Publications by authors named "Vimi Rewari"

69 Publications

Feasibility of anterior temporalis muscle ultrasound for assessing muscle wasting in ICU: a prospective cohort study.

J Ultrasound 2022 Jul 25. Epub 2022 Jul 25.

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

Purpose: Skeletal muscle ultrasound is a valuable tool for assessing muscle wasting in ICU. Previous studies on skeletal muscle ultrasound in ICU have been performed on lower limb muscles. The current study is formulated to assess the feasibility and reliability of anterior temporalis (AT) muscle ultrasound for measuring muscle wasting in ICU.

Methods: In this prospective cohort study in 48 critically ill patients with sepsis, muscle layer thicknesses (MLTs) and mean grayscale (GS) values of anterior temporalis muscles and quadriceps femoris (Q) were measured at baseline and serially till 7 days. Correlation was made between baseline and change in MLT and GS values of AT and Q muscle and these parameters were compared between ICU survivors and non survivors.

Results: Baseline anterior temporalis MLTs or their longitudinal changes over 7 days did not correlate significantly with the corresponding parameters of quadriceps femoris muscles. The baseline GS values of two muscle groups correlated weakly at baseline, but the change in GS over 7 days showed no correlation. The baseline MLTs of both muscle groups and their longitudinal change over 7 days did not correlate with ICU length of stay. The change in MLT of AT over 7 days was significantly greater in ICU non-survivors compared to survivors.

Conclusion: Measurement of ultrasonographic muscle layer thickness and grayscale parameters of anterior temporalis muscle did not show good correlation with that of quadriceps muscle.
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http://dx.doi.org/10.1007/s40477-022-00703-1DOI Listing
July 2022

Postoperative dengue haemorrhagic shock and Trichosporon fungal sepsis: a multidisciplinary rescue.

BMJ Case Rep 2022 Jul 5;15(7). Epub 2022 Jul 5.

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

A woman in her 30s had robotic pyeloplasty done for right ureteropelvic junction obstruction. Incidentally she developed dengue viral fever starting on postoperative day 1 itself, which progressed to dengue haemorrhagic shock by 1 week, complicating pyeloplasty due to pelvicalyceal haematoma. Dengue associated shock was superimposed with subsequent gram-negative bacterial sepsis, further complicated later with Trichosporon fungal sepsis. She was managed under multidisciplinary care, involving urology, infectious disease and ICU care. Her diagnostic and difficult management issues due to these rare sequential medical issues in an otherwise usually uncomplicated postsurgical phase are discussed along with short review of literature. This case highlights the importance of early diagnosis, timely supportive care and appropriate management in such tropical infections with significant associated mortality.
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http://dx.doi.org/10.1136/bcr-2022-249814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9258485PMC
July 2022

Ingestion poisoning related lung injury- a pictorial review.

Emerg Radiol 2022 Aug 14;29(4):757-767. Epub 2022 Apr 14.

Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, 110029, India.

Poison ingestion is a medical emergency requiring immediate care in the emergency department. Respiratory symptoms with ingested poisons can occur due to aspiration, cardiopulmonary effects, or direct lung toxicity due to injury of the alveolar epithelium. Chest imaging (chest radiographs/CT) is usually performed in the emergency setting to evaluate such symptoms. It is often impossible to elicit the nature of the poison ingested by the patients due to their unconscious state. Identification of the culprit poison can expedite the patient's management towards a specific antidote or help understand the underlying mechanism causing the pulmonary symptoms. The imaging manifestations depend on the underlying mechanisms, varying for each ingested poison, forming an imaging signature which has not been adequately discussed in existing literature. Poisons like paraquat and organophosphate are important to differentiate as indiscriminate use of oxygen therapy in the former can exacerbate the lung injury caused by redox cycling. In this pictorial assay, we present the chest imaging spectrum of commonly ingested poisons, and further suggest algorithmic approach towards identification of common poisons based on their chest imaging.
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http://dx.doi.org/10.1007/s10140-022-02044-2DOI Listing
August 2022

Assessment of role of inferior vena cava collapsibility index and variations in carotid artery peak systolic velocity in prediction of post-spinal anaesthesia hypotension in spontaneously breathing patients: An observational study.

Indian J Anaesth 2022 Feb 24;66(2):100-106. Epub 2022 Feb 24.

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

Background And Aims: Post-spinal anaesthesia hypotension (PSH) is common and can lead to significant morbidity and mortality. The inferior vena cava collapsibility index (IVCCI) and carotid artery peak systolic velocity variations (CAPVV) are two widely used parameters for assessing the volume status of critically ill patients which have also been investigated as predictors of PSH and hypotension after induction of general anaesthesia. In this study, we evaluated the diagnostic accuracy of IVCCI and CAPVV as predictors of PSH.

Methods: A total of 50 patients aged between 18 and 65 years undergoing elective lower abdominal surgeries under spinal anaesthesia were included. The IVCCI and CAPVV were measured using ultrasound pre-operatively. After administering spinal anaesthesia, haemodynamic data were collected till 15 min. Our primary objective was to evaluate the role of IVCCI and CAPVV to predict PSH. The secondary objectives were to compare the predictive efficacy of these two parameters and to detect other parameters for predicting PSH. We constructed the receiver operator characteristic (ROC) curves for IVCCI and CAPVV and obtained the best cut-off values.

Results: The PSH occurred in 34% of the patients. IVCCI >21.15 could predict PSH with 58.8% sensitivity and 69.7% specificity. CAPVV >18.33 predicted PSH with 70.6% sensitivity and 54.6% specificity and IVC max/IVCCI >60 could predict PSH with 58.8% sensitivity and 54.5% specificity. A composite model comprising IVCmax (maximum IVC diameter), CAPVV, and baseline mean blood pressure was able to predict PSH.

Conclusion: Both IVCCI and CAPVV have poor diagnostic accuracy in predicting PSH in adult patients undergoing elective infra-umbilical surgery.
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http://dx.doi.org/10.4103/ija.ija_828_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8963237PMC
February 2022

Effect of positive end expiratory pressure on atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia: A lung ultrasonography study.

J Perioper Pract 2022 Mar 24:17504589211045218. Epub 2022 Mar 24.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India.

Postoperative pulmonary complications vary in major upper abdominal surgery. The objective of this study was to assess the effect of positive end expiratory pressure on the incidence of atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia using lung ultrasound. The patients were randomised into receiving either no positive end expiratory pressure (Group I) or positive end expiratory pressure of 5cm HO (Group II). Lung ultrasound was performed at various time points - baseline, 10 minutes, 2 hours after induction, during closure of skin and 30 minutes post extubation. The lung aeration as assessed by Total Modified Lung Ultrasound Score was worse in the Group I as compared to the Group II at 2 hours post induction. Driving pressure in Group II was significantly reduced compared to Group I. Application of positive end expiratory pressure, as minimal as 5cm HO, as a single intervention, helps in significantly reducing the Total Modified Lung Ultrasound Score after a duration of more than 2 hours and also attaining low driving pressures during intraoperative mechanical ventilation.
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http://dx.doi.org/10.1177/17504589211045218DOI Listing
March 2022

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study.

Int J Urol 2022 07 23;29(7):668-674. Epub 2022 Mar 23.

Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Objectives: Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited.

Methods: In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects.

Results: Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) μg and 240.0 (145.0, 370.0) μg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] μg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] μg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups.

Conclusions: Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.
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http://dx.doi.org/10.1111/iju.14867DOI Listing
July 2022

Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study.

Indian J Urol 2022 Jan-Mar;38(1):53-61. Epub 2022 Jan 1.

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

Introduction: Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation.

Materials And Methods: The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13-15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days.

Results: The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, < 0.001), had early diuresis, better graft turgidity and urine output than Group S.

Conclusion: Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia.Clinical trial identifier number-CTRI/2016/07/007111.
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http://dx.doi.org/10.4103/iju.iju_239_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8796753PMC
January 2022

Temporal Evolution of the PcvCO-PaCO/CaO-CcvO Ratio vs Serum Lactate during Resuscitation in Septic Shock.

Indian J Crit Care Med 2021 Dec;25(12):1370-1376

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

Background: Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO-PaCO/CaO-CcvO ratio may be used as an alternative for the same. The primary outcome of the study is to evaluate the correlation between serum lactate and PcvCO-PaCO/CaO-CcvO ratio measured at various time points to a maximum of 24 hours in patients with septic shock [mean arterial pressure (MAP) <65 mm Hg]. The secondary outcomes were to study the (1) relationship between the PcvCO-PaCO/CaO-CcvO ratio and lactate clearance at 6, 12, and 24 hours as compared to the initial serum lactate, (2) to ascertain whether the PcvCO-PaCO/CaO-CcvO ratio and the arterial lactate levels in the first 24 hours are able to predict mortality at day 28 of enrollment, and (3) to determine whether the PcvCO-PaCO/ CaO-CcvO ratio and arterial lactate are useful in discriminating survivors from nonsurvivors.

Materials And Methods: Thirty patients with sepsis-induced hypotension who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilization of MAP and 6 hourly thereafter for the first 24 hours. Patients were followed up to day 28 of enrollment for mortality and organ system failure.

Results: A positive correlation was observed between arterial lactate and PcvCO-PaCO/CaO-CcvO ratio at 0, 6, 12, and 18 hours ( = 0.413, = 0.02; = 0.567, = 0.001; = 0.408, = 0.025; = 0.521, = 0.003, respectively). No correlation was seen between PcvCO-PaCO/CaO-CcvO ratio and lactate clearance. The subgroup analysis showed that PcvCO-PaCO/CaO-CcvO ratio >1.696 at 24 hours of resuscitation predicted 28-day mortality (sensitivity: 80%, specificity 69.2%, area under the receiver operating characteristic curve 0.82).

Conclusion: The PcvCO-PaCO/CaO-CcvO ratio and lactate are positively correlated during the first 24 hours of active resuscitation from sepsis-induced hypotension, and a threshold of 1.696 mm Hg/mL/dL at 24 hours significantly differentiates survivors from nonsurvivors (CTRI/2017/11/010342).

How To Cite This Article: Madabhushi S, Trikha A, Anand RK, Ramachandran R, Singh PM, Rewari V. Temporal Evolution of the PcvCO-PaCO/CaO-CcvO Ratio vs Serum Lactate during Resuscitation in Septic Shock. Indian J Crit Care Med 2021; 25(12):1370-1376.
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http://dx.doi.org/10.5005/jp-journals-10071-24044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8693105PMC
December 2021

Effect of Change in Body Weight on Clinical Outcomes in Critically Ill Patients.

Indian J Crit Care Med 2021 Sep;25(9):1042-1048

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

Background: Intravenous fluid optimization is an essential component of managing patients in a critical care setting. A cumulative positive fluid balance is consistent with poor outcomes in patients admitted to the intensive care unit (ICU). The overall utility of net cumulative fluid balance as a surrogate for assessing fluid overload has been interrogated.

Materials And Methods: This study was a prospective single-center observational study, which was done to correlate body weight changes with fluid balance in ICU patients and evaluate its impact on clinical outcomes. Inclusion criteria consisted of adult patients who were admitted to the critical care unit on specialized beds with integrated weighing scales between September 2017 and December 2018. The evaluation of the effect of changes in body weight on ICU survival was the primary objective of the study.

Results: We enrolled 105 patients in this study. The ICU mortality was 23.80% with non-survivors showing more weight gain than the survivors. Statistically significant weight gain was documented in the non-survivors on days 3 and 4 (1.9 vs 1.05; = 0.0084 and 2.6 vs 1.6; = 0.0030) of ICU admission. Non-survivors had greater cumulative positive fluid balance on fourth, fifth, and sixth days post-ICU admission when compared to survivors (3586 vs 1659 mL, = 0.0322; 5418 vs 1255 mL, = 0.0017; and 5430 vs 2305 mL = 0.0264, respectively). In multivariate regression analysis, cumulative fluid balance did not correlate with days on mechanical ventilation or length of stay in ICU. Changes in body weight and cumulative fluid balance showed a good correlation.

Conclusion: In patients admitted to the ICU, weight gain on third and fourth days of admission is concordant with increased ICU mortality. Body weight changes were seen to correlate well with the cumulative fluid balance.

How To Cite This Article: Mishra RK, Pande A, Ramachandran R, Trikha A, Singh PM, Rewari V. Effect of Change in Body Weight on Clinical Outcomes in Critically Ill Patients. Indian J Crit Care Med 2021;25(9):1042-1048.
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http://dx.doi.org/10.5005/jp-journals-10071-23978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8664026PMC
September 2021

Colonic interposition for oesophageal replacement surgery in a patient with left broncho-oesophageal fistula: anaesthetic management.

BMJ Case Rep 2021 Aug 19;14(8). Epub 2021 Aug 19.

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

Management of an uncorrected broncho-oesophageal fistula in the perioperative period is a challenge for the anaesthesiologist. Positive pressure ventilation which is inevitable during surgery will lead to gastric insufflation and there is a high risk of aspiration of gastric contents. In this case report, we discuss how we used a double lumen tube to occlude a pericarinal broncho-oesophageal fistula. This method was quite effective as it obviated the need for isolating the lung as well as ensured smooth delivery of positive pressure ventilation during the surgery.
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http://dx.doi.org/10.1136/bcr-2021-243738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8378378PMC
August 2021

Effectiveness of enteral ivabradine for heart rate control in septic shock: A randomised controlled trial.

Anaesth Intensive Care 2021 Sep 18;49(5):366-378. Epub 2021 Aug 18.

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

Persistent tachycardia in patients with septic shock predicts poor outcome. This study sought to investigate the effect of the cardiac pacemaker current inhibitor ivabradine on heart rate and cardio-circulatory function in patients with septic shock. After informed consent, 60 patients with septic shock and persistent tachycardia (heart rate >95 /minute) were prospectively randomly assigned to receive either standard therapy for septic shock (group S) or standard therapy along with enteral ivabradine (group I) for the initial 96 hours after enrolment. Primary outcome was the difference in heart rate between the two groups during the first 96 hours. Secondary outcomes included the effect of ivabradine on haemodynamic, oxygenation, myocardial function and organ function parameters, incidence of adverse events and 30-day overall survival. Heart rate was lower in group I compared to group S (median difference in area under the curve -25.6 (95% confidence intervals -31.4 to -15.9) /minute; <0.001). Vasopressor requirements, blood lactate levels, Sequential Organ Failure Assessment scores and E/e' ratio were lower in group I compared to group S. Stroke volume index and ejection fraction were higher in group I while cardiac index and oxygen delivery parameters were maintained similar to group S. There was no difference in 30-day mortality or in the incidence of serious adverse events. Enteral ivabradine is effective in reducing heart rate, and improving haemodynamic parameters and cardiac function in patients with septic shock and persistent tachycardia, without increasing the incidence of adverse events.
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http://dx.doi.org/10.1177/0310057X211009913DOI Listing
September 2021

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: Alternate Techniques.

Authors:
Vimi Rewari

Anesth Analg 2021 09;133(3):e41-e42

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/10.1213/ANE.0000000000005641DOI Listing
September 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

Haemodynamic responses following orotracheal intubation in patients with hypertension---Macintosh direct laryngoscope versus Glidescope®videolaryngoscope.

Indian J Anaesth 2021 Apr 15;65(4):321-327. Epub 2021 Apr 15.

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

Background And Aims: Glidescope®videolaryngoscope (GVL) is a video intubation system with 60° angle blade that provides excellent laryngeal view, does not require alignment of oral, pharyngeal, and laryngeal axes for visualisation of glottis, thus causing less stimulation of orolaryngopharynx. The aim of this study was to compare haemodynamic responses (blood pressure and heart rate) and airway morbidity using the Macintosh direct laryngoscope (MDL) and the Glidescope®videolaryngoscope (GVL) in hypertensive patients.

Methods: Fifty patients with hypertension controlled on antihypertensive medications scheduled for elective surgery under general anaesthesia were randomly assigned to group GVL ( = 25) or group MDL ( = 25). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) were recorded at baseline, after induction, pre-intubation, at intubation, 1, 2, 3, 4, and 5 min after intubation. Time to intubation, number of attempts, complications during intubation, and postoperative airway complications (sore throat, hoarseness, dysphagia, and cough) were also recorded.

Results: There was a statistically significant increase in SBP, DBP, and MBP at intubation [( = 0.003, 0.013, 0.03), 1 min ( = 0.001, 0.012, 0.02), 2 min ( = 0.04, 0.02, 0.04), and 3 min ( = 0.02, 0.01)] in the MDL group as compared to GVL group. The time to intubate was significantly greater in the GVL group as compared to MDL group ( = 0.0006). There was no significant difference in the incidence of intraoperative and postoperative airway complications.

Conclusion: In the hands of an experienced anaesthesiologist, the use of GVL in controlled hypertensive patients is associated with less haemodynamic response as compared to Macintosh Laryngoscope without any increase in airway complications.
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http://dx.doi.org/10.4103/ija.IJA_417_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174590PMC
April 2021

Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery: A randomized controlled trial.

Surgery 2021 07 24;170(1):277-283. Epub 2021 Mar 24.

Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background: As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions.

Methods: Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmHO was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally.

Results: Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups.

Conclusion: Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.
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http://dx.doi.org/10.1016/j.surg.2021.01.047DOI Listing
July 2021

[Awake nasal fibre optic intubation --- a simple manoeuvre for easy navigation of the fiberscope through the nasopharynx].

Braz J Anesthesiol 2019 Nov - Dec;69(6):641. Epub 2019 Oct 17.

All India Institute of Medical Sciences, Department of Otorhinolaryngology, Ansari Nagar, Índia.

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http://dx.doi.org/10.1016/j.bjan.2019.06.011DOI Listing
July 2020

Continuous wound infiltration of local anaesthetics for acute postoperative pain - A revisit.

Indian J Anaesth 2019 Jun;63(6):425-427

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India E-mail:

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http://dx.doi.org/10.4103/ija.IJA_425_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6573056PMC
June 2019

Compression with the ultrasound probe to prevent malposition of central venous catheter in the ipsilateral internal jugular vein during axillary vein cannulation.

J Clin Ultrasound 2019 Feb 25;47(2):95-96. Epub 2018 Nov 25.

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/10.1002/jcu.22666DOI Listing
February 2019

Ultrasonography and Seldinger's technique: Using the best of both worlds for difficult radial artery cannulation!

J Anaesthesiol Clin Pharmacol 2018 Jul-Sep;34(3):420-421

Department of Anesthesiology, 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_15_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194826PMC
November 2018

Bougie-associated bronchial injury complicated by a nephropleural fistula after percutaneous nephrolithotomy: a tale of two complications.

BMJ Case Rep 2018 Apr 17;2018. Epub 2018 Apr 17.

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

We present a case of bronchial injury following bougie-assisted endotracheal intubation in a patient with difficult airway scheduled to undergo right percutaneous nephrolithotomy under general anaesthesia. The patient developed pleuritic pain along with right pleural effusion on the third postoperative day which was diagnosed by the anaesthesiologist who was following up the patient for airway trauma-associated complications. However, the patient was diagnosed to have a nephropleural fistula, a rare complication of supracostal access to percutaneous nephrolithotomy, which was managed successfully.
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http://dx.doi.org/10.1136/bcr-2017-223969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905817PMC
April 2018

Feasibility of dexmedetomidine as sole analgesic agent during robotic urological surgery: A pilot study.

J Anaesthesiol Clin Pharmacol 2017 Apr-Jun;33(2):187-192

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

Background And Aims: Opioid-free anesthesia decreases postoperative nausea and vomiting, emergence agitation, prolonged sedation, ileus, and urinary retention. The feasibility of the use of dexmedetomidine as sole analgesic agent has been shown in patients undergoing bariatric and gynecological laparoscopic surgery. We explored its use for robotic urological surgery.

Material And Methods: Thirty patients were randomized to receive either dexmedetomidine (Group D) or fentanyl (Group F) along with total intravenous anesthesia with propofol. The hemodynamic parameters and number of doses of rescue analgesics used intraoperatively and postoperatively were noted. Recovery parameters at the end of surgery were also recorded.

Results: The dose of intraoperative rescue fentanyl was not significantly different between groups ( = 0.13). The hemodynamic profile of patients in the two groups was comparable except the heart rate was significantly more in Group D after intubation and at 60 min. The mean arterial pressure was significantly lower after the initial loading dose of study drug in Group D. The recovery profiles were not significantly different between groups.

Conclusion: The study reveals that dexmedetomidine has equal analgesic efficacy as fentanyl for intraoperative use and can be used as the sole analgesic agent in patients undergoing robotic urological surgery.
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http://dx.doi.org/10.4103/0970-9185.209753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520590PMC
August 2017

Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy?: A randomized control trial.

J Clin Anesth 2017 Aug 12;40:7-10. Epub 2017 Apr 12.

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

Study Objective: To compare the incidence of postoperative nausea and vomiting (PONV) during perioperative administration of 5% dextrose and normal saline in laparoscopic cholecystectomy.

Design: Prospective, randomized, double-blind trial.

Setting: Operating rooms in a tertiary care hospital of Northern India.

Patients: One hundred patients with American Society of Anesthesiologists status I to II undergoing laparoscopic cholecystectomy were enrolled in this study.

Interventions: Patients were randomized into two groups [normal saline (NS) group and 5% dextrose (D) group]. Both the groups received Ringer acetate (Sterofundin ISO) intravenously as a maintenance fluid during intraoperative period. Besides this, patients of group NS received 250ml of 0.9% normal saline and patients of group D received 5% dextrose @ 100ml/h started at the time when gall bladder was taken out. It was continued in the postoperative period with the same rate till it gets finished.

Measurements: Incidence of PONV, Apfel score, intraoperative opioids used and consumption of rescue antiemetics.

Main Results: Demographic data was statistically similar. Out of total 100 patients, 47 patients (47%) had PONV. In group D, 14 patients (28%) had PONV while in group NS, 33 patients (66%) had PONV within 24h of surgery (p value 0.001). The incidence of PONV was reduced by 38% in group D which is significantly lower when compared with that of group NS (p value 0.001). The consumption of single dose of rescue antiemetics in group D was also reduced by 26% when compared to that of group NS (p value 0.002).

Conclusions: Perioperative administration of 5% dextrose in patients undergoing laparoscopic surgery can reduce PONV significantly and even if PONV occurs, the quantity of rescue antiemetics to combat PONV is also reduced significantly.
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http://dx.doi.org/10.1016/j.jclinane.2017.03.048DOI Listing
August 2017

Factors affecting the haemodynamic behaviour of patients undergoing pheochromocytoma and paraganglioma removal: A review.

Cardiovasc Endocrinol 2017 Jun 17;6(2):73-80. Epub 2017 May 17.

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

Pheochromocytoma and paraganglioma are catecholamine-secreting tumours associated with major haemodynamic upheavals. The cardiovascular and other organ-related morbidity and even mortality has been ascribed to the major haemodynamic effects of these tumours. Many factors affect the nature and intensity of these haemodynamic changes. The rarity of these tumours as well as their extremely varied clinical presentation preclude conduct of randomized-controlled trials that may provide evidence in terms of these factors and the ways to predict and control them. Many retrospective studies and case reports, however, do provide some insight into their haemodynamic behaviour. Factors such as tumour pathology, associated genetic syndromes, anatomical attributes and perioperative drug therapy affect the haemodynamics of patients with these unique tumours. Knowledge of these factors and their presumed and known association with haemodynamic behaviour of the patients is important during the perioperative care of these patients. The review focuses on the tumour-related, patient-related and the perioperative care-related factors that affect the haemodynamic behaviour of these patients during the surgical removal of these tumours.
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http://dx.doi.org/10.1097/XCE.0000000000000090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768518PMC
June 2017

Current perioperative management of pheochromocytomas.

Indian J Urol 2017 Jan-Mar;33(1):19-25

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

Neuroendocrine tumors which have the potential to secrete catecholamines are either associated with sympathetic adrenal (pheochromocytoma) or nonadrenal (paraganglioma) tissue. Surgical removal of these tumors is always indicated to cure and prevent cardiovascular and other organ system complications associated with catecholamine excess. Some of these tumors have malignant potential as well. The diagnosis, localization and anatomical delineation of these tumors involve measurement of catecholamines and their metabolic end products in plasma and urine, I-metaiodobenzylguanidine scintigraphy, computed tomography, and/or magnetic resonance imaging. Before surgical removal of the tumors, the optimization of blood pressure, as well as intravascular volume, is an important measure to avoid and suppress perioperative adverse hemodynamic events. Preoperative preparation includes the use of alpha-adrenergic antagonists, beta-adrenergic antagonists with or without other antihypertensive agents, fluid therapy as well as insulin therapy for hyperglycemia if required. Due attention should be given to type and dose of alpha-receptor antagonists to be used and the duration of this therapy to achieve an optimal level of preoperative "alpha-blockade." Despite this preoperative preparation, many patients will have hypertensive crises intraoperatively which need to be promptly and carefully managed by the anesthesia team which requires intensive and advanced monitoring techniques. The most common complication after tumor removal is hypotension which may require fluid therapy and vasopressor support for a few hours. With advancement in surgical and anesthetic techniques, the incidence of severe morbidity and mortality associated with the surgery is low in high volume centers.
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http://dx.doi.org/10.4103/0970-1591.194781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5264186PMC
February 2017

Transversus Abdominis Plane Block for Inguinal Hernia Repair in a Premature Infant: A Case Report.

A A Case Rep 2017 Jan;8(2):31-32

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

In this report, we describe the case of a premature infant (36 weeks' postgestational age) who underwent left inguinal hernia repair under general anesthesia without the use of any airway device. Anesthesia was induced and maintained with sevoflurane in oxygen and nitrous oxide. An ultrasound-guided transversus abdominis plane block was performed that provided effective analgesia, obviating the need for opioids in the intraoperative period. The infant's hemodynamics remained stable throughout the surgery. This report also briefly explains the advantages of using a transversus abdominis plane block, compared with neuraxial blockade, for hernia repair surgery.
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http://dx.doi.org/10.1213/XAA.0000000000000415DOI Listing
January 2017

Analgesic efficacy of ultrasound guided transversus abdominis plane block versus local anesthetic infiltration in adult patients undergoing single incision laparoscopic cholecystectomy: A randomized controlled trial.

Anesth Essays Res 2016 Sep-Dec;10(3):561-567

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

Background: Transversus abdominis plane (TAP) block has been used to provide intra- and post-operative analgesia with single incision laparoscopic (SIL) bariatric and gynecological surgery with mixed results. Its efficacy in providing analgesia for SIL cholecystectomy (SILC) via the same approach remains unexplored.

Aims: The primary objective of our study was to compare the efficacy of bilateral TAP block with local anesthetic infiltration for perioperative analgesia in patients undergoing SILC.

Settings And Design: This was a prospective, randomized, controlled, double-blinded trial performed in a tertiary care hospital.

Materials And Methods: Forty-two patients undergoing SILC were randomized to receive either ultrasound-guided (USG) bilateral mid-axillary TAP blocks with 0.375% ropivacaine or local anesthetic infiltration of the port site. The primary outcome measure was the requirement of morphine in the first 24 h postoperatively.

Statistical Analysis: The data were analyzed using -test, Mann-Whitney test or Chi-square test.

Results: The 24 h morphine requirement (mean ± standard deviation) was 34.57 ± 14.64 mg in TAP group and 32.76 ± 14.34 mg in local infiltration group ( = 0.688). The number of patients requiring intraoperative supplemental fentanyl in TAP group was 8 and in local infiltration group was 16 ( = 0.028). The visual analog scale scores at rest and on coughing were significantly higher in the local infiltration group in the immediate postoperative period ( = 0.034 and = 0.007, respectively).

Conclusion: USG bilateral TAP blocks were not effective in decreasing 24 h morphine requirement as compared to local anesthetic infiltration in patients undergoing SILC although it provided some analgesic benefit intraoperatively and in the initial 4 h postoperatively. Hence, the benefits of TAP blocks are not worth the effort and time spent for administering them for this surgery.
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http://dx.doi.org/10.4103/0259-1162.186620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062234PMC
October 2016

Magnesium sulfate or diltiazem as adjuvants to total intravenous anesthesia to reduce blood loss in functional endoscopic sinus surgery.

J Clin Anesth 2016 Nov 10;34:179-85. Epub 2016 May 10.

AIIMS, New Delhi, India. Electronic address:

Study Objective: This study was designed to know whether addition of magnesium sulfate (MgSO4) or diltiazem to total intravenous anesthesia (TIVA) (propofol) aided reduction in blood loss during functional endoscopic sinus surgery (FESS). The secondary outcomes measured were surgeon's assessment of the surgical field and hemodynamics.

Design: Randomized, double-blinded, placebo-controlled trial.

Setting: Operating room.

Patients: Forty-five American Society of Anesthesiologists I and II adult patients (18-60years) undergoing FESS.

Interventions: All groups received propofol-fentanyl TIVA. Patients were randomly allocated to 1 of the 3 groups (MgSO4 group, n=15; diltiazem group, n=15; saline group, n=15).

Measurements: Intraoperative bleeding was quantified, and quality of surgical field was graded. Hemodynamic parameters were recorded.

Main Results: Addition of both MgSO4 and diltiazem significantly reduced blood loss (240 and 350mL) in comparison to control group (415mL) (P=.003). The surgical field was significantly better in the MgSO4 group compared with the diltiazem (P=.028) and saline groups (P=.0001).

Conclusion: It was concluded that the addition of both MgSO4 and diltiazem to TIVA propofol results in significant reduction in blood loss and significant improvement in the quality of surgical field during FESS without causing any adverse effects on the hemodynamics or on the recovery from anesthesia. The surgical field in the MgSO4 group was significantly better than that in the diltiazem group (P=.04).
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http://dx.doi.org/10.1016/j.jclinane.2016.03.068DOI Listing
November 2016

Resurfacing of ketamine: The subanesthetic paradigm.

J Anaesthesiol Clin Pharmacol 2016 Jul-Sep;32(3):286-7

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

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http://dx.doi.org/10.4103/0970-9185.188823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5009831PMC
September 2016

Refractory hypotension during paraganglioma removal - do we have to worry?

Indian J Anaesth 2016 Aug;60(8):606-8

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

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http://dx.doi.org/10.4103/0019-5049.187817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4989818PMC
August 2016

Laparoscopic Surgery for Pheochromocytoma and Paraganglioma Removal: A Retrospective Analysis of Anaesthetic Management.

Curr Hypertens Rev 2016 ;12(3):222-227

Department of Anaesthesiology, Pain medicine and critical care. Room Number 5013, All India Institute of Medical Sciences, Ansari nagar, Delhi, India.

Introduction: Minimal invasive approaches to pheochromocytoma (PCC) and paraganglioma (PGL) removal may be complicated by the hemodynamic disturbances that are associated with the catecholamine secretion from the tumour. The anaesthetic and perioperative monitoring techniques need to be customized to handle these complications effectively. This retrospective analysis was undertaken to review the perioperative management of these patients handled by the same anaesthetic and surgical team.

Methods: Case details were collected and data analysed for the perioperative management of 29 patients who underwent laparoscopic removal of PCC and PGL. Parameters collected included details of preoperative alpha-and beta blockade, tumour size, number of hypertensive surges, dose of sodium nitroprusside (SNP) and other vasodilators used and incidence of postoperative hypotension and other complications.

Results: All patients received prazosin for pre-operative optimization. Hypertensive emergencies were seen in 4 patients during induction and endotracheal intubation and in 1 patient during pneumoperitoneum insufflation. Overall mean number of hypertensive emergencies was 3.41 (SD-2.45). The patients undergoing PGL removal had significantly more crisis compared to those undergoing unilateral PCC removal. The dose of SNP used correlated significantly with tumour size.

Conclusion: Laparoscopic surgery for PCC and PGL removal is associated with hypertensive emergencies which are amenable to usual doses of antihypertensives used intraoperatively. Surgical factors like tumour size and location affect the number of crisis and the dose of anti-hypertensives used more than the anaesthetic drugs and procedures.
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http://dx.doi.org/10.2174/1573402112666160510122357DOI Listing
December 2017
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