triple-H therapy. In this report, we describe one such patient who developed cardiac failure after triple-H therapy. This was diagnosed by using a bioreactance noninvasive cardiac output monitoring. Continuous cardiac output monitoring by this technique facilitated treatment of cardiac failure with milrinone and dobutamine. At discharge, the patient had no neurologic deficits.

Background: Positioning a patient in prone position under anaesthesia significantly alters cardiovascular physiology. Cervical myelopathy patients are known to have autonomic dysfunction. Such patients when positioned in prone position under anaesthesia carry a higher risk of developing haemodynamic changes and this can compromise spinal cord perfusion. Materials and Methods: This prospective observational study was conducted on 15 patients with cervical myelopathy who underwent surgery in prone position. The non invasive cardiac output monitor (NICOM) was used to record various haemodynamic parameters. The haemodynamic parameters were recorded at baseline, post induction, post intubation, prior to prone position, post prone position, and every five minutes thereafter upto 20 mins. The haemodynamic parameters that were recorded using the NICOM monitor: HR - Heart rate (beats/min), NIBP - non invasive blood pressure (mmHg), MAP - mean arterial pressure (mmHg), CO - cardiac output (l/min), CI - cardiac index (l/min/m2), SV - Stroke volume (ml/beat), SVV -stroke volume variability (%), TPR - total peripheral resistance (dynes. sec/cm5. Results: We found that MAP, HR, SV, TPR significantly decreased from baseline values to 20 min post positioning. Changes in CO, CI and SVV were not statistically significant. Conclusions: Hypotension can occur commonly in cervical myelopathy patients after prone positioning. We conclude that the decrease in MAP is due to decrease in TPR, SV. But the cardiac output is maintained. We can use of vasopressors or inotropes to treat such hypotension rather than administering IV fluids.

Early and effective systemic management plays an important role in the outcome of patients with stroke. Vigilant respiratory and hemodynamic monitoring and optimisation along with nutritional and metabolic correction goes a long way in improving results of definitive treatment in patients with stroke. This review discusses the systemic changes occurring after stroke and provides current evidence in the management of these factors, which significantly influence the outcome.

Background: Bispectral index score (BIS) is a processed electroencephalographic parameter used to measure level of sedation in anaesthetised patients. In few studies of psychiatric patients undergoing electroconvulsive therapy (ECT), it was observed that the BIS values were lower at baseline. It is not clear from those studies whether the BIS values are really low. Also, it is not clear whether the lower values are related to the primary psychiatric illness or the due to the effect of ECT. Therefore, we studied the BIS values in psychiatric illnesses and compared them with the normal controls. Materials and Methods: BIS index was recorded in 237 patients with various psychiatric illness (Group P) and 40 control patients without any psychiatric illness undergoing spinal surgery (Group C). BIS values were recorded in supine position before breakfast and before the morning doses of antipsychotic/benzodiazepine medications. It was recorded during resting state in all the subjects. Results: BIS values were lower in group P compared to control group (a mean of 89.8 ± 7.8 vs 95.7 ± 2.4, P < 0.0001). In the group P, the patients with psychosis and bipolar disorder had significantly lower BIS values than the patients with depression ( P= 0.04). Conclusions: BIS values in psychiatric patients are lower than those in the control group. Psychotic and bipolar disorders are associated with significantly lower BIS values than the depression.