Publications by authors named "Rajeshwari Subramaniam"

55 Publications

Anaesthetic Management of Secretory Paraganglioma With Cyanotic Heart Disease: Double Trouble.

Cureus 2022 May 25;14(5):e25328. Epub 2022 May 25.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, New Delhi, IND.

Paragangliomas (PGL) in paediatric patients are rarely diagnosed with neuroendocrine tumours. Anaesthetic management of paraganglioma is challenging due to exaggerated haemodynamic alterations. Further associated cardiovascular diseases like congenital cyanotic heart disease (CCHD) with paragangliomas make its management daring and if not properly managed can increase morbidity. We herein discuss the successful anaesthetic management of a 10-year-old child with paraganglioma and associated atrial septal defect (ASD) with pulmonary stenosis (PS) for adrenalectomy. Overlapping the clinical spectrum between CCHD and catecholamine-secreting tumour makes the case very challenging. Management of the patient with CCHD and PGL needs a multidisciplinary approach, and intensive vigilance and monitoring are needed for the successful management of such challenging cases.
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http://dx.doi.org/10.7759/cureus.25328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9231819PMC
May 2022

Mucormycosis in COVID-19 Patients: A Case-Control Study.

Microorganisms 2022 Jun 13;10(6). Epub 2022 Jun 13.

Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India.

(1) Background: During the second wave of COVID-19, India faced a rapid and sudden surge of not only COVID19-delta variant cases but also mucormycosis, making the infection even more fatal. We conducted a study to determine factors associated with the occurrence of mucormycosis in patients with COVID-19. (2) Methods: This case-control study comprised 121 patients; 61 cases (mucormycosis with COVID-19) and 60 controls. Patients were included from April 10, 2021 onwards. Follow-up was conducted after about 90 days and health status was recorded based on the modified Rankin Scale (mRS). (3) Results: Mucormycosis with COVID-19 cases had a median (IQR) age of 49 (43-59) years with 65.6% males and were older (95% CI 1.015-1.075; = 0.002) than in the control group with median (IQR) 38 (29-55.5) years and 66.6% males. Baseline raised serum creatinine (OR = 4.963; 95% CI 1.456-16.911; = 0.010) and D-dimer (OR = 1.000; 95% CI 1.000-1.001; = 0.028) were independently associated with the occurrence of mucormycosis in COVID-19 patients. Additionally, diabetes mellitus (OR = 26.919; 95% CI 1.666-434.892; = 0.020) was associated with poor outcomes and increased mortality in patients with mucormycosis with COVID-19 as per the multivariable analysis. A total of 30/61 mucormycosis patients had intracranial involvement. (4) Conclusions: The study observed elevated levels of baseline raised creatinine and D-dimer in mucormycosis pa-tients with COVID-19 as compared to the control group. However, future studies may be conducted to establish this cause-effect relationship.
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http://dx.doi.org/10.3390/microorganisms10061209DOI Listing
June 2022

Safety and Efficacy of Low-dose Selective Spinal Anesthesia with Bupivacaine and Fentanyl as Compared to Intravenous Sedation and Port-Site Infiltration for Outpatient Laparoscopic Tubal Ligation: A Randomized Controlled Trial.

Anesth Essays Res 2021 Jul-Sep;15(3):290-295. Epub 2022 Feb 7.

Department of Anesthesiology, Pain medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Selective spinal anesthesia has been safely applied for short-duration outpatient gynecological laparoscopic procedure. However, this anesthesia technique is often inadequate and not tolerated by awake patients due to pneumoperitoneum and visceral manipulation.

Aims: We aimed to conduct a study to compare spinal anesthesia with bupivacaine, fentanyl, and i.v. sedation with i.v. sedation and laparoscopic port-site infiltration with local anaesthetic in outpatient laparoscopic tubal ligation procedures.

Settings And Design: 100 female patients posted for elective surgeries were recruited for a prospective single blind randomised control trial in a tertiary care center in two groups.

Materials And Methods: In Group S, patients receive intrathecal 3 mg hyperbaric bupivacaine 0.5% plus 20 microgram fentanyl along with intravenous (i.v.) fentanyl at 1μg.kg.h and in Group C i.v. fentanyl at 1μg.kg.h along with laparoscopic port site infiltration with 0.5% bupivacaine. Postoperatively, overall patient satisfaction, visual analog score (VAS) score, duration of motor blockade, sensory blockade, and time to attain discharge criteria and any adverse.

Statistical Analysis: Continuous variables between the groups were compared by the independent -test and Wilcoxon rank sum. Chi-square and Fisher exact test used for the categorical value.

Results: Overall VAS was significantly lower and patient satisfaction was higher in Group S than Group C. Time to oral intake was significantly prolonged in Group C 126.33 (±29.54) compared to group S 110.81 (±29.54). The requirement of total rescue analgesia (fentanyl) was significantly higher in Group C 2.0 (±0.6) μg.kg compared to group S 0.79 (±0.53) μg.kg. Incidence of postoperative nausea vomiting (PONV) was significantly greater in Group C while incidence of pruritus was significantly greater in Group S.

Conclusion: Low-dose intrathecal anesthesia with 3 mg bupivacaine and 20 μg fentanyl provided better analgesia, patient satisfaction and with less opioids consumption.
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http://dx.doi.org/10.4103/aer.aer_121_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8936871PMC
February 2022

Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial.

Indian J Crit Care Med 2021 Oct;25(10):1147-1154

Department of Medicine, All India Institute of Medical Sciences, Delhi, India.

Background: Administration of vitamin D to unselected heterogeneous critically ill patients did not demonstrate outcome benefit. The current study was undertaken to identify if early administration of vitamin D can reduce intensive care unit (ICU) length of stay and improve clinical outcomes in critically ill patients with sepsis.

Methods: This single-center randomized double-blind placebo-controlled trial was done in the ICU and emergency inpatient ward of a tertiary care teaching institute in New Delhi, India. A total of 126 adult patients aged 18 to 80 years of either sex diagnosed to have sepsis were included within 24 hours of admission to the hospital and randomized into vitamin D or placebo groups. The patients in the intervention group received vitamin D3 540,000 units dissolved in 45 mL of milk. The placebo group received 45 mL of milk.

Results: The median length of ICU stay (8 vs 9 days; = 0.32), median length of hospital stay (12 vs 12 days; = 0.33), median duration of vasopressors requirement (4 vs 3 days; = 0.84), median duration of mechanical ventilation (5 vs 7 days; = 0.23), requirement of tracheostomy (34 vs 39%; = 0.71), and 90-day mortality [35 vs 46%; = 0.29; HR 0.72 (0.42-1.24)] were similar in vitamin D and placebo arm.A subgroup analysis in patients with severe vitamin D deficiency (vitamin D <12 ng/mL) revealed a significantly decreased incidence of tracheostomy (28 vs 57%; = 0.04), a trend toward decreased 90-day mortality [34 vs 66%; = 0.08; HR 0.44 (0.19-1.01)], and duration of mechanical ventilation (6 vs 11 days; = 0.05) in patients receiving vitamin D.

Conclusion: Administration of large-dose vitamin D within 24 hours of admission does not reduce the length of ICU stay in critically ill sepsis patients.

How To Cite This Article: Bhattacharyya A, Subramaniam R, Baidya DK, Aggarwal P, Wig N. Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial. Indian J Crit Care Med 2021;25(10):1147-1154.
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http://dx.doi.org/10.5005/jp-journals-10071-23993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8645802PMC
October 2021

Risk of SARS-CoV-2 Infection among Healthcare Providers Involved in Cardiopulmonary Resuscitation in COVID-19 Patients.

Indian J Crit Care Med 2021 Aug;25(8):920-922

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India.

Cardiopulmonary resuscitation (CPR) is considered an aerosol-generating procedure. The aim of this study was to identify the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare providers (HCPs) involved in CPR in coronavirus 2019 (COVID-19) patients. An online and offline anonymous survey with a preformed questionnaire was conducted among the HCPs involved in the care of COVID-19 patients. HCPs who developed reverse transcription-polymerase chain reaction-positive confirmed COVID-19 and/or symptomatic influenza-like illness (ILI) within 14 days of their involvement in CPR of a confirmed COVID-19 patient were identified. Activities performed during CPR, the cumulative number of CPR performed, any breach in personal protective equipment (PPE), type of the mask used, use of any pharmacological prophylaxis, and any psychological impact among HCPs were also identified. A total of 393 HCPs participated in the survey; out of them, 197 HCPs participated in CPR at least once (CPR group) and the rest 196 did not (control group). Ten in the control group and five in the CPR group developed confirmed COVID-19 within the next 2 weeks; however, only one of these five had a breach in PPE during CPR. To conclude, participation in CPR does not increase the risk of SARS-CoV-2 infection in HCPs caring for the COVID-19 patients. The study was approved by the ethics committee of the All India Institute of Medical Sciences, New Delhi, vide letter number: IEC-676/03.07.2020, dated July 4, 2020. Soni L, Maitra S, Ray BR, Anand RK, Subramaniam R, Baidya DK. Risk of SARS-CoV-2 Infection among Healthcare Providers Involved in Cardiopulmonary Resuscitation in COVID-19 Patients. Indian J Crit Care Med 2021;25(8):920-922.
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http://dx.doi.org/10.5005/jp-journals-10071-23924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559757PMC
August 2021

Comparison of High-Flow Nasal Cannula and Noninvasive Ventilation in Acute Hypoxemic Respiratory Failure Due to Severe COVID-19 Pneumonia.

Respir Care 2021 12 28;66(12):1824-1830. Epub 2021 Sep 28.

Department of Anesthesiology, Pain Medicine and Critical Care All India Institute of Medical Sciences, New Delhi, India.

Background: Efficacy of high-flow nasal cannula (HFNC) over noninvasive ventilation (NIV) in severe coronavirus disease 2019 (COVID-19) pneumonia is not known. We aimed to assess the incidence of invasive mechanical ventilation in patients with acute hypoxemic respiratory failure due to COVID-19 treated with either HFNC or NIV.

Methods: This was a single-center randomized controlled trial performed in the COVID-19 ICU of a tertiary care teaching hospital in New Delhi, India. One hundred and nine subjects with severe COVID-19 pneumonia presenting with acute hypoxemic respiratory failure were recruited and allocated to either HFNC ( 55) or NIV ( 54) arm. Primary outcome was intubation by 48 h. Secondary outcomes were improvement in oxygenation by 48 h, intubation rate at day 7, and in-hospital mortality.

Results: Baseline characteristics and [Formula: see text]/[Formula: see text] ratio were similar in both the groups. Intubation rate at 48 h was similar between the groups (33% NIV vs 20% HFNC, relative risk 0.6, 95% CI 0.31-1.15, = .12). Intubation rate at day 7 was lower in the HFNC (27.27%) compared to the NIV group (46.29%) (relative risk 0.59, 95% CI 0.35-0.99, = .045), and this difference remained significant after adjustment for the incidence of chronic kidney disease and the arterial pH (adjusted OR 0.40, 95% CI 0.17-0.93, = .03). Hospital mortality was similar between HFNC (29.1%) and NIV (46.2%) group (relative risk 0.6, 95% CI 0.38-1.04, = .06).

Conclusions: We were not able to demonstrate a statistically significant improvement of oxygenation parameters nor of the intubation rate at 48 h between NIV and HFNC. These findings should be further tested in a larger randomized controlled trial. The study was registered at the Clinical Trials Registry of India (www.ctri.nic.in; reference number: CTRI/2020/07/026835) on July 27, 2020.
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http://dx.doi.org/10.4187/respcare.09130DOI Listing
December 2021

A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial.

Indian J Crit Care Med 2021 Jul;25(7):754-760

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India.

Introduction: Although various preventive strategies have been advocated, delirium is common in critically ill patients and is associated with increased morbidity, mortality, and long-term adverse effects. The efficacy of a novel delirium prevention bundle in mechanically ventilated critically ill patients was investigated in this study.

Methods: In this randomized controlled trial, 50 mechanically ventilated adult patients in a tertiary care medical-surgical intensive care unit (ICU) were randomized to receive either delirium prevention bundle protocol or standard of care protocol. Delirium was assessed daily using the Confusion Assessment Method for the ICU (CAM-ICU) score by an independent investigator up to 28 days or death or discharge. The primary outcome was the incidence of new-onset delirium. Secondary outcomes were duration of mechanical ventilation, ICU length of stay (ICU-LOS), hospital LOS, and other adverse events.

Results: There was a 20% reduction in the incidence of delirium in the intervention group (36 vs 56%; = 0.156). The 28-day mortality (28 vs 24%; = 0.747), duration of mechanical ventilation (9 vs 12 days; = 0.281), ICU-LOS (11 vs 12 days; = 0.221), and hospital LOS (16 vs 20 days; = 0.062) were similar between the groups.

Conclusion: Implementation of delirium prevention bundle does not reduce the incidence of delirium compared to standard of care protocol in mechanically ventilated critically ill patients.

How To Cite This Article: Malik AK, Baidya DK, Anand RK, Subramaniam R. A New ICU Delirium Prevention Bundle to Reduce the Incidence of Delirium: A Randomized Parallel Group Trial. Indian J Crit Care Med 2021;25(7):754-760.
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http://dx.doi.org/10.5005/jp-journals-10071-23881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286373PMC
July 2021

Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis.

Indian J Crit Care Med 2021 Jun;25(6):660-667

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Data are lacking on the role of cellular components of hematological system as biomarkers for prognosis of sepsis. We planned to identify if these parameters measured at admission to ICU and at 72 hours can be useful as prognostic marker in septic critically ill patients.

Materials And Methods: In this prospective observational study, 130 adult patients with sepsis were recruited. Various hematological study parameters (total, differential, and absolute leukocyte count, platelet count, platelet distribution width, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio) were noted at day 1 and day 3 of admission. Primary outcome was 28-day mortality, and secondary outcomes were duration of mechanical ventilation, vasopressor requirement, ICU length of stay, and requirement of renal replacement therapy. The variables were compared between two groups and using binary regression model and were evaluated as prognostic markers for 28-day mortality.

Results: Data from = 129 were analyzed. At day-28, = 58 (44.96%) patients survived. Baseline and demographic parameters were comparable between survivors and nonsurvivors. Admission Sequential Organ Failure Assessment score was more in nonsurvivors than survivors [8 (6-8) vs 6 (4-8); = 0.002]. In nonsurvivors, monocyte, lymphocyte, basophil, eosinophil, and platelet count were significantly less at day 1 and lymphocyte, eosinophil, basophil and platelet count were significantly less at day 3. NLR and PLR at day 3 were significantly more in nonsurvivors. On logistic regression analysis, age, thrombocytopenia on day 1, and low eosinophil count on day 3 predicted 28-day mortality ( = 0.006, = 0.02, and = 0.04, respectively).

Conclusion: Thrombocytopenia on day 1 and eosinopenia on day 3 may predict 28-day mortality in sepsis.

How To Cite This Article: Sinha H, Maitra S, Anand RK, Aggarwal R, Rewari V, Subramaniam R, . Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis. Indian J Crit Care Med 2021;25(6):660-667.
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http://dx.doi.org/10.5005/jp-journals-10071-23874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286394PMC
June 2021

Preoperative planning for central venous cannulation in conjoint twins.

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):569-570. Epub 2021 Jan 18.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_596_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022058PMC
January 2021

Airway challenge in repaired tracheo-esophageal fistula patient.

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):563-564. Epub 2021 Jan 18.

Deptartment of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_139_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022062PMC
January 2021

Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock.

Indian J Crit Care Med 2021 Mar;25(3):310-316

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. : After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18-65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders." Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 ( = 0.016), 0.440 ( = 0.052), and 0.044 ( = 0.853) in control, sepsis, and septic shock patients, respectively. Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, . Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310-316. www.ctri.nic.in, CTRI/2017/11/010434.
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http://dx.doi.org/10.5005/jp-journals-10071-23764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7991757PMC
March 2021

A case of neglected hepatorenal dysfunction during the COVID pandemic.

Indian J Med Microbiol 2021 Apr 26;39(2):262-264. Epub 2021 Mar 26.

Department of Anaesthesia, AIIMS, 110029, New Delhi, India. Electronic address:

As the world fights with the Coronavirus, most of the hospitals are gearing up for the care of these patients. As most of the attention these days is being given on Coronavirus, the patients suffering from other clinical infections are being neglected. SARS-CoV-2 is being kept as the top differential in patients presenting with fever and respiratory distress. We hereby present a case of patient returning from Indonesia during the pandemic presenting with a history of hepatic, renal dysfunction with fever and cough. Due to the pandemic, the patient's fever and cough outweighed the hepatic and renal dysfunction, and the patient had to undergo dialysis before the final diagnosis of leptospirosis could be made.
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http://dx.doi.org/10.1016/j.ijmmb.2021.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997676PMC
April 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
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8521097PMC
February 2021

Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study.

Indian J Crit Care Med 2021 Jan;25(1):85-87

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Coronavirus disease 2019 (COVID-19) is a type of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 pneumonia has characteristic radiological features. Recent evidence indicates usefulness of chest X-ray and lung ultrasound (LUS) in detecting COVID-19 pneumonia.

Materials And Methods: In this prospective observational study, chest X-ray and LUS features of 50 adults with COVID-19 pneumonia at the time of presentation were described.

Results: Chest X-ray findings were present in 96% of patients, whereas all patients have ultrasound finding. Proportion (95% CI) of patients having bilateral opacities in chest X-ray was 96% (86.5-98.9%), ground glass opacity 74% (60.5-84.1%), and consolidation 50% (36.7-63.4%). In LUS, shred sign and thickened pleura was present in all patients recruited in this study. Air bronchogram was present in at least one area in 80% of all patients and B-lines score of more than 2 was present in at least one lung area in 84% patients. Number of lung areas with "shred sign" were higher in hypoxemic ( = 0.005) and tachypneic ( = 0.006) patients and pleura line abnormalities were present in more lung areas in hypoxemic patients ( = 0.03).

Conclusion: According to our study, LUS is a useful tool not only in diagnosing, but it also correlates with requirement of respiratory support in COVID-19 patients.

How To Cite This Article: Behera S, Maitra S, Anand RK, Baidya DK, Subramaniam R, Kayina CA, Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study. Indian J Crit Care Med 2021;25(1):85-87.
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http://dx.doi.org/10.5005/jp-journals-10071-23705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874276PMC
January 2021

SARS- CoV-2 infection presented as acute exacerbation of bronchial Asthma.

J Anaesthesiol Clin Pharmacol 2020 Jul-Sep;36(3):412-413. Epub 2020 Sep 15.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_414_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812949PMC
September 2020

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients.

Indian J Crit Care Med 2020 Nov;24(11):1143-1144

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Nair PR, Maitra S, Ray BR, Anand RK, Baidya DK, Subramaniam R. Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients. Indian J Crit Care Med 2020;24(11):1143-1144.
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http://dx.doi.org/10.5005/jp-journals-10071-23663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751036PMC
November 2020

SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients.

Indian J Crit Care Med 2020 Nov;24(11):1141-1142

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Kayina CA, Maitra S, Anand RK, Ray BR, Baidya DK, Subramaniam R. SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients. Indian J Crit Care Med 2020;24(11):1141-1142.
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http://dx.doi.org/10.5005/jp-journals-10071-23595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751029PMC
November 2020

Anaesthetic considerations in a child with methylmalonic acidemia and its literature review.

BMJ Case Rep 2020 Dec 9;13(12). Epub 2020 Dec 9.

Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, New Delhi, India.

Methyl malonyl coenzyme A mutase deficiency is a rare autosomal inherited inborn error in branched-chain amino acid metabolism characterised by the accumulation of methylmalonic acids. There is relative paucity of literature regarding anaesthetic management of these children presenting for incidental major abdominal surgery. Preoperative management includes goal-directed correction of dehydration, metabolic acidosis and hyperammonemia. Anaesthetic goals include avoidance of factors that can trigger metabolic crisis like hypercapnia, hypothermia, hypoxia, surgical stress, hypovolaemia, hypotension and so on. Herein, we are reporting the anaesthetic management of a 17-month-old child with methylmalonic acidemia (MMA) posted for a major upper abdominal surgery for excision of an adrenal mass, which was incidentally diagnosed during admission for an episode of metabolic crisis. We aim to highlight the specific nuances of pathophysiology of the disease, preoperative optimisation, anaesthetic considerations, role of advanced monitoring and regional anaesthesia and current literature on the management of patients with MMA.
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http://dx.doi.org/10.1136/bcr-2020-237270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733119PMC
December 2020

Epidemiological & clinical characteristics & early outcome of COVID-19 patients in a tertiary care teaching hospital in India: A preliminary analysis.

Indian J Med Res 2020 Jul & Aug;152(1 & 2):100-104

Department of Anesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: In this study we describe the epidemiological data, comorbidities, clinical symptoms, severity of illness and early outcome of patients with coronavirus disease 2019 (COVID-19) from a tertiary care teaching hospital in New Delhi, India.

Methods: In this preliminary analysis of a prospective observational study, all adult patients admitted to the screening intensive care unit (ICU) of the institute who fulfilled the WHO case definition of COVID-19 and confirmed to have SARS-CoV-2 infection by reverse transcription-polymerase chain reaction were included. Demographics, clinical data and 24 h outcome were assessed.

Results: The preliminary analysis of 235 patients revealed that the mean age was 50.7±15.1 yr and 68.1 per cent were male. Fever (68.1%), cough (59.6%) and shortness of breath (71.9%) were the most common presenting symptoms. Hypertension (28.1%) and diabetes mellitus (23.3%) were the most common associated comorbid illnesses. Patients with mild, moderate, severe and critical illness were 18.3, 32.3, 31.1 and 18.3 per cent, respectively, at the time of ICU admission. The proportions (95% confidence interval) of patients requiring any form of oxygen therapy, oxygen therapy by high-flow nasal cannula and invasive mechanical ventilation were 77, 21.7 and 25.5 per cent, respectively, within 24 h of hospital admission. The 24 h ICU mortality was 8.5 per cent, and non-survivors had higher respiratory rate (P <0.01, n=198) and lower baseline oxyhaemoglobin saturation (P <0.001, n=198) at presentation and higher baseline serum lactate (P <0.01, n=122), total leucocyte count (P <0.001, n=186), absolute neutrophil count (P <0.001, n=132), prothrombin time (P <0.05, n=54) and INR (P <0.05, n=54) compared to survivors.

Interpretation & Conclusions: Nearly half of the patients presented with severe and critical disease and required high-flow nasal oxygen or invasive mechanical ventilation at admission. Severity of the presenting respiratory illness, haematological parameters and lactate rather than age or presence of comorbidity predicted early death within 24 h.
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http://dx.doi.org/10.4103/ijmr.IJMR_2890_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853262PMC
September 2020

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial.

Indian J Anaesth 2020 Jun 1;64(6):507-512. Epub 2020 Jun 1.

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

Background And Aims: Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures.

Methods: The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software.

Results: Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement ( = 0.01) and postoperative fentanyl requirement until 24 h ( = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment ( = 0.000).

Conclusion: ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.
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http://dx.doi.org/10.4103/ija.IJA_868_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398014PMC
June 2020

Anaesthetic management of a COVID-19 parturient for caesarean section - Case report and lessons learnt.

Indian J Anaesth 2020 May 23;64(Suppl 2):S141-S143. Epub 2020 May 23.

Department of Anaesthesiology Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

The corona virus disease 2019 (COVID-19) pandemic sweeping across the world has severely strained health care resources (equipment and personnel) forcing us to rethink strategies to provide obstetric care while judiciously using resources. We describe the anaesthetic management of a mildly symptomatic, COVID-19 positive, 28-year-old second gravida with term pregnancy who was taken up for an elective caesarean section under subarachnoid block in a standalone maternity facility. Challenges encountered and modifications of standard procedures so as to optimize patient care and minimize exposure of health care professionals are also discussed.
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http://dx.doi.org/10.4103/ija.IJA_509_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293367PMC
May 2020

Role of serial lactate measurement to predict 28-day mortality in patients undergoing emergency laparotomy for perforation peritonitis: prospective observational study.

J Intensive Care 2019 11;7:58. Epub 2019 Dec 11.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India.

Background: Serial lactate measurement is found to predict mortality in septic shock. Majority of patients with perforation peritonitis for emergency laparotomy are in sepsis and mortality rate is substantial. However, lactate dynamics has not been studied in this patient population.

Methods: After institutional ethics clearance and informed written consent, 113 patients with suspected or proven perforation peritonitis presenting for emergency laparotomy were recruited in this prospective observational trial. Baseline Mannheim peritonitis index (MPI), SOFA and APACHE II score were calculated. Lactate values were obtained at baseline, immediate and 24-h postoperative period. Primary outcome was 28-day mortality.

Results: Mortality was 15.04% at 28 days. Age, SOFA, qSOFA, APACHE, preoperative lactate, MPI and site of perforation were significantly different between survivors and non-survivors. Arterial lactate values at preoperative (cut off 2.75 mmol/L), immediate postoperative (cut off 2.8 mmol/L) and 24 h-postoperative period (cut off 2.45 mmol/L) independently predicted mortality at day 28. Combination of MPI and 24-h lactate value was best predictor of mortality with AUC 0.99.

Conclusion: Preoperative, immediate postoperative and 24-h postoperative lactate value independently predict 28-day mortality in perforation peritonitis patients undergoing emergency laparotomy. Combination of MPI and 24-h lactate value is the most accurate predictor of mortality.

Trial Registration: Clinical Trial Registry of India - CTRI/2018/01/011103.
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http://dx.doi.org/10.1186/s40560-019-0418-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907168PMC
December 2019

Recurrent syncope in a child and video assisted thoracoscopic surgery - The long and short of it.

Indian J Anaesth 2019 Oct 10;63(10):847-850. Epub 2019 Oct 10.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Long QT syndrome (LQTS) is a myocardial repolarisation disorder caused by cardiac ion channelopathy and one of its common presentations is recurrent syncope. This reduced repolarisation reserve in LQTS can be unmasked by perioperative factors like electrolyte imbalance, drugs, hypothermia and changes in cardiac autonomic tone. We report the anaesthetic management of left thoracoscopic sympathectomy in a 5-year-old child with LQTS and epicardial pacemaker in situ. It is very challenging to isolate the lung on one hand and prevent the predisposition to torsadogenic potential on the other.
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http://dx.doi.org/10.4103/ija.IJA_180_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6798626PMC
October 2019

Anesthetic Management of a Unique Case of Double-Outlet Right Ventricle With Glenn Shunt for Cesarean Delivery: A Case Report.

AANA J 2018 Oct;86(5):408-411

is a senior resident, in the Department of Anesthesiology, at AIIMS, in New Delhi, India.

Double-outlet right ventricle is a rare congenital cardiac anomaly resulting in intracardiac mixing of oxygenated and deoxygenated blood. Surgical palliation involves staged conversion to Fontan circulation, with an intermediate stage using a Glenn shunt. We report the case of a patient at 36 weeks of gestation, with a partially palliated double-outlet right ventricle and a Glenn shunt, who presented with severe dyspnea and worsening cyanosis. After preoperative optimization, a combined spinal-epidural technique was successfully used for cesarean delivery. The anesthetic concerns and perioperative management of patients with complex cardiac physiology are discussed in this report. Carefully titrated combined spinal-epidural technique can be safe and effective for such cases.
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October 2018

Comparison of ultrasound-guided versus conventional palpatory method of dorsalis pedis artery cannulation: A randomized controlled trial.

Saudi J Anaesth 2019 Oct-Dec;13(4):295-298

Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India.

Background: Whether use of ultrasound (USG) to cannulate dorsalis pedis artery (DPA) increases first pass successful cannulation, decreases the number of attempts and complications as compared to palpation technique was assessed in this study.

Design: Randomized controlled trial.

Setting: Operating room.

Patients: About 60 adult patients undergoing any head-neck or faciomaxillary surgery requiring arterial cannulation were enrolled.

Intervention: DPA was cannulated either by USG-guided technique (USG group) or by palpation technique (palpation group) with 30 patients in each group.

Measurement: Data were assessed for "first-attempt success" of cannulation, number of attempts, assessment time, cannulation time, cannulation failure, and incidence of complications.

Main Results: Successful first pass DPA cannulation was similar between the groups (ultrasound group vs. palpation group, 76.7% vs. 60%, respectively) [relative risk (95% confidence interval (CI) = 0.69 (0.43, 1.13), = 0.267)] as was the number of attempts required for successful cannulation [median (interquartile range (IQR) number of attempts 1 (1-2) in palpation group and USG group U 1 (1-1); = 0.376]. Median (IQR) assessment time was significantly less ( < 0.0004) in palpation group [palpation group 12 (9-17) vs. USG group U 19 (15-21)]. However, cannulation time was significantly higher ( = 0.0093) in Group [median (IQR) 17.5 (12-36 s) and 11.5 (9-15)]. Although the total procedure time (sum of both assessment time and cannulation time) remain statistically similar between two groups ( = 0.8882).

Conclusions: Use of USG for the cannulation of DPA is feasible, but it is not associated with significant increase in first-attempt success rate, decrease in total number of cannulation attempts or total procedure time.
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http://dx.doi.org/10.4103/sja.SJA_766_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753743PMC
October 2019

Anaesthetic concerns in preterm and term neonates.

Indian J Anaesth 2019 Sep;63(9):771-779

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for "Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia", as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.
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http://dx.doi.org/10.4103/ija.IJA_591_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761779PMC
September 2019

Perioperative management of patient with Conn's syndrome and severe hypokalaemia: How low is too low?

Indian J Anaesth 2019 Jan;63(1):67-68

Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

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http://dx.doi.org/10.4103/ija.IJA_562_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341878PMC
January 2019

Reply to Dr Woodham et al.

Reg Anesth Pain Med 2018 11;43(8):890-891

Department of Anesthesiology All India Institute of Medical Sciences New Delhi, India Department of Surgery All India Institute of Medical Sciences New Delhi, India.

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http://dx.doi.org/10.1097/AAP.0000000000000872DOI Listing
November 2018

Role of anesthesiologist in intrapartum treatment procedure: A case and review of anesthetic management.

J Anaesthesiol Clin Pharmacol 2018 Apr-Jun;34(2):148-154

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

The intrapartum treatment (EXIT) procedure is a rare form of perinatal resuscitation. It is basically a bridge therapy between partial delivery of the child and stabilization of its cardiorespiratory functions. This procedure has multiple anesthetic challenges including maternal anesthesia, maintenance of uteroplacental flow, tocolysis till the neonate is stabilized, management of postpartum hemorrhage, fetal, and neonatal anesthesia. This review also describes a case of cervical teratoma in fetus, for which the EXIT was performed in our institute. In addition to the case description, multiple concerns specific for EXIT procedure are discussed in this review.
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http://dx.doi.org/10.4103/joacp.JOACP_239_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066899PMC
August 2018

Comparison of Macintosh, McCoy, and Glidescope video laryngoscope for intubation in morbidly obese patients: Randomized controlled trial.

Saudi J Anaesth 2018 Jul-Sep;12(3):433-439

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Objectives: The aim of the study was to compare time to intubation and glottic visualization between Macintosh, McCoy, and Glidescope video laryngoscope (GVL) in morbidly obese patients.

Methodology: Forty-five American Society of Anesthesiologists I-III morbidly obese patients were randomized into three groups of 15 each and time to intubation, Cormack-Lehane grading, and Intubation Difficulty Score (IDS) were compared.

Results: GVL took more time to intubate (TTI) compared to Macintosh and McCoy laryngoscope ( = 0.0001). Overall IDS were similar between the groups.

Conclusion: To conclude, GVL takes longer TTI with no added advantage in IDS and hemodynamic response to intubation in morbidly obese patients. McCoy is only as effective as Macintosh and hence Macintosh laryngoscope should be laryngoscope of choice due to its widespread availability and familiarity.
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http://dx.doi.org/10.4103/sja.SJA_754_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044164PMC
August 2018
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