Introduction: Pain from propofol injection can be severe and distressing in some patients. Various methods and agents has been used to alleviate this pain. One of the agents is ketamine which has been used in different sub-anaesthetic doses to reduce propofol injection pain in comparison with different agents. None of the studies till date have used ketamine in dose less than 0.1 mg/kg. The aim of the present study was to compare ketamine in doses of 0.05 and 0.1 mg /kg to attenuate propofol injection pain. Material and Method: 48 ASA I and II adult patients undergoing different elective surgical procedures under general anaesthesia were randomised into 3 groups of 16 patients each. Group A patients received ketamine 0.05 mg/kg in 2 ml while group B patients received ketamine 0.1mg/kg in 2ml. Group C patients served as placebo control and were administered 2ml 0.9% normal saline intravenously. The venous drainage was occluded manually by rubber tourniquet at mid-arm. Subsequently the study drug or the placebo was administered as per group allocation. One minute later, 25 % of calculated propofol induction dose was injected over 5 seconds. VAS score for pain of propofol injection was assessed at 0, 1 and 2 minutes after the propofol injection. Thereafter, general anaesthesia technique was continued as per standard technique giving the remaining 75% of propofol. Patient’s heart rate and blood pressure were recorded at 0, 1 and 2 minutes after the administration of 25% of the calculated dose of propofol. Any evidence of hallucination was observed in the recovery room. Results: Demographic profile and the ASA grade of the patients in the 3 groups was uniformly distributed. The mean VAS score for pain perception in group B patients at 1 and 2 minutes was 0.56 and 1.06 respectively. In contrast, the mean VAS for pain was 3.88 and 5.06 at 1 and 2 minutes respectively in group C. The VAS score of patients belonging to group A was closer to that seen in group B patients. This difference in VAS score was statistically highly significant between the groups at 1 and 2 minutes. A significant fall in systolic blood pressure was noted at 2 minutes after administering 25% of the propofol induction dose in all the 3 groups. In contrast, no significant changes were noted at one minute when compared to baseline. There was insignificant fall in the heart rate at 1 and 2 minutes following the administration of 25 % propofol in group A and B. In contrast, an insignificant rise in heart rate was noted at 1 and 2 minutes in group C. Conclusion: The results of this study demonstrate that 0.01 mg/kg of ketamine administered one minute prior to propofol injection is effective and superior to 0.05 mg / kg of ketamine in relieving propofol injection pain without any side effects.

Sir, Placement of a central venous catheter (CVC) carries a complication rate of 17.9%.[1] Use of ultrasound guidance has been advocated as standard of care to reduce complications and achieve higher success rate.[234] However, ultrasound-guided cannulation does not altogether negate accidental arterial puncture as has been found in our patient. A 3-year-old female child weighing 16.9 kg and having a midline brain stem tumour with hydrocephalus was posted for elective tumour excision. Following uneventful tracheal intubation and maintenance of anaesthesia with 50% oxygen in air, 1.5% sevoflurane and remifentanil (0.25 μg/kg/min) infusion, it was decided to place an arterial line and a CVC. Positive end expiratory pressure of 4-cmH2O was now momentarily applied, which resulted in a well-dilated right internal jugular vein (IJV) on imaging using linear probe of Mindray ultrasound machine (Shenzhen Mindray Bio-medical Electronics co. Ltd., Zhenzhen 518057, P.R. China). Right IJV was punctured at first attempt by a 4th-year anaesthesia resident with the needle directed at a 45° angulation. After free aspiration of blood, a guide wire was passed through the needle uneventfully. Following dilatation of the cannulation site, a 5.5 Fr paediatric multi-lumen CVC with blue flex tip (Arrow International, Inc, 2400 Bernville Road, PA, USA) was passed. All three ports were checked for free aspiration of blood. The CVC was fixed at 8 cm mark and sterile transparent dressing was applied. At this stage, an intravenous line containing 5% dextrose in 0.45% normal saline was attached to the distal 20-gauge catheter port. Contrary to expectation, there was no flow of the fluid although blood could be freely aspirated from this port. However, a minimal spontaneous backflow of blood was noted in the infusion line. Despite changing to a different port, the infusion was not dripping. At this stage, doubt was raised that the line could be in an artery, and the transducer of the arterial line was connected to the CVC and an arterial waveform was noted. Before removing the catheter, ultrasound imaging was done to confirm the position of the catheter in the artery. As expected, the puncture site and IJV were significantly to the right of the carotid artery. Further scanning and change of probe angle revealed a pulsating vessel underneath the jugular vein, which could be the subclavian artery (SA). Surprisingly, the catheter was seen to pass through the internal jugular lumen and then to lie in the SA [Figure 1]. The CVC was now removed and compression for 5 min was applied. A fresh CVC was placed in the same IJV uneventfully.Figure 1: Internal jugular vein and the subclavian artery with evidence of central venous catheter passing through them. (IJV-Internal jugular vein, SCA-Subclavian artery, CVC-Central venous catheter)We postulate a sequence of events that led to inadvertent SA puncture in our patient. The SA was about 2.5 mm deeper to the IJV as revealed by ultrasound [Figure 1]. The indentation of the wall of IJV while puncturing the vein or displacement of needle tip later after the probe was removed could be the reason for the needle tip entering the SA. We suggest five key points to avoid this mistake while cannulating IJV in paediatric patients where the SA is only a few mm away. First, needle should be kept angulated in relation to skin, close to 30° instead of 45° during puncture as this tangential approach results in less application of posterior forces that tend to collapse the vein wall. Also, angulation helps where the IJV diameter is less than the longitudinal length of bevel of needle.[5] Second, double wall puncture should be kept in mind where the vein diameter is small.[5] Third, it is essential that the tip of the needle be constantly identified with ultrasound as it approaches the vein and puncture is made.[6] Fourth, the path of guide wire should be confirmed by ultrasound prior to dilatation of the vessel. Lastly, a higher neck approach may be adopted in children so as to increase the distance between IJV and the SA, thereby reducing the possibility of its inadvertent puncture. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Raised levels of D-dimer have been noted in patients with COVID-19.The existing evidence emplies that the highest levels of D-dimer in the critically ill Covid-19 patient shows a linear relationship between the D-dimer measurement and the severity of the disease.However, that should also mean a patient on the road to recovery would have decrease in prothrombotic state and hence lower D-dimer readings.This study hypothesized that D-dimer trend would start to return towards normal as patients recovered from this illness.The present study included 43 patients with COVID-19 infection treated in the ICU at Khoula Hospital, Muscat, Oman from 10th May to 5th August 2020.Six readings of D-dimer were taken from the time of admission of Covid-19 npatient to their discharge from the ICU or demise.The data was statistically analyzed using generalized linear model, paired 't' test and Wilcoxon Signet Ranks test.D-dimer demonstrated a statistically significant difference by the value of 4 μg/ml in patients who were eventually extubated compared to those who died while in the ICU, despite that, as a trend over time was insignificant.In conclusion, this study suggests that D-dimer would be noteworthy in assessing severity as a single time-point, however not as a prognostic value in evaluating improvement of critically ill patients of COVID-19.

Specialized stroke units are known to provide best care for stroke patients. However in their absence, patients are often shifted to regular intensive care units that are already overburdened. We carried out a retrospective study to identify ischemic stroke patients who can be safely cared outside the intensive care unit (ICU) using National Institute of Health Stroke Scale (NIHSS) score as predictor of serious morbidity and mortality. We analyzed 50 ischemic stroke patients with complete records of NIHSS score and well-documented complications, if any, while being nursed in our ICU. The results show that patients having NIHSS score between 0-4 rarely have any complications other than very trivial ones’. These patients can be cared in high dependency units or stroke wards with dedicated trained nursing staff. Furthermore we noted that the patients at maximum risk of serious morbidity and mortality have NIHSS score greater than 15. These patients frequently need ventilatory/ hemodynamic support or management of cerebral edema and elevated ICP and hence justify ICU support.

Succinylcholine is administered in small doses to relieve post-extubation laryngospasm. We report a 3-month-old infant weighing 5.1 kg who developed severe laryngospasm after tracheal extubation following reversal of rocuronium bromide neuromuscular block. Succinylcholine 2.5 mg promptly relieved the spasm but apnea lasted for nearly an hour in a patient with normal dibucaine number. We postulate that this prolonged apnea was related to the timing of succinylcholine administration in relation to the degree of recovery from non-depolarising neuromuscular block.

A high incidence of lymphopenia has been reported in Covid-19 patients. The initial neutrophil-to-lymphocyte ratio (NLR) of ≥ 3.13 in Covid-19 patients predicts a high propensity of these patients to progress to critical illness. However, it has not yet been established if NLR would start to lower towards a normal ratio of 1-3 during patient’s road to recovery. This study hypothesized that NLR would start to return towards normal as patients recovered from this illness. This study included 43 patients with Covid-19 infection treated in the ICU at Khoula Hospital, Muscat from 10 th May to 5 th August 2020. Seven readings of NLR (NLR1 to NLR7) from the time of going on ventilator (NLR1) to discharge of patient (NLR7) from the ICU were statistically analyzed using paired ‘t’ test for patients who recovered or those who died. NLR values demonstrated a progressive fall in patients who recovered when comparison was made between NLR1 with other readings (NLR2 to NLR7). On the contrary, insignificant changes in NLR values were observed when comparison was made between NLR1 with subsequent day’s readings in patients who died while in ICU. In conclusion, this study suggests that the NLR of patients who survived showed a downward trend from its initial high values. In contrast, patients who died while in the ICU, NLR values showed little change from their basal value.

Introduction: Subdural hematoma is a rare but serious complication of accidental dural puncture during epidural or spinal anesthesia.This case report emphasizes the importance of close follow-up of patients with post dural puncture headache following accidental dural puncture and methods to identify development of subdural hematoma in such patients.Case report: a 23-year-old healthy primigravida developed accidental dural puncture while trying to locate epidural space using a Tuohy needle for painless labor.The patient complained of headache on the 2 nd post-operative day that was significantly relieved by analgesics, bed rest and hydration.Later she presented with severe headache that became persistent and lost its correlation with change of posture.Other than feeling nauseated she had no other additional signs and symptoms.Diagnosis of the SDH was confirmed via CT and treated surgically.The patient recovered completely. Conclusion:One should consider the possibility of subdural hematoma in patients when postdural puncture headache is prolonged or has a change in the character of headache with or without neurological symptoms for an early successful intervention.

Majority of Indian hospitals still lack the provision of acute postoperative pain relief service. In other parts of the world, field of acute pain management strategy has witnessed a surge in its implementation. Today, acute pain has begun to be recognized not merely as a distressing symptom but also as a precursor of chronic, debilitating pain. This development warrants that we in India address this issue on an urgent basis through the use of analgesic/narcotic combination via parenteral/oral/rectal route as well as by performing regional blocks, to meet the interpatient variability and available facility. In this review article, we have provided the organization and function of acute pain service (APS) program that can be adapted to a wide spectrum of Indian hospitals. We have outlined the role of APS team including the use of easily available analgesic/narcotic drug combinations for various categories of Indian hospitals dealing with different grades of surgical conditions, including those hospitals that are not sufficient in resources and funding. This article has also tabulated possible regional block techniques with their indications for treating acute postoperative pain in combination with parenteral/oral/rectal analgesics/narcotics in the more developed Indian hospitals. Staffing and equipment requirements have also been outlined.

Despite advances in needle size and design, postdural puncture headache (PDPH) still remains a significant cause of morbidity in parturients receiving spinal anesthesia. Several treatment options have been suggested to treat PDPH ranging from bed rest, rehydration, and analgesics to epidural blood patch. At our institution, we adhere to a strict protocol for managing PDPH wherein adrenocorticotrophic hormone (ACTH) is one of the treatment steps in cases of unrelieved PDPH. We carried out a 1-year retrospective analysis to note the efficacy of ACTH in managing PDPH in patients undergoing spinal anesthesia for cesarean section. All patients with PDPH were followed up for at least 2 months after being discharged from the hospital to note recurrence, if any. Data revealed that a total of 614 patients received spinal anesthesia during this period using a 25- or 26-G Quincke needle with the patient in the sitting position using a midline approach. Totally 31 patients developed PDPH and all patients reported their headache spontaneously. As per protocol, if the PDPH did not resolve or lessen in intensity with bed rest and simple analgesics (paracetamol, diclofenac or tramadol alone, or in combination) over the first 24 h, two injections of ACTH (1.5 μg/kg in 500 ml saline intravenous over 30 min) were administered 12 h apart. No further injections of ACTH were administered. If any treatment modality demonstrated relief or attenuation in PDPH, the patient was observed for the next 2 days. If there was no further improvement, next step of the protocol using epidural blood patch was adopted. Of these 614 patients, 31 developed PDPH giving an incidence of 5.04%. The first line of conservative treatment with bed rests and simple analgesics was successful in relieving or alleviating PDPH in 20 patients (64.5%) within 24 h. About 11 patients (35.5%) went on to receive ACTH as the second conservative line of management. In 10 of these 11 patients (90.9%), PDPH either resolved or showed significant relief between 12 and 48 h after the last ACTH injection. No further treatment was required in them. In 1 out of 11 (9.1%) patients who received ACTH, PDPH remained unresolved and the patient went on to receive epidural blood patch for alleviation of her symptoms. Epidural blood patch resulted in 90% relief of her PDPH. In conclusion, initial conservative line of treatment using analgesic combination resolved PDPH in 64.5% of patients while ACTH had a 90.9% of efficacy when administered 24–48 h after the onset of PDPH.

Background and Aim: Exchanging endotracheal tube (ETT) with classic laryngeal mask airway™ (CLMA™) prior to emergence from anaesthesia is a safe technique to prevent the coughing and haemodynamic changes during extubation. We had compared CLMA™ and AMBU laryngeal mask™ (ALM™) during ETT/laryngeal mask (LM) for haemodynamic changes and other parameters. Methods: A total of 100 American Society of Anesthesiologist Grade I and II adult female patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were selected and randomly divided into two groups of 50 patients each. In Group I, CLMA™ and in Group II, ALM™ was placed prior to tracheal extubation. Haemodynamic parameters were recorded during ETT/LM exchange. Glottic view was seen through the LM using flexible fibrescope. Coughing/bucking during removal of LM, ease of placement and post-operative sore throat for both groups were graded and recorded. Statistical Analysis: Data within the groups was analysed using paired t-test while between the groups was analysed using unpaired t-test. Chi-square test was used to analyse grades of glottic view, coughing, and post-operative sore throat. Results: In Group I, there was a significant rise in systolic blood pressure and heart rate in contrast to insignificant rise in Group II. Glottis view was significantly better in Group II. Incidence of coughing, ease of placement and post-operative sore throat was identical between both groups. Conclusion: ALM™ is superior to CLMA™ for exchange of ETT before extubation due to greater haemodynamic stability during exchange phase and is better positioned.