OBJECTIVE:Our primary objective was to determine the ability of mid-regional proadrenomedullin (MR-proADM) levels to predict outcomes, i.e., mortality and clinical cure within 30 days in post-laparotomy patients. The secondary objective was to correlate MR-proADM with other markers of sepsis, such as procalcitonin (PCT) and lactate, and to determine the ability of MR-proADM levels to predict the presence or absence of sepsis on preoperative days 3, 5, and 7 in post-laparotomy patients.  Methods: This was a single-center prospective pilot observational study. Patients ≥18 years of age who underwent emergency laparotomy (EL) under general anesthesia at a tertiary care hospital between January 2022 and July 2023 were enrolled. MR-proADM, lactate, PCT, and sequential organ failure assessment (SOFA) scores were measured pre-operatively and on days 3, 5, and 7. Detection of sepsis, clinical cure, and 30-day all-cause mortality were ascertained. RESULTS:MR-proADM demonstrated statistically significant correlation with PCT (p<0.001) at all time points, the SOFA score at preoperative, day 5, and day 7, and lactate on day 7 (p<0.001). MR-proADM levels were higher on days 5 and 7 in patients who failed to achieve clinical cure (p=0.0003 and 0.0004, respectively). At all time points, the discriminatory ability of MR proADM to distinguish sepsis from non-sepsis was good. A comparison of MR-proADM levels in patients with 30-day all-cause mortality was performed. The non-survivors had significantly elevated MR-proADM levels at all time points. CONCLUSIONS:MR-proADM is a valuable biomarker that correlates strongly with lactate, PCT, and the SOFA score and can help detect sepsis. Persistently higher values were associated with absence of clinical cure and 30-day all-cause mortality in patients undergoing EL.

Objective:This study aimed to analyze the association between preoperative diaphragmatic weakness in older adult patients and the need for postoperative mechanical ventilation after major surgery. We hypothesized that preoperative diaphragmatic weakness would significantly increase the need for postoperative mechanical ventilation. Methods:It was a single-center, prospective, observational study that included 90 older adult patients aged more than 50 years who underwent abdominal surgery under general anaesthesia. A portable ultrasound was used to assess the percentage increase in the diaphragm thickening fraction (TFdi) during a maximal inspiratory effort, preoperatively and before extubation. The perioperative change in diaphragmatic function, the development of outcomes, i.e., extubation/mechanical ventilation, and the optimal cut-off of TFdi to predict outcomes were analyzed. Results:The patients with a preoperative TFdi <35% had a higher requirement for mechanical ventilation (24.5% or 1:3) as compared to those with TFdi ≥35% (7.3% or 1:13). In multivariate linear regression analysis, TFdi (preoperative) was the only independent predictor of TFdi (before extubation), explaining a substantial proportion of the variance (adjusted R2=0.71). The optimal cut-off value of TFdi (preoperative) ≤28.9 predicted intensive care unit stay with 73% sensitivity and 73% specificity, and a high negative predictive value (93.2%). Conclusion:Our study found that a significant percentage of older adult patients had a preexisting diaphragmatic weakness that was associated with extubation failure and the need for postoperative mechanical ventilation.

Background and Aims: Skull pin application during craniotomy elicits haemodynamic responses that may be detrimental to the patient. This study evaluates and compares the effects of intravenous (IV) lignocaine, dexmedetomidine, and lignocaine-dexmedetomidine on haemodynamic and stress response to skull pins. Methods: This randomised study was conducted on 160 patients aged 18-60 years. Patients for craniotomy with skull pin application were randomly assigned to receive IV lignocaine 2 mg/kg (15 min) followed by 1.5 mg/kg/h (Group L), dexmedetomidine 1 mu g/kg (15 min) followed by 0.5 mu g/kg/h (Group D), lignocaine 2 mg/kg (15 min) followed by 1.5 mg/kg/h and dexmedetomidine 1 mu g/kg (15 min) followed by 0.5 mu g/kg/h (Group LD), and normal saline bolus (15 min) followed by 5 mL/h (Group N) for 30 min after skull pin insertion. Haemodynamic variables (heart rate, mean arterial pressure, and bispectral index) and stress response (serum cortisol, prolactin, blood sugar, and neutrophil-lymphocyte ratio (NLR)) were observed at different periods. For group comparisons, a one-way analysis of variance was used for preoperative blood sugar, and the Kruskal-Wallis test was used for heart rate, blood pressure, bispectral index, serum cortisol, serum prolactin, and neutrophil-to-lymphocyte ratio (NLR). Results: Haemodynamic fluctuations were less in groups D and LD. Group LD had decreased levels of serum cortisol (P < 0.001), prolactin (P = 0.315), and NLR (P = 0.002). Blood sugar increased in all groups but was significant in groups N and D (P < 0.001). Conclusion: The dexmedetomidine-lignocaine infusion is associated with few haemodynamic fluctuations and decreased stress response compared to lignocaine or dexmedetomidine alone, hence better in attenuating skull pin response.

BACKGROUND:Effective pain management during craniotomy is crucial for optimizing hemodynamics, recovery, and patient satisfaction. This study evaluated the efficacy of ketamine and magnesium sulfate as adjuvants to bupivacaine in preemptive scalp blocks, focusing on hemodynamics, postoperative pain, and analgesic consumption. METHODS:This study included 102 patients undergoing supratentorial craniotomy, randomized into three groups (n = 34 in each): Group K (ketamine), Group M (magnesium sulfate), and Group C (saline). Each group received a preemptive scalp block with bupivacaine with the respective adjuvants. Hemodynamics, postoperative pain (Critical-Care Pain Observation Tool, CPOT), and analgesic consumption were measured at various time points. RESULTS:Ninety-seven patients were analyzed. Scalp block reduced the hemodynamic response to pin insertion in all groups. Intra-operative fentanyl consumption was significantly lower in the ketamine (191.82 ± 53.18 µg) compared to the saline (304.06 ± 48.73 µg) and magnesium groups (275.31 ± 59.04 µg, p < 0.001). The time (hours) to the first post-operative analgesic demand was longer in the ketamine (12.97 ± 4.13) compared to the saline (3.03 ± 1.47) and magnesium groups (4.19 ± 1.45, p < 0.001). Ketamine resulted in the lowest CPOT scores at 4 h (0.30 ± 0.53) post-operatively compared to magnesium (1.12 ± 0.66) and saline (1.66 ± 0.55, p < 0.001). CONCLUSIONS:Scalp block, with or without adjuvants, is effective in managing pin response. This study highlights ketamine as a valuable adjuvant to bupivacaine, significantly reducing analgesic consumption and prolonging pain relief. Magnesium provides moderate benefits. These findings support the preemptive use of ketamine in scalp block to enhance analgesia and maintain hemodynamic stability during craniotomy. However, further studies are needed to correlate the serum levels of ketamine to identify whether the effect is as adjuvant to local anesthetic or due to its systemic absorption.

BACKGROUND:Paediatric cardiac surgery patients are prone to a systemic inflammatory response on cardiopulmonary bypass. Regional and epidural anaesthesia suppresses an unbalanced hyperinflammatory response generated due to the interplay within the neuro-endocrine-immune network. Regional and epidural anaesthesia reduces the inflammatory response. This study evaluated the effect of thoracic epidural anaesthesia (TEA) on the neutrophil-to-lymphocyte ratio (NLR), a marker for inflammation. METHOD:This was a retrospective, observational cohort study of paediatric cardiac surgery patients conducted at a tertiary care hospital between January 2024 and June 2024. A total of 52 paediatric patients aged 1-12 years were included. The patients were categorized into TEA with general anaesthesia (TEA-GA) and isolated general anaesthesia (GA) groups. Patients in the TEA-GA group (n = 26) were compared to the isolated GA group (n = 26) for the primary outcome of NLR at 24 hours postoperatively. The secondary outcomes of the study were extubation within six hours, ventilation duration, ICU stay, postoperative stay in the hospital (PLoS), time to initiate oral intake, and arterial blood gas (ABG) parameters at the time of extubation. MEASUREMENTS AND MAIN RESULTS:Baseline characteristics, including age, gender, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) score, and bypass time, were comparable between the groups. Although there was a 10-fold rise in NLR from baseline to 24-hour postoperative time, there was no significant difference in NLR at 24 hours (TEA-GA group: median = 10.75, IQR = 9.85-11.8 vs. GA group: median = 7.37, IQR = 4.45-13.95; p = 0.56). There were no significant differences in the secondary outcomes, except partial pressure of arterial carbon dioxide (31.59 ± 4.05 in the TEA-GA group vs. 34.0 ± 4.5 in the GA group; p < 0.05). CONCLUSION:According to this study, TEA-GA may not affect postoperative NLR compared to GA alone in paediatric cardiopulmonary bypass.

Objective: Various electroencephalogram-based monitors have been introduced to objectively quantify anaesthesia depth. However, limited data are available on their comparative clinical efficacy in various surgical procedures. Therefore, we planned this study to compare the relative efficacy of patient state index (PSI) vs. Bi-spectral index (BIS) assessment in patients undergoing elective spine surgery under general anaesthesia. Methods: This prospective, parallel-group, single-center study included patients undergoing major spine surgery with neuromonitoring. Patients were randomized into two groups, i.e., group B (undergoing surgery under BIS monitoring) and group P (undergoing surgery under PSI monitoring). The primary objective was to compare the time to eye opening after stopping anaesthetic drug infusions. Results: The mean propofol dose required for induction in group B was 130.45±26.579, whereas that in group P, it was 139.28±17.86 (P value 0.085). The maintenance doses of propofol and fentanyl required for surgery were also comparable between the groups. Time to eye opening was 12.2±4.973 in group B and 12.93±4.19 in group P, with a P value of 0.2664 (U-statistic-684.50). Conclusion: The intraoperative PSI and BIS had similar clinical efficacy in terms of the dose of propofol required for induction, time of induction, maintenance dose of propofol and fentanyl, time of eye opening, and recovery profile in patients undergoing elective spine surgery under neuromonitoring.

Background Preoperative anxiety in neurosurgical patients is high due to life-threatening illness and uncertainty of the surgical outcome. This study assessed preoperative anxiety and its influencing factors in patients undergoing intracranial tumor surgeries utilizing the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Methods One-hundred twenty patients, 18 to 65 years of age, of either sex, American Society of Anesthesiologists (ASA) grades I/II posted for elective craniotomy and tumor excision, were selected for the study. Various components of the APAIS were explained, and the level of anxiety and need for information were noted. The level of anxiety and depression by HADS (Hospital Anxiety and Depression Scale) score was also evaluated. Results The mean age was 38.00 +/- 12.15 years. About 57.5% of the patients were male. Eighteen (15%) patients had an educational qualification of class 10, 60(50%) of 10 + 2, 36 (30%) were graduates, and 6 (5%) had a postgraduate qualification. The mean APAIS for total anxiety was 11.10 +/- 1.79; the score for need for information was 6.28 +/- 1.61. Mean total anxiety scores were higher in female patients (11.96 vs. 10.46, p < 0.001). Higher anxiety was observed in ASA status I patients (11.33 vs. 10.539 ASA I vs. II, p = 0.020). Significantly higher anxiety was observed in patients educated till class 10 (p = 0.012). A significantly higher need for information was observed in postgraduates ( p = 0.012). Eighty (66.7%) patients had clinical anxiety, and 35 (29.2%) had clinical depression on the HADS score. Conclusion Neurosurgical patients have higher anxiety due to intracranial pathology, site of surgery, and unpredictability of outcome. Demographic and clinical variables do affect anxiety levels.

Postoperative pain management aims to minimize side effects while achieving pain and discomfort reduction or elimination. The needs of each patient are taken into account when providing postoperative pain relief, which is contingent upon clinical, patient-related, and local factors. The patient's subjective assessment of pain is the ultimate determination of the extent to which pain is relieved. It has been demonstrated that using both systemic lignocaine and systemic dexmedetomidine together can effectively reduce postoperative pain and enhance the quality of recovery following surgery. To evaluate and compare the quality of recovery score (QoR 40) with perioperative infusion of lignocaine and dexmedetomidine and analgesic requirement in postoperative period with the use of perioperative infusion of lignocaine or dexmedetomidine. 135 female subjects posted for elective trans-abdominal hysterectomy under general anaesthesia were randomized to receive an infusion of Lignocaine (1.5 mg/kg over 15 minutes followed by a 2 mg/kg/h infusion until the end surgery) (Group 1) or Normal saline (10 ml over 15 minutes followed by infusion @1ml/kg/hr till the end of surgery) (Group 2) and inj. Dexmedetomidine (DEX) 1 mcg/kg over 15 minutes followed by infusion @0.6mcg/kg/hr till the end of surgery. (Group 3). Intraoperative hemodynamics, extubation variables, postoperative analgesic requirement, and quality of recovery score were evaluated. Lignocaine and dexmedetomidine infused intraoperatively preserved hemodynamics and met early extubation criteria. The duration of the first postoperative analgesic requirement as well as the total amount of analgesics needed in a 24-hour period were similar in groups 1 and 3, but significantly longer in the placebo “group 2. In Group 1, Group 2, & Group 3, the median (IQR) recovery score (QoR-40) was 184(178-191), 178(171-180), and 180(177-188). While there was no significant difference between the lignocaine and dexmedetomidine groups (p>0.209), it was significant” when compared to saline (p<0.001).The application of intraoperative lignocaine/dexmedetomidine infusions was linked to early recovery, a lower need for postoperative analgesics, and a higher Quality of Recovery score, which indicated higher levels of patient satisfaction.

Background: Stellate ganglion block (SGB) is effectively utilized in various sympathetically mediated pain conditions of head and neck, upper limb such as complex regional pain syndrome, postherpetic neuralgias, but there has been a paucity of evidence of SGB for the management of phantom limb pain (PLP). Methods: Ten upper extremity PLP patients underwent ultrasound-guided SGB block. Under real-time needle tip visualization and after ensuring negative aspiration, 5 mL of 1% lignocaine and 4 mg of dexamethasone were injected. Postprocedure pain score (numerical rating scale [NRS]) and patient satisfaction score (Likert scale) were noted, and patients were followed-up for the next 60 days. Results: The baseline NRS score (Mean [standard deviation]) of 7.8 (0.748) showed significant reduction ( P < 0.001) to 2.8 (0.748) at immediate postinjection, to 2.6 (0.663) at day 7, at day 30 (2.9 [0.7]), and at day 60 (30.775). Most of the patients (80%–90%) were somewhat to very much satisfied with the treatment response (score 4–5 on Likert scale) at all the follow-up intervals. Only mild and transient adverse events were demonstrated in two patients who developed hoarseness of voice. Conclusion: Ultrasound-guided SGB effectively reduces pain and improves patient satisfaction in postamputee patients who developed PLP, over 2 months of the follow-up period. Further prospective randomized controlled trials over a larger duration with more sample size are needed to provide more concrete evidence.

The use of phenytoin is widespread in neurosurgical patients, especially in space-occupying lesions. It has predominant renal excretion and has been known to cause tubulointerstitial nephritis on chronic use. Despite its common use, there has not been definitive literature on urine discoloration due to phenytoin except for a commentary dated back in 1983 which refuted the finding of urine discoloration by phenytoin use.[1] Hence, we intend to highlight a case where there was episode of red discoloration of urine in a pediatric patient posted for excision of the cerebellar tumor under general anesthesia.

1 Senior Resident, 2 Junior Resident, 3 Professor andHead of Department, Department of Anaesthesiology andCritical Care, All India Institute ofMedical Sciences, Rishikesh, India ............................................................................................................................................................................................................................................................................................................ Correspondence to: S. Agrawal Email: sanjay.anaes@aiimsrishikesh.edu.in Accepted: 25 February 2023

Pressure sores over bony prominences of heel or sacrum due to positioning are commonly reported, however, the same occurring over malar prominences are rarely seen. We report a case of pressure sore over malar prominence in a patient undergoing surgery in the prone position on horseshoe headrest. These injuries pose a risk of infection, need for surgical intervention, increasing woes, and health cost burden of the patient. Patient care team should aim to prevent such complications by appropriate support device selection, adequate padding, and frequent position changes.

Abstract Hemophilia is a genetic disease presenting with increased chances of perioperative bleeding. Preoperative recognition, assessment of risk, and careful titration of factor VIII transfusion are important for anesthesia management and decrease of morbidity. Here we present a case of severe hemophilia with an open wound of the knee scheduled for flap rotation and cover.

Background: Acute postoperative pain is associated with poor quality of recovery after surgery. Perioperative use of intravenous lignocaine or dexmedetomidine have demonstrated better pain control, early return of bowel function, and effects on quality of recovery.Methods: Ninety-six women planned for elective robotic abdominal hysterectomy were ran-domized into four groups. Groups received lignocaine infusion (1.5 mg.kg-1 loading, 2 mg.kg-1. h-1 infusion) (Group I), dexmedetomidine infusion (1 mu g.kg-1 loading, 0.6 mu g.kg-1.h-1 infusion) (Group 2), lidocaine (1.5 mg.kg-1 loading, 2 mg.kg-1.h-1 infusion), and dexmedetomidine infu-sions (1 mu g.kg-1 loading, 0.5 mu g.kg-1.h-1 infusion) (Group 3), and normal saline 10 mL loading, 1 mL.kg-1.h-1 infusion) (Group 4). Primary outcome was visual analogue pain scores at 1, 2, 4, 12, and 24 hours after surgery. Secondary outcomes included postoperative fentanyl require-ment, time of return of bowel sounds and flatus, QoR15 score on day 1, 2, and discharge.Results: The VAS was significantly lower in Groups 2 and 3 compared to Groups 1 and 4. Total postoperative fentanyl consumption in the first 24 hours was 256.25 +/- 16.36 mcg (Group 1), 177.71 +/- 16.81 mcg (Group 2), 114.17 +/- 16.19 mcg (Group 3), and 304.42 +/- 31.26 mcg (Group 4), respectively. Time to return of bowel sounds and passage of flatus was significantly shorter in Groups 2 and 3 (p < 0.01). QoR15 scores after surgery were higher in Group 3 compared to Groups 1, 2, and 4, (p < 0.01) respectively.Conclusion: Combined infusion of lignocaine and dexmedetomidine significantly decreased postoperative pain, fentanyl consumption, and improved quality of recovery score after surgery in patients undergoing Robotic abdominal hysterectomy.(c) 2021 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Acromegaly, a neuroendocrine disorder due to excess growth hormone and insulin like growth factor-1, has large spectrum of underlying comorbidities. Hereby we report acromegalic cardiomyopathy in 65 year old male patient who also had acromegalic changes involving various other systems and anesthetic management of the same when he was scheduled for definitive transnasal trans-sphenoidal resection of pituitary adenoma.

Context: The incidence of myoclonus after etomidate induction is 50%–80%. The present study evaluated the efficacy of oral pregabalin for the prevention of etomidate-induced myoclonus. Settings and Design: A prospective, randomized, placebo-controlled, double-blind study. Subjects and Methods: Seventy-four patients of the American Society of Anesthesiologists physical status Grade I or II scheduled for elective surgery under anesthesia were recruited. Following exclusion, 66 patients were randomized into two groups. In Group P patients received pregabalin 150 mg orally 1 h before induction of anesthesia and in Group C patients received placebo tablet. The primary outcome was the incidence and severity of myoclonus. The secondary outcome was the postoperative sedation level. Results: The incidence and severity of myoclonus were significantly decreased in Group P compared with Group C (P < 0.05). The postoperative sedation score was significantly higher in Group P compared to Group C (P > 0.05). Conclusion: Pretreatment with pregabalin 150 mg orally reduced the incidence and severity of etomidate-induced myoclonus however incidence of sedation was more.

Background and Aims: Subclavian vein (SCV) cannulation can be performed using either supraclavicular (SC) or infraclavicular (IC) long-axis approach under ultrasound guidance (USG). However, their relative efficacy remains debatable. The aim of this study was to compare these two approaches in terms of safety, ease, success rate, and record the incidence of complications. Methods: We studied 90 adult patients distributed into two groups of 45 each. Data regarding the time taken for first venous puncture, the time required for inserting the catheter, the total number of attempts, the incidence of guidewire misplacement, and other mechanical complications were compared using Student's t-test for quantitative data and Chi-square test for qualitative value. Results: Mean puncture time was significantly lesser in group SC than IC (P-value < 0.001). Mean catheter insertion time taken was also significantly less in group SC than IC (P-value = 0.003). The first attempt rate was higher in group SC than IC (P = 0.013). Guidewire misplacement was seen in the IC group, P = 0.001. No pneumothorax, haemothorax, or arterial puncture were noted in our study in any of the groups. Conclusion: We conclude that for right-sided SCV cannulation using USG in the long axis, the SC approach is superior to the IC approach in terms of overall ease of cannulation. It was associated with a relatively shorter procedure time, higher success rate in the first attempt, lesser incidence of guidewire misplacement, and other complications. It should be considered as an alternative approach to the IC approach in patients requiring central line insertion.

Background Catheter-related bladder discomfort (CRBD) is a frequent complaint after awakening from anesthesia in patients receiving perioperative bladder catheterization. Overactive bladder (OAB) and CRBD show similar symptoms; thus, drugs used for the management of OAB influence symptoms of CRBD. Trospium chloride has been found effective in managing resistant cases of OAB. We evaluated the efficacy of oral trospium on CRBD in the postoperative period. Methods Sixty-four male and female adult patients, with planned spinal surgery and requiring urinary bladder catheterization, were randomly divided into two groups of 32 each. Group T patients received 60 mg extended-release oral trospium (extended-release) 1 h before induction of anesthesia and Group C patients received a similar-looking placebo. The anesthetic technique was identical in both groups. The CRBD score was evaluated in the postoperative ward using a 4-point scale (1 = no discomfort, 2 = mild, 3 = moderate, 4 = severe). Readings were recorded on arrival (0 h), and 1 h, 2 h, and 6 h postoperatively. All patients received fentanyl for postoperative pain relief. Results The incidence of CRBD was significantly higher in Group C than in Group T at 0 h (66% vs. 22%, P = 0.001) and 1 h postoperatively (72% vs. 28%, P = 0.001). The incidence of moderate to severe CRBD was higher in Group C at postoperative 2 h (82% vs. 14%, P = 0.004). There was no significant difference in postoperative fentanyl requirements. Conclusions Pretreatment with 60 mg extended release trospium reduced the incidence and severity of CRBD in the early postoperative period.