Trends in oxygen therapy in patients with moderate to severe COVID-19 admitted to the ICU

The most concerning complication of severe acute respiratory syndrome corona virus 2 (SARSCoV-2) pneumonia is acute hypoxemic failure. Though various antivirals, steroids, immunomodulators have been tried, oxygen therapy remains the mainstay of treatment. After obtaining institutional ethical clearance, a prospective observational study was conducted on 102 COVID-19 positive patients aged 20 years and above, admitted in the ICU with moderate to severe disease. COVID-19 infection was confirmed by polymerase chain reaction or rapid antigen test. Data of two demographically comparable groups i.e., patients on HFNO and NIV was analysed outcome was defined as discharge from ICU, shift to other non-invasive modes of oxygen therapy, endotracheal intubation or death, and comfort level for each mode. The data was analysed using SPSS-16.0, Chi-square test and “t” value test were applied.Comparison ofthe mean number of invasive ventilator free days of HFNO and NIV was insignificant(p>0.05). Among the patients on HFNO (high flow nasal oxygen) 49.09% were stepped down to NRB (non-rebreathing mask) whereas 7.27% went for intubation which is significant compared to NIV mask (non-invasive ventilation), where 13.64% were stepped down to HFNO and 34.09% were intubated (p=0.000).Oxygen therapy with HFNO is associated with better outcome and less mortality when compared with NIV.

Excision of intra-dural dorsal spine meningioma with intra-operative neuromonitoring in a patient with post-pneumonectomy status- an anaesthetic challenge

Post-pneumonectomy status is associated with various anatomical and physiological changes. Intra-operative neuromonitoring allows for safe neurosurgery with minimal neurological damage. Intra-operative neuromonitoring requires that the anaesthetic technique be modified taking into considerations the effects of various anaesthetic agents on evoked potentials to allow for optimal monitoring. We present a case of 65 year old female patient, with post-pneumonectomy status posted for excision of intra-dural D10 meningioma with intra-operative neuromonitoring. The case was successfully conducted with meticulous planning and preparation with complete excision of lesion and no neurological deficit post-operatively.

Combined popliteal and saphenous nerve block vs NSAIDS for post operative analgesia in below knee surgery patients: A cross-sectional study

Peripheral nerve blocks are becoming increasingly popular to control postoperative pain in orthopaedic limb surgeries. An outstanding feature of nerve block is its lack of adverse effects, reduced requirement of analgesics and better patient satisfaction. To compare the efficacy of combined popliteal and saphenous nerve block with NSAIDS for postoperative pain relief in below knee surgery patients. We performed a prospective randomized study involving seventy patients. All patients underwent an elective orthopaedic procedure below knee under spinal anaesthesia. Thirty five patients had received a combined popliteal and saphenous nerve block and the rest thirty-five received intravenous NSAIDS at the end of surgical procedure. Post operative VAS Score, time for first rescue analgesia, total diclofenac requirement, total anti-emetic requirement and complications if any were noted.: The statistical power of sample was 80% and type I error (α) of 0.05. The distribution of the data was evaluated using the Shapiro-Wilk test. For data with a non-normal distribution, the Mann-Whitney U test was used in intergroup comparisons. The data were expressed as the median, minimum and maximum (min-max). For comparison of postoperative analgesic use, the chi-square test was used, and complication rates were compared using a cross-ratio test. P-values less than 0.05 were considered to be statistically significant in all the analyses.: Patients with a combined popliteal and saphenous nerve block had significantly less pain at six hours, twelve hours and twenty four hours (p value <0.001) postoperatively. Time for request of rescue analgesia was prolonged. Total diclofenac and anti emetic requirement was also reduced. Also higher level of satisfaction was achieved among this group of patients. : A combined popliteal and saphenous nerve block provides significantly better postoperative pain relief than NSAIDS in patients who underwent below knee surgeries.

A case report of anaesthesia for craniotomy in sitting position

Tumors in the posterior fossa can be done in lateral, supine, prone, sitting and in park bench positions. Depending on the exact position of the lesion and the technical preference of the surgeon, sitting position may be preferred. Sitting position grants best possible access to deeper structures with minimal retraction. However, maintenance of anaesthesia in this position for long duration pose some serious challenges to the anaesthesiologist including high risk of venous air embolism (VAE), hemodynamic instability and respiratory disturbances. Here, we present a case report of a 36year old male diagnosed with pineal gland space occupying lesion (SOL), operated in the sitting position under general anaesthesia. We discuss about anaesthetic management and possible complications that can be encountered.

Anaesthetic management of a case of pulmonary thromboembolism with pulmonary artery hypertension posted for bipolar hemiarthroplasty

Lower limb long bone fractures are vulnerable for venous thromboembolism leading to pulmonary thromboembolism. Here, we present a case of preexisting pulmonary thromboembolism with pulmonary artery hypertension posted for bipolar hemiarthroplasty.In hemodynamically stable patients it is better to operate the underlying fracture early to avoid recurrence and worsening of pulmonary thromboembolism. This case was successfully managed under general anesthesia.

To observe the changes of optic nerve sheath diameter following the use of total intravenous anaesthesia with propofol or inhalational anaesthesia with desflurane during laparoscopic surgeries

Optic nerve sheath diameter measurement is a simple, non-invasive and yet accurate intracranial pressure (ICP) assessment technique during laparoscopic surgery. The pneumoperitoneum induced by insufflating carbon-dioxide and steep angle of trendelenburg position is associated with physiological changes resulting in increased ICP during laparoscopic surgery. We aimed to observe the changes of ONSD (surrogate marker of ICP) following the use of total intravenous anaesthesia in comparison to desflurane during laparoscopic surgery.Patients scheduled for elective laparoscopic surgery were randomly assigned to the TIVA or DES group in this randomized study. Ultrasonographic measurements of ONSD were conducted before administration of anaesthesia (T0), 10 mins, 30 mins, 1 hr after the trendelenburg position (T1,T2,T3), 5mins after resuming the supine position (T4) and at post-anaesthetic care unit (T5). The primary outcome measure was the comparison of the mean ONSD of both the eyes of the patients of both the groups that is TIVA versus DES (inhalational anaesthetic) group.A total of 60 patients were analysed in our study. The mean ONSD value at T1, T2, T3 and T4 (for right eye p=0.002,0.001,<0.01,0.03 respectively and for left eye p=0.004,<0.01,<0.01,0.02 respectively) were significantly lower for patients in TIVA group as compared with those in DES group.Our result suggests that TIVA may be a better option than inhalational anaesthesia to prevent rise in intracranial pressure in patients undergoing laparoscopic surgery and preventing devastating complications caused by raised intracranial pressure in succeptible patients.

Anaesthesia management of a case of huge neck mass due to cervical spine chondrosarcoma with distorted anatomy

Chondrosarcoma is the tumor which affects bone and soft tissue with only 2% spinal involvement. Anesthetic management becomes challenging in patients with cervical chondrosarcoma. Here, we are presenting a case of huge neck mass due to cervical spine chondrosarcoma in 70 year old male hypertensive patient. The patient has distorted anatomy with mucosal edema with left tracheal deviation and compression from right side. Awake Nasal Fiberoptic intubation was done with cuffed ETT no 8. The neck mass was removed and Anterior Cervical Discectomy and Fusion (ACDF) with bone grafting. The case was managed with adequate analgesia, replacement of fluids and Blood and Blood products. Considering complex cervical spine surgery and airway edema the patient was shifted to Surgical Intensive Care Unit (ICU) for elective ventilation and advanced monitoring. After serial ABG and proper weaning the patient was extubated next morning smoothly. Extensive preoperative evaluation, planning, clinical judgement and skilled experienced personale are essential for proper execution of difficult airway cases.

Anaesthesia management of a difficult airway patient with severe aortic stenosis for major oncosurgery

Over the past few decades, oncosurgical procedures are increasing in number, require considerable expertise and training for anaesthetising such patients. Aortic Stenosis itself poses great challenge, causes significant increase in morbidity and mortality in the perioperative period. Head, neck oncosurgical procedures with difficult airway requiring awake fiberoptic intubation in such patients adds to the challenge.We describe once such case of previously operated Carcinoma of oral cavity with new growth involving mandible for excision of tumour with neck dissection and mandibular reconstruction with a free Fibula flap. This patient now presented with anticipated difficult airway with restricted mouth opening and a recent diagnosis of severe Aortic stenosis with mean gradient across aortic valve of 52mmHg and valve area 0.8 cm2.Such patient requires multidisciplinary team approach by cardiologist, anaesthesiologist, surgeon and intensivist to prevent perioperative morbidity and facilitate early recovery.