Abstract Background and Aims: Dexamethasone is used as an adjuvant to prolong the duration of peripheral nerve blocks. This study compares the effectiveness of intravenous (IV) versus perineural dexamethasone as an adjuvant to 0.5% ropivacaine for erector spinae plane block (ESPB) in patients undergoing modified radical mastectomy (MRM). Material and Methods: This prospective, double-blind, randomized study was conducted on 60 American Society of Anesthesiologists (ASA) physical status I/II adult females undergoing MRM under general anesthesia. Patients were divided into three groups: ropivacaine perineural dexamethasone (RPD), ropivacaine IV dexamethasone (RID), and ropivacaine normal saline (RNS). Time to rescue analgesia and morphine consumption over various time points (4, 8, 12, 24, and 48 h) were recorded postoperatively. Pain was assessed using the numeric rating scale (NRS). Results: The median time to first rescue analgesia was significantly higher in the RPD group (n = 20) 720 min [interquartile range (IQR: 465–1440), 95% confidence interval (CI): 638.78–1564.21)] in comparison to the RID group (n = 20) 435 min (IQR: 405–480, 95% CI: 284.8–811.1) and control (RNS) group (n = 20) 360 min (IQR: 240–415, 95% CI: 297.6–376.36) (P = 0.01). The median total morphine consumption in 24 h was least in the RPD group 2.0 mg (IQR: 1.0–3.0, 95% CI: 2–3) compared to the the RID 6.0 mg (IQR: 3.2–6.0, 95% CI: 6–8) and RNS groups 7.5 mg (IQR: 6.0–9.5, 95% CI: 6–8) (P = 0.01). The NRS scores both at rest and at physical activity were also lowest in the RPD group compared to other groups at various time points (4, 8,12, 24, and 48 h). Conclusions: Perineural dexamethasone added as an adjuvant to 0.5% ropivacaine to ESPB prolongs the duration of analgesia, reduces morphine consumption, and reduces NRS scores at rest and physical activity as compared to IV dexamethasone in patients undergoing MRM.

Abstract Background and Aims: This study evaluates the analgesic efficacy of ketamine and dexmedetomidine as an adjuvant with ropivacaine 0.2% in pectoral nerve type II block (PECS-II) in modified radical mastectomy. The primary outcome of the study was the time to first rescue analgesia postoperatively. The secondary outcomes were intraoperative and postoperative opioid consumption and postoperative pain on the numerical rating scale. Material and Methods: Seventy-five adult female patients who underwent a modified radical mastectomy participated in this prospective, randomized, double-blinded clinical trial. The patients received 30 ml of 0.2% ropivacaine with or without adjuvants by the ultrasound-guided PECS-II block. Group R (n = 25) received ropivacaine 0.2% without adjuvants. Group RD (n = 25) and group RK (n = 25) received dexmedetomidine 1μg/kg and ketamine 1 mg/kg, respectively, along with ropivacaine 0.2%. Results: Duration of analgesia determined by time to first rescue analgesia was longer in group RD (18.42 ± 02.15 h) compared to group RK (15.91 ± 03.21 h) and group R (14.64 ± 02.85 h), which was statistically significant (P < 0.001). Fentanyl consumption in the first 48 h after surgery was significantly less in the dexmedetomidine group compared to other groups. Conclusion: We conclude that dexmedetomidine with 0.2% ropivacaine in the PECS-II block provides better postoperative analgesia and has less sedative effects than ketamine with 0.2% ropivacaine.

Abstract Background and Aims: Enhanced recovery after surgery recommends preoperative consumption of carbohydrate within 2 hours before elective surgery to reduce perioperative discomfort and improve patient outcome. Material and Methods: This prospective interventional study included 105 adult patients, undergoing elective open gynecological surgery under neuraxial anesthesia. Groups I, II, and III were administered commercially available preoperative carbohydrate drink, oral rehydration solution (ORS), and mineral water, respectively, at night and 3 hours before surgery. The primary objective was to assess the difference in hunger, thirst, anxiety, nausea, and fatigue using visual analog scale, postoperative blood sugar levels, and quality of recovery (QoR) 40 questionnaire among groups. Results: Severe hunger (22.9%), thirst (31.4%), and anxiety (34.3%) were experienced more in group III, while in group I and II, no patient had severe discomfort. The mean blood sugar levels in group III (111.3 ± 12.3, 129.4 ± 7.3) were higher compared to group I and II at both 1 hour and 24 hours after initiation of anesthesia. The mean QoR score was the highest in group I compared to group II and group III (P < 0.001). The majority of the patients in group I (77.1%) had an early return of gastrointestinal function and a shorter length of hospital stay. Conclusions: The overall effectiveness of commercially available preoperative carbohydrate solution was more compared to ORS and mineral water. The consumption of ORS drink resulted in less thirst and satisfactory outcomes due to its higher electrolyte content, making it a suitable option for low resource setting.

Abstract Background and Aims: Left head rotation maneuver improves the glottic view during direct laryngoscopy. We assessed whether rotating the head to the left side to 45° in supine position improves the glottic view as assessed with the percentage of glottic opening (POGO) score during video laryngoscopy compared to sniffing position. Ease of intubation, time to intubate, and hemodynamic changes were also assessed. Material and Methods: This prospective, observational study was conducted in 41 patients with difficult airway requiring video laryngoscope–aided nasotracheal intubation. Following intravenous induction and neuromuscular blockade, indirect laryngoscopy was attempted with C-MAC videolaryngoscope with the patient’s head in sniffing position. Best glottic view was graded as per the POGO scoring system. In patients having partial or no glottic view, patient’s head was rotated to the left side to 45° and the best glottic view was obtained and scored. Intubation was attempted in this position, and ease of intubation was documented. Results: Majority of patients showed improvement of >25% POGO score following left head rotation compared to sniffing position (85.37% vs. 14.63%). Significantly higher number of patients in sniffing position had a POGO score of 0–25%, while it was >50–100% in left head rotation position. Median POGO score was significantly higher in left lateral position compared to sniffing position (75% vs. 25%). Intubation was easy in 69.29% of patients. There was no significant change in hemodynamic parameters during intubation. Conclusion: Rotating the head to the left side to 45° in supine position improved the glottic view during indirect laryngoscopy using C-MAC videolaryngoscope compared to sniffing position.

Abstract Background and Aims: Traumatic cervical spine injury (tCSI) is associated with an increased risk of postoperative pulmonary complications (POPC) after surgical fixation. Sugammadex provides superior neuromuscular recovery; however, its effectiveness in reducing POPC in tCSI remains unclear. The primary outcome of this study was the ultrasonographic lung aeration score (LAS) at 24 hours after surgery. Secondary outcomes included extubation success in the operation theatre, POPC, length of intensive care unit stay, duration of mechanical ventilation, need for tracheostomy, hospital stay after surgery, and in-hospital mortality. Material and Methods: In this prospective, double-blinded, randomised control trial, 75 patients undergoing elective fixation of tCSI were randomly allocated to either the neostigmine (N) group (n = 37) or sugammadex (S) group (n = 38) for neuromuscular blockade (NMB) reversal. A P value less than 0.05 was considered statistically significant. Results: There was no significant difference in LAS at 24 hours between groups [median (range) LAS: 2 (0–18) in the N group, 2 (0–19) in the S group] (P = 0.632) or in any other secondary outcomes. The incidence of POPC was 27.03% in the N group and 26.32% in the S group (P = 0.944) Exploratory analysis did not find any difference in outcomes based on the level [high (C1–C4) vs. low (C5–C7)] or severity [American Spinal Injury Association (ASIA) impairment scale: A, B vs. C, D, E] of spinal injury (P > 0.05). A LAS of 4 at 24 h predicted the development of POPC within 7 days with 80% sensitivity and 87.27% specificity (area under the receiver operator characteristics curve: 0.9032). Conclusion: In tCSI, NMB reversal using either sugammadex or neostigmine resulted in comparable LAS at 24 h postoperatively following cervical spine fixation. Additionally, a LAS of 4 was found to be a strong predictor of POPC within a 7-day follow-up period.

Abstract Background and Aims: Intravenous magnesium sulfate is known to reduce hemodynamic response of laryngoscopy and intubation. However, it is associated with some systemic side effects. We compared the efficacy of nebulized and intravenous magnesium sulfate pretreatment on attenuation of hemodynamic response during tracheal intubation. Material and Methods: Sixty-six American Society of Anesthesiologists classification I–II patients aged 18–65 were randomly assigned to two groups: Group IV, which received 30 mg/kg of intravenous magnesium sulfate, and Group IN, which received the same dose via nebulization. Intubation was performed by an experienced anesthesiologist who was blinded to group allocation. The primary outcomes were heart rate (HR) and mean arterial pressure (MAP) during laryngoscopy and intubation. Secondary outcomes included propofol consumption for anesthesia induction, time to achieve a train-of-four (TOF) ratio of 0 after vecuronium administration, and any adverse effects. Results: Both groups showed similar attenuation of hemodynamic responses during laryngoscopy and intubation (HR: P =0.139, MAP: P =0.40). Propofol consumption (mg) was comparable between the groups (113.64 in Group IN vs. 113.79 in Group IV, P = 0.629). However, the time (seconds) to achieve a TOF ratio of 0 was significantly shorter in Group IV compared to Group IN (228.33 vs. 247.09, P = 0.035). Conclusion: Nebulized magnesium sulfate was as effective as intravenous magnesium sulfate in reducing hemodynamic changes during intubation, offering a noninvasive alternative for managing this response.

Abstract Background and Aims:: Laryngeal Mask Airway Protector (LMPt) and Laryngeal Mask Airway Proseal (LMPs) have a high oropharyngeal leak pressure (OLP) but have not been compared for laparoscopic surgery. It was hypothesized that LMPs and LMPt have different clinical performances while managing the airway of patients undergoing laparoscopic surgery. The aim of the study was to compare the LMPs and LMPt for managing the airway of patients undergoing laparoscopic surgery. Material and Methods: This was a prospective, single-blind, randomized, comparative trial. It included adult patients of either gender with American Society of Anesthesiologists physical status I/II planned for elective laparoscopic surgery. The airway of the recruited subjects was managed with either LMPs (group R, n = 60) or LMPt (group T, n = 60). OLP was the primary outcome variable. Number of attempts, insertion success, device insertion duration, ease of insertion, hemodynamics, gastric tube insertion, and complications were secondary outcome variables. Numerical data and dichotomous data were analyzed using student’s t-test and χ2 test, respectively. Results: The OLP was statistically greater (P < 0.001) in group T before (30.23 ± 1.48 vs. 25.33 ± 1.40 cm H2O) and during (31.77 ± 0.65 vs. 27.12 ± 1.11 cm H2O) the pneumoperitoneum. The baseline and secondary outcome variables were statistically similar between the groups. Conclusions: For patients undergoing elective laparoscopic surgery, both LMPt and LMPs are suitable for airway management, but LMPt provides a higher OLP. More trials are required to validate these findings across different surgical settings and patient populations.

Abstract Background and Aims: Desflurane helps in prompt awakening when discontinued. Since desflurane has a lesser blood: gas solubility than nitrous oxide, we hypothesized that use of air with desflurane would result in a rapid recovery compared to desflurane with nitrous oxide. Materials and Methods: After approval from the institutional ethical committee was obtained, this prospective, nonrandomized study (CTRI/2017/11/010558) was conducted. This study included 110 American Society of Anesthesiologists I–II patients aged 18–60 years, of either sex, undergoing general anesthesia using desflurane with air or nitrous oxide for elective surgery. The primary objective was to compare the time taken to achieve a modified Aldrete score of 9/10. The secondary objectives were to compare time to spontaneous respiration, time to extubation, time to verbal response, time to orientation, intraoperative opioid consumption, and incidence of explicit recall between groups. P <0.05 was considered significant. Results: The time required to achieve modified Aldrete score of 9/10 was higher in those who received nitrous oxide (899.09 ± 426.85 s) compared to those who received air (464.27 ± 190.28 s; P < 0.01). Time taken for spontaneous respiration, extubation, verbal response, and orientation was significantly higher with the use of desflurane with nitrous oxide compared to use of air. The intraoperative opioid requirement was statistically significant, but clinically not significant. Explicit recall was not seen in any of the patients. Conclusion: Nitrous oxide delays the elimination of desflurane compared to air, thus delaying extubation and recovery and mitigating the beneficial effects of desflurane.

Abstract Background and Aims: Regional anesthesia plays a crucial role in perioperative medicine, influencing both immediate and long-term outcomes. However, there is a lack of data regarding the utilization and practices of plexus and peripheral nerve blocks. We attempted to investigate the practices of plexus and peripheral nerve blocks using a validated questionnaire. Material and Methods: A questionnaire was validated by 14 experts and was distributed online for the response. There were 1020 responses, and the data are expressed as frequencies and percentages. There were 58.2% females and 41.8% males, including 32.3% of the respondents with more than 20 years of experience and 27.5% having 10–20 years of experience. Participants from teaching hospitals, government, and private college comprised 49.7%, while those from the corporates and private practitioners constituted 50.2%. Results: Most participants fell into the age range of 31–40 years, followed by 41–50 years. The regional blocks were performed daily by 21.8%, weekly by 23.8%, every 15 days by 38.4%, and monthly by 16% of the participants. Furthermore, 43.6% of the participants discussed the block plan with the patients. The most common blocks of the upper limb and lower limb were the supraclavicular approach of the brachial plexus block (90.8%) and the fascia iliaca (82.5%), respectively. Conclusions: The present survey highlights the details about the present practices, advantages, and limiting factors for using plexus and peripheral nerve blocks. This is the first data acquired with a validated survey from a South Asian Country, which can be used to compare changes in future practices.

Abstract Background and Aims: Medical oxygen (O2) is a lifesaving therapy in the intensive care unit (ICU). However, overzealous use and poorly defined O2 targets in ICU patients can increase the risk of hyperoxemia. We aimed to assess the administration and titration of O2 therapy in ICU patients requiring invasive mechanical ventilation (IMV) support. Material and Methods: In this prospective observational study, all adult patients requiring IMV for more than 24 hours were included over 1 year (December 2020–November 2021). Patients who refused to give consent or required IMV support for less than 24 hours, did not have arterial blood gas data, were at risk for imminent death, or required extracorporeal membrane oxygenation or hyperoxemia therapy were excluded. We calculated the incidence of hyperoxemia (SpO2 > 98%), physicians’ response to hyperoxemia, and factors associated with hyperoxemia. Multivariable logistic regression (MLR) analysis was done to assess factors associated with hyperoxemia. Results: Among 400 recruited patients and 4631 observations, 211 patients and 1669 observations had hyperoxemia. In 398 observations, oxygen was decreased. Physicians were reluctant to decrease oxygen when hyperoxemia was observed at lower inspired oxygen (χ2 = 182.1, P value < 0.001). On MLR analysis, the duration of IMV, minute ventilation, and inspired and partial pressure of oxygen were statistically significantly associated with hyperoxemia. Conclusions: Hyperoxemia was observed in approximately one-third of observations noted in mechanically ventilated patients. Physicians were reluctant to decrease oxygen when hyperoxemia was encountered at lower inspired oxygen.

Abstract Background and Aims: Postoperative pain management in open live donor hepatectomy is vital. This study aimed to compare postoperative analgesia provided by intrathecal morphine (ITM) and epidural in open live donor hepatectomy. Material and Methods: Patients were divided into two groups. In the epidural (EPI) group, a bolus dose of 0.125% levobupivacaine (5–6 mL) with 3 mg of preservative-free morphine (diluted in 5 mL of 0.9% normal saline) was injected. In the postoperative period, infusion of levobupivacaine 0.125% at a rate of 5–8 mL/hour was continued for 3 days. In the intrathecal group (ITM), 0.3 mg morphine with 1.5 mL of 0.5% bupivacaine heavy was injected. General anesthesia was administered. Postoperatively, both groups received intravenous fentanyl patient-controlled analgesia. Numerical rating score (NRS) scores were recorded at 0, 2, 4, 12, 24, 36, 48, and 72 hours postoperatively. Data were analyzed using the Student t-test, Mann–Whitney U test, and Fisher’s exact test. P < 0.05 was considered significant. Results: A total of 60 patients were enrolled. The postoperative fentanyl consumption for the first 24 hours was significantly higher in the EPI group compared to the ITM group (162.5 mcg vs. 75 mcg, respectively; P = 0.023). NRS up to 12 hours in the postoperative period at rest, on movement, and for shoulder pain were significantly lower in the ITM group compared to the EPI group (P = 0.000). Conclusions: ITM significantly decreased fentanyl consumption in the first 24 hours when compared to the epidural group in patients undergoing open donor hepatectomy.

Abstract Difficult venous access is characterized by non-visible and non-palpable veins; a highly experienced operator is required with the use of technological aids to insert a vascular device. Patients with difficult venous cannulation undergo multiple, painful attempts to gain peripheral venous access. Compared to adults, inserting a central venous cannulation (CVC) is thought to be a more difficult procedure in children, particularly in neonates and young infants. IJV catheterization is perceived as the gold-standard route for CVC but remains difficult for newborn, premature, and critically ill children. Therefore, in recent years, novel ultrasound-guided brachiocephalic venous (BCV) cannulation in neonates has gained popularity. The aim of this narrative review was to assess the success rate. The primary objective of this review was to determine the first-attempt success rate. The secondary objectives were the total number of attempts, cannulation time, overall success rate, and complications. All articles relevant to BCV cannulation were searched in six major databases (PubMed, Embase, Medline, Ovid, PMC, and Google Scholar). A total of 16 records were included in this narrative review. According to Breschan et al., Merchaoui et al., and Vafek et al., the success rate of BCV cannulation in children was 89.1%, 98.4%, and 50%, respectively. Kumar et al., Erroz et al., and Breschan et al. found that the first-attempt success rate was higher in the in-plane left BCV (74%, 73% and 82.9% respectively). Falay et al. and Erroz et al. found a lower complication and infection with BCV cannulation. There is evidence that during CVC placement, US-guided BCV cannulation has a higher first-attempt success rate, requires less cannulation time, and has a lower complication rate in comparison to other approaches.

Abstract Background and Aims: Postoperative pain is a major cause of discomfort after laparoscopic surgeries and thus necessitates prevention and treatment. This study aims to evaluate and compare two different doses of intraperitoneally nebulized (aerosol size: 0.4–4.5 micrometers) dexamethasone for the prevention of postoperative pain. Material and Methods: In this double-blind, randomized control study, 135 patients undergoing laparoscopic surgeries were randomly assigned to three groups after obtaining ethical committee clearance and CTRI registration. Intraperitoneal nebulization was performed using the Aeroneb device, with group A receiving 16 mg dexamethasone, group B receiving 8 mg dexamethasone, and group C receiving 0.9% normal saline. The primary outcome was assessed by measuring visceral, somatic, and referred pain using a visual analog scale (VAS) at 6 hours postoperatively. Secondary outcomes included VAS at 1 and 24 hours, the hemodynamic response to pneumo-peritoneum, 24-hour anti-emetics, and opioid consumption. Results: VAS score at 6 hours was 0.9 ± 1.06 in group A, 1.7 ± 1.45 in group B, and 2.3 ± 1.87 in group C for referred pain; the values were statistically significant (P = 0.01). VAS score was 0.7 ± 0.76 in group A, 1.7 ± 1.82 in group B, and 2.2 ± 2.06 in group C for dull aching pain; the results were statistically significant at 24 hours (P = 0.001). None of the values at any time point were statistically significant (P < 0.05) for incisional pain. The rise in heart rate after 5 minutes of pneumoperitoneum was the least in group A compared to group C (P = 0.01). Group C had the highest consumption of anti-emetics and rescue analgesics (P = 0.001). Conclusions: Intraperitoneal dexamethasone nebulization of 16 mg and 8 mg both are equi-effective in decreasing the severity of pain after laparoscopic surgeries compared to normal saline nebulization (P = 0.001).