Publications by authors named "Hemanshu Prabhakar"

156 Publications

COVID-19 and the perioperative neuroscience - A narrative review.

Saudi J Anaesth 2021 Jan-Mar;15(1):19-26. Epub 2021 Jan 5.

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India.

Among the several medical specialties, anesthesiologists are probably the most affected ones from the coronavirus disease (COVID-19) pandemic as they are at the frontline. In the present stage of the pandemic, where we are observing community transmission, more people with elective neurologic and neurosurgical problems are likely to be tested positive for this virulent disease. Neuroanesthesiologists play an important role in the perioperative period and in neuroradiology suite. It is imperative to know the best available ways by which health care providers can manage their patients and also necessary steps to prevent the spread of infection, not only amongst themselves but also between patients. A high index of suspicion in such patients may help avoid delay in diagnosis and catastrophic sequelae. An overall knowledge about the disease will help plan the clinical management of neurologic patients, during the perioperative period.
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http://dx.doi.org/10.4103/sja.SJA_668_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016045PMC
January 2021

Phenytoin Sodium and Acetate-Maleate Buffered Balanced Salt Solutions are Physically Incompatible!

Indian J Crit Care Med 2021 Mar;25(3):352

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Mahajan C, Singh BP, Kapoor I, Prabhakar H. Phenytoin Sodium and Acetate-Maleate Buffered Balanced Salt Solutions are Physically Incompatible! Indian J Crit Care Med 2021;25(3):352.
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http://dx.doi.org/10.5005/jp-journals-10071-23756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7991754PMC
March 2021

Twenty-one Days of Solitude.

Indian J Crit Care Med 2021 Mar;25(3):249-250

Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

As the world is now gradually coming out of the "lockdown" phase, one can expect a change in the demographics and epidemiology of trauma. With traffic back on roads and shifting life again towards "normalcy", it is imperative to carry out introspection and see how we can stop trauma from reaching its pre-COVID levels. Prabhakar H. Twenty-one Days of Solitude. Indian J Crit Care Med 2021;25(3):249-250.
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http://dx.doi.org/10.5005/jp-journals-10071-23757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7991768PMC
March 2021

Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Craniotomy: A Systematic Review.

J Neurosurg Anesthesiol 2021 Mar 12. Epub 2021 Mar 12.

All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India.

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http://dx.doi.org/10.1097/ANA.0000000000000764DOI Listing
March 2021

Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature.

Indian J Crit Care Med 2021 Feb;25(2):126-133

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Aim And Objective: Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs).

Background: Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols.

Review Results: Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation.

Conclusion: This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles.

Clinical Significance: In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice.

How To Cite This Article: Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, . Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021;25(2):126-133.
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http://dx.doi.org/10.5005/jp-journals-10071-23712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922463PMC
February 2021

Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery.

Cochrane Database Syst Rev 2021 Feb 25;2:CD012968. Epub 2021 Feb 25.

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Background: Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia.

Objectives: To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality.

Search Methods: On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials.

Selection Criteria: We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia.

Data Collection And Analysis: Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome.

Main Results: Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias.

Authors' Conclusions: Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.
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http://dx.doi.org/10.1002/14651858.CD012968.pub2DOI Listing
February 2021

Awake craniotomy in pediatric population is possible!

Paediatr Anaesth 2020 06;30(6):722

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1111/pan.13877DOI Listing
June 2020

Rufinamide add-on therapy for drug-resistant epilepsy.

Cochrane Database Syst Rev 2020 11 8;11:CD011772. Epub 2020 Nov 8.

Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.

Background: Epilepsy is a central nervous system disorder (neurological disorder). Epileptic seizures are the result of excessive and abnormal cortical nerve cell electrical activity in the brain. Despite the development of more than 10 new antiepileptic drugs (AEDs) since the early 2000s, approximately a third of people with epilepsy remain resistant to pharmacotherapy, often requiring treatment with a combination of AEDs. In this review, we summarised the current evidence regarding rufinamide, a novel anticonvulsant medication, which, as a triazole derivative, is structurally unrelated to any other currently used anticonvulsant medication when used as an add-on treatment for drug-resistant epilepsy. In January 2009, rufinamide was approved by the US Food and Drug Administration for the treatment of children four years of age and older with Lennox-Gastaut syndrome. It is also approved as an add-on treatment for adults and adolescents with focal seizures. This is an updated version of the original Cochrane Review published in 2018.

Objectives: To evaluate the efficacy and tolerability of rufinamide when used as an add-on treatment for people with drug-resistant epilepsy.

Search Methods: We imposed no language restrictions. We contacted the manufacturers of rufinamide and authors in the field to identify any relevant unpublished studies.

Selection Criteria: Randomised, double-blind, placebo-controlled, add-on trials of rufinamide, recruiting people (of any age or gender) with drug-resistant epilepsy.

Data Collection And Analysis: Two review authors independently selected trials for inclusion and extracted the relevant data. We assessed the following outcomes: 50% or greater reduction in seizure frequency (primary outcome); seizure freedom; treatment withdrawal; and adverse effects (secondary outcomes). Primary analyses were intention-to-treat (ITT) and we presented summary risk ratios (RRs) with 95% confidence intervals (CIs). We evaluated dose response in regression models. We carried out a risk of bias assessment for each included study using the Cochrane 'Risk of bias' tool and assessed the overall certainty of evidence using the GRADE approach.

Main Results: The review included six trials, representing 1759 participants. Four trials (1563 participants) included people with uncontrolled focal seizures. Two trials (196 participants) included individuals with established Lennox-Gastaut syndrome. Overall, the age of adults ranged from 18 to 80 years and the age of children ranged from 4 to 16 years. Baseline phases ranged from 28 to 56 days and double-blind phases from 84 to 96 days. Five of the six included trials described adequate methods of concealment of randomisation, and only three described adequate blinding. All analyses were by ITT. Overall, five studies were at low risk of bias and one had unclear risk of bias due to lack of reported information around study design. All trials were sponsored by the manufacturer of rufinamide and therefore were at high risk of funding bias. The overall RR for 50% or greater reduction in seizure frequency was 1.79 (95% CI 1.44 to 2.22; 6 randomised controlled trials (RCTs), 1759 participants; moderate-certainty evidence), indicating that rufinamide (plus conventional AED) was significantly more effective than placebo (plus conventional AED) in reducing seizure frequency by at least 50% when added to conventionally used AEDs in people with drug-resistant focal epilepsy. Data from only one study (73 participants) reported seizure freedom: RR 1.32 (95% CI 0.36 to 4.86; 1 RCT, 73 participants; moderate-certainty evidence). The overall RR for treatment withdrawal (for any reason and due to AED) was 1.83 (95% CI 1.45 to 2.31; 6 RCTs, 1759 participants; moderate-certainty evidence), showing that rufinamide was significantly more likely to be withdrawn than placebo. Most adverse effects were significantly more likely to occur in the rufinamide-treated group. Adverse events significantly associated with rufinamide were headache, dizziness, somnolence, vomiting, nausea, fatigue, and diplopia. The RRs for these adverse effects were as follows: headache 1.36 (95% Cl 1.08 to 1.69; 3 RCTs, 1228 participants; high-certainty evidence); dizziness 2.52 (95% Cl 1.90 to 3.34; 3 RCTs, 1295 participants; moderate-certainty evidence); somnolence 1.94 (95% Cl 1.44 to 2.61; 6 RCTs, 1759 participants; moderate-certainty evidence); vomiting 2.95 (95% Cl 1.80 to 4.82; 4 RCTs, 777 participants; low-certainty evidence); nausea 1.87 (95% Cl 1.33 to 2.64; 3 RCTs, 1295 participants; moderate-certainty evidence); fatigue 1.46 (95% Cl 1.08 to 1.97; 3 RCTs, 1295 participants; moderate-certainty evidence); and diplopia 4.60 (95% Cl 2.53 to 8.38; 3 RCTs, 1295 participants; low-certainty evidence). There was no important heterogeneity between studies for any outcomes. Overall, we assessed the evidence as moderate to low certainty due to wide CIs and potential risk of bias from some studies contributing to the analysis.

Authors' Conclusions: For people with drug-resistant focal epilepsy, rufinamide when used as an add-on treatment was effective in reducing seizure frequency. However, the trials reviewed were of relatively short duration and provided no evidence for long-term use of rufinamide. In the short term, rufinamide as an add-on was associated with several adverse events. This review focused on the use of rufinamide in drug-resistant focal epilepsy, and the results cannot be generalised to add-on treatment for generalised epilepsies. Likewise, no inference can be made about the effects of rufinamide when used as monotherapy.
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http://dx.doi.org/10.1002/14651858.CD011772.pub3DOI Listing
November 2020

COVID-19 and Diagnosing Brain Death: An Ambiguity.

Turk J Anaesthesiol Reanim 2020 Oct 1;48(5):436. Epub 2020 Oct 1.

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

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http://dx.doi.org/10.5152/TJAR.2020.879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556647PMC
October 2020

Parkinsonism-like features following reconstructive cranioplasty.

Neurol Sci 2021 04 20;42(4):1591-1592. Epub 2020 Oct 20.

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India.

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http://dx.doi.org/10.1007/s10072-020-04814-7DOI Listing
April 2021

Vitamins as adjunctive treatment for coronavirus disease!

Ann Intensive Care 2020 Sep 29;10(1):127. Epub 2020 Sep 29.

AIIMS, New delhi, India.

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http://dx.doi.org/10.1186/s13613-020-00748-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523483PMC
September 2020

Diagnostic Imaging of Patients With Coronavirus Disease (COVID-19): Benefit Versus Risk.

AJR Am J Roentgenol 2020 11 25;215(5):W61. Epub 2020 Aug 25.

All India Institute of Medical Science, New Delhi, India.

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http://dx.doi.org/10.2214/AJR.20.24091DOI Listing
November 2020

COVID-19 Infection: Perioperative Implications: Comment.

Anesthesiology 2020 09;133(3):677-678

All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1097/ALN.0000000000003423DOI Listing
September 2020

Precision Medicine in Acute Brain Injury: A Narrative Review.

J Neurosurg Anesthesiol 2020 Jun 23. Epub 2020 Jun 23.

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India.

Over the past few years, the concept of personalized medicine has percolated into the management of different neurological conditions. Improving outcomes after acute brain injury (ABI) continues to be a major challenge. Unrecognized individual multiomic variations in addition to multiple interacting processes may explain why we fail to observe comprehensive improvements in ABI outcomes even when applied treatments appear to be beneficial logically. The provision of clinical care based on a multiomic approach may revolutionize the management of traumatic brain injury, delayed cerebral ischemia after subarachnoid hemorrhage, acute ischemic stroke, and several other neurological diseases. The challenge is to incorporate all the information obtained from genomic studies, other omic data, and individual variability into a practical tool that can be used to assist clinical decision-making. The effective execution of such strategies, which is still far away, requires the development of protocols on the basis of these complex interactions and strict adherence to management protocols. In this review, we will discuss various omics and physiological targets to guide individualized patient management after ABI.
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http://dx.doi.org/10.1097/ANA.0000000000000710DOI Listing
June 2020

Prognostic Value of Serially Estimated Serum Procalcitonin Levels in Traumatic Brain Injury Patients With or Without Extra Cranial Injury on Early In-hospital Mortality: A Longitudinal Observational Study.

Neurocrit Care 2021 02;34(1):182-192

Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, 7th Floor, 710, New Delhi, 110029, India.

Background: Traumatic brain injury (TBI) is associated with majority of trauma deaths, and objective tools are required to understand the severity of injury. The application of a biomarker like procalcitonin (PCT) in TBI may allow for assessment of severity and thus aid in prognostication and correlation with mortality and outcome.

Aims: The primary objective is to determine the correlation between PCT concentrations with TBI outcomes (mainly in terms of mortality) at intensive care unit (ICU)/hospital discharge. Secondary objectives are to evaluate correlation with associated extra cranial injuries and complications during hospital stay.

Methods: In total, 186 TBI patients aged > 18 years with minimum survival for at least 12 h admitted to the ICU at the level 1 trauma center were prospectively included in the study and divided into two groups: TBI with and without extra cranial injuries. All admitted patients were treated according to the standard institutional protocol. The PCT levels were obtained on admission, on day 2, and 5. Clinical, laboratory, diagnostic, and therapeutic data were also collected. Primary mortality is defined as death related to central nervous system (CNS) injury, while secondary mortality defined as death related to sepsis or extracranial cause.

Results: Median PCT levels at admission, day 2, and day 5 in TBI patients with extracranial injuries were 3.0, 0.83, and 0.69 ng/ml. In total, primary mortality was observed in 18 (9.7%) patients, while secondary causes were attributable in 20 (12.3%) patients. Regression analysis for primarily CNS cause of mortality showed PCT cutoff level at admission more than 5.5 ng/ml carried sensitivity and specificity of 75%, but for secondary cause (sepsis) of mortality, PCT cutoff values on day 2 > 1.15 ng/ml were derived significant with sensitivity of 70% and specificity of 66%. No significant association of parameters like length of ICU stay, Glasgow outcome scale (GOS), and primary/secondary mortality with the presence of extracranial injuries in TBI patients as compared with TBI alone was noted.

Conclusion: This observational study demonstrates the poor correlation between PCT concentrations with outcome at days 1, 2, and 5 post-injury. The predicted relationship between PCT levels and outcome was not confirmed, and that these results do not support the prognostic utility of PCT biomarker in this population for outcome (mortality) assessment in TBI patients with or without extracranial injuries.
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http://dx.doi.org/10.1007/s12028-020-01009-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292243PMC
February 2021

COVID 19 and brain crosstalks.

Clin Neurol Neurosurg 2020 09 5;196:105991. Epub 2020 Jun 5.

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India.

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http://dx.doi.org/10.1016/j.clineuro.2020.105991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274099PMC
September 2020

Psychological Effects of COVID-19 on Children of Health Care Workers.

Anesth Analg 2020 09;131(3):e169-e170

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India,

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http://dx.doi.org/10.1213/ANE.0000000000005034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288786PMC
September 2020

COVID-19 and Neuroinvasion.

Anesth Analg 2020 08;131(2):e91-e92

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India,

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http://dx.doi.org/10.1213/ANE.0000000000004918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202115PMC
August 2020

Pressure inside Endoscope: An Important Intraoperative Surrogate!

J Pediatr Neurosci 2019 Oct-Dec;14(4):238. Epub 2019 Dec 3.

Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

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http://dx.doi.org/10.4103/jpn.JPN_147_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935979PMC
December 2019

Effect of magnesium and lignocaine on post-craniotomy pain: A comparative, randomized, double blind, placebo-controlled study.

Saudi J Anaesth 2019 Oct-Dec;13(4):299-305

Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Lignocaine and Magnesium have an analgesic action and reduce perioperative opioid requirements. We carried out this study to evaluate the effect of magnesium and lignocaine on postoperative pain as assessed using the visual analog scale (VAS) and fentanyl consumption. We also measured S-100 B levels and noted the side effect of drugs if any.

Materials And Methods: In this prospective preliminary study, 45 patients undergoing supratentorial craniotomy for tumor surgery were randomized to receive either lignocaine (group I-1.5 mg/kg bolus followed by 2 mg/kg/h infusion), saline (Group II) or magnesium (group III: bolus of 50 mg/kg followed by 25 mg/kg/hr) intraoperatively. The amount of fentanyl required, VAS over first 24 hours and any side effects were noted. S100 B levels were also measured to assess brain protective effect of these drugs, if any. Appropriate statistical tests were applied for analysis of data and a value < 0.05 was considered statistically significant.

Results: None of the patient experienced any adverse hemodynamic effect intraoperatively secondary to the study drugs. The amount of intraoperative fentanyl consumption was comparable among the three groups. The mean VAS score was significantly less in group I and III [Group I (15.3 ± 6.0), Group II (24.8 ± 6.7), Group III (17.9 ± 7.6); ( < 0.01)]. The fentanyl consumed in first 24 hours was significantly less in those patients who received lignocaine and magnesium [Group I (204.4 ± 136.4), Group II (383 ± 168.2), Group III (194 ± 148.9); ( = 0.01)]. S100 value did not differ in the lignocaine and the saline group during the perioperative period. However, a significant decline was noted in the levels of S100 B in the magnesium group.

Conclusion: Intraoperative infusion of lignocaine and magnesium results in lower VAS score and decreases the postoperative opioid requirement in patients undergoing craniotomy for excision of supratentorial tumors.
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http://dx.doi.org/10.4103/sja.SJA_837_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753769PMC
October 2019

Postoperative Cognitive Dysfunction.

Indian J Crit Care Med 2019 Jun;23(Suppl 2):S162-S164

Department of Neuroanesthesiology and Critical Care, AIIMS, Delhi, India.

Cognitive dysfunction is a common complication in primary or metastatic brain tumors and can be correlated to disease itself or various treatment modalities. The symptoms of cognitive deficits may include problems with memory, attention and information processing. Primary brain tumors are highly associated with neurocognitive deficit and poor quality of life. This review discusses the pathophysiology, risk factors and assessment of cognitive dysfunction. It also gives an overview of the effect of anesthetics on postoperative cognitive dysfunction and its management.
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http://dx.doi.org/10.5005/jp-journals-10071-23196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707501PMC
June 2019

Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!

Indian J Crit Care Med 2019 Jun;23(6):287

Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Shukla RK, Kapoor I, Mahajan C, Prabhakar H. Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!. Indian J Crit Care Med 2019;23(6):287.
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http://dx.doi.org/10.5005/jp-journals-10071-23183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698348PMC
June 2019

Erroneous high entropy values in a patient undergoing brachial plexus repair.

J Clin Anesth 2019 Dec 2;58:29-30. Epub 2019 May 2.

AIIMS, New Delhi, India.

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http://dx.doi.org/10.1016/j.jclinane.2019.04.029DOI Listing
December 2019

Comparison of Full Outline of UnResponsiveness (FOUR) score and the conventional scores in predicting outcome in aneurysmal subarachnoid haemorrhage patients.

Indian J Anaesth 2019 Apr;63(4):295-299

Department of Anaesthesiology, King Fahad Medical College, Riyadh, Saudi Arabia.

Background And Aims: Full Outline of UnResponsiveness (FOUR) score is a more comprehensive score used to assess eye response, motor response, brainstem reflexes, and respiration that was introduced to overcome the drawbacks of Glasgow coma scale (GCS) score. Our aim was to assess which score best predicts mortality and poor outcome in aneurysmal subarachnoid haemorrhage (aSAH) patients.

Methods: This cohort study, prospectively evaluated the use of FOUR score to assess the mortality and outcome in aSAH patients during the period from November 2015 to November 2016. For each patient of aSAH, GCS, FOUR score, Hunt and Hess (HH) score and World Federation of Neurological Surgeons (WFNS) score were determined at the time of admission to neurosurgical intensive care unit. All patients were followed till 28 days post-SAH and their outcome were assessed by Glasgow outcome scale (GOS). We calculated the sensitivity (Sn) and specificity (Sp) for each of these scores. We generated the receiver operating characteristic curve (ROC), quantified the accuracy by the area under curve (AUC), and also calculated their 95% confidence interval (95% CI).

Results: A total of 75 aSAH patients were enrolled for the study. The mortality was 24/75 (32%) with 23 in-hospital deaths. FOUR score was highly specific (86.27%) and sensitive (75%) for the prediction of mortality. However, for predicting 28-day outcome, WFNS and HH grade were most specific (92.5%), whereas FOUR and HH score was moderately specific (68.57%).

Conclusion: FOUR score is among the most specific and moderately sensitive tool for prediction of mortality. However, WFNS and HH grade are more specific in predicting the 28-day outcome.
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http://dx.doi.org/10.4103/ija.IJA_786_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6460986PMC
April 2019

Neuroprotective role of dexmedetomidine in epilepsy surgery: A preliminary study.

Neurol India 2019 Jan-Feb;67(1):163-168

National Institute of Medical Malaria Research, New Delhi, India.

Purpose: Long standing temporal lobe epilepsy (TLE) causes cerebral insult and results in elevated brain injury biomarkers, S100b and neuron specific enolase (NSE). Surgery for TLE, has the potential to cause additional cerebral insult. Dexmedetomidine is postulated to have neuroprotective effects. The aim of this study was to assess the effect of intraoperative dexmedetomidine on S100b and NSE during TLE surgery.

Materials And Methods: 19 consenting adult patients with TLE undergoing anteromedial temporal lobectomy were enrolled and divided into two groups. Patients in Group D (n = 9) received dexmedetomidine whereas patients in Group C (n = 10) received saline as placebo in addition to the standard anaesthesia technique. Blood samples of these patients were drawn, before induction of anaesthesia, at the end of surgery, as well at 24 hours and 48 hours postoperatively, and analysed for serum S100b and NSE.

Results: The demographic and clinical profile was comparable in both the groups. The baseline S100b in group C and group D was 66.7 ± 26.5 pg/ml and 34.3 ± 21.7 pg/ml (P = 0.013) respectively. After adjustment for the baseline, the overall value of S100b was 71.0 ± 39.8 pg/ml and 40.5 ± 22.5 pg/ml (P = 0.002) in the control and study group, respectively. The values of S100b (79.3 ± 53.6 pg/ml) [P = 0.017] were highest at 24 hours postoperatively. The mean value of NSE in the control and study group was 32.8 ± 43.4 ng/ml (log 3.0 ± 0.1) and 13.51 ± 9.12 ng/ml (log 2.42 ± 0.60), respectively. The value of NSE in both the groups was comparable at different time points.

Conclusions: Lower perioperative values of S100b were observed in patients who received intraoperative dexmedetomidine. Dexmedetomidine may play a role in cerebroprotection during epilepsy surgery.
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http://dx.doi.org/10.4103/0028-3886.253616DOI Listing
December 2019

Recurrent transient episodes of left bundle branch block immediately following surgery - A rare phenomenon.

Indian J Anaesth 2019 Feb;63(2):153-155

Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/ija.IJA_637_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383469PMC
February 2019