A bstract Background Tracheostomy is integral in long-term intensive care of coronavirus disease-2019 (COVID-19) patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. Materials and methods We conducted a retrospective, single-center, observational study of severe COVID-19 patients who underwent elective tracheostomy ( n = 65) during critical care in a tertiary care institute in Central India from May 1, 2020, to April 30, 2021. Data were collected from Medical records, ICU charts, and follow-up visits by patient. A primary objective was to study the clinical characteristics, tracheostomy complications, weaning outcomes, and mortality at 28 and 60 days of ICU admission. We categorized the cohort into two groups (deceased and survivor) and studied association of clinical parameters with 28-day mortality. Cox Proportional regression analysis was applied to calculate the hazard ratio among the predictors of mortality with p value <0.05 as significant. Results Elective tracheostomy was done in 69 of 436 (15.8%) patients on invasive mechanical ventilation, of which 65 were included. Tracheostomy was percutaneous in 45/65 (69%) and surgical in 20/65 (31%) with timing from intubation as early in 41/65 and late in 24/65 with most common indication as weaning failure followed by anticipated prolonged ventilation. Tracheostomy complications were present in 29/65 (45%) patients with no difference in complication rates between timing and type of tracheostomy. Downsizing, decannulation, and weaning were successful in 22%, 32 (49%), and 35/65 (54%) patients after tracheostomy. The 28-day mortality was 30/65 (46%). The fractional inspired oxygen concentration (FiO 2 ) requirement in survivors was lower (0.4–0.6, p = 0.015) with a higher PaO 2 /FiO 2 ratio (118–200, p = 0.033). Early tracheostomy within 7 days of intubation was not associated with weaning or survival benefit. Conclusions We suggest that tracheostomy should be delayed to after 7 days of intubation, especially till FiO 2 reduces to 0.5 with improvement in PaO 2 /FiO 2 for better outcomes and avoiding a wasted procedure (CTRI/2021/07/034768). Study Highlights Tracheostomy is integral in care of COVID-19 patients needing prolonged ventilation. There is no difference in complications in early/late or percutaneous dilatational/surgical technique. We observed successful weaning post-tracheostomy in 54% patients. Mortality at 28 days was 46%. Early tracheostomy within 7 days of intubation did not improve weaning or survival. How to cite this article Karn...

Laryngoceles are rare dilated laryngeal saccules that can present as acute airway obstruction and lead to airway emergencies. A man, presented to the emergency room, with difficulty in breathing and change in voice. An unevaluated pulsatile swelling was present on the left side of neck. Since, the patient was in stridor, an awake fiberoptic bronchoscopy (FOB)-guided intubation was planned with readiness for emergency tracheostomy, if needed. On FOB, an edematous supraglottic area with a narrowed glottic opening was observed. The procedure was abandoned and a surgical tracheostomy was performed to secure the airway. Postoperative contrast-enhanced CT neck revealed a huge laryngocele in left cervical region. We recommend that a high index of suspicion for presence of laryngocele should be kept in mind when a patient presents with stridor with pulsatile neck swelling. Timely aspiration of laryngocele may help in amelioration of the respiratory distress avoiding emergency tracheostomy.

Objectives: The objectives of this study were to compare the quality of sedation provided by intravenous (i.v.) and intramuscular (im) ketamine for pediatric magnetic resonance imaging (MRI). Materials and Methods: This study was a non-randomized, single-blinded, and prospective observational study. After receiving approval from the Institutional Ethics Committee, a total of 108 children aged 2–7 years were divided into two groups, with 54 children in each group. In the i.v. group, children received ketamine at a dose of 1.5 mg/kg intravenously, while in the im group, children received ketamine at a dose of 4 mg/kg intramuscularly. If a Ramsay sedation score of 6 (RSS-6) was not achieved, half of the loading dose of ketamine was repeated. In both groups, rescue propofol boluses of 1 mg/kg intravenously were administered whenever the child moved. The primary outcome measure was the quality of sedation, which was assessed by a blinded radiologist. The time taken to reach RSS-6, the number of rescue propofol boluses, the total time wasted in taking repeat sequences, and the time required to achieve a modified Aldrete score of 9 (MAS-9) were recorded. Results: The im group demonstrated significantly better sedation quality. In the i.v. group, the time to achieve RSS-6 was significantly shorter, but it required more rescue propofol boluses to maintain sedation. The i.v. group also experienced a notable increase in the total time wasted during repeat sequences. On the other hand, the i.v. group exhibited a shorter time to reach MAS-9 compared to the im group. Conclusion: The im group showed superior sedation quality when compared to the i.v. group. However, it is important to consider that the im group experienced a longer recovery time.

Background Perioperative aspiration of gastric contents is a serious complication and its severity depends upon the gastric volume and nature of the aspirate. Diabetic patients are more prone for aspiration because of delayed gastric emptying. USG-guided gastric examination can help in aspiration risk assessment by identifying the nature and volume of the gastric contents. This prospective observational study compared, USG-guided gastric contents and volume in fasting diabetic and non-diabetic patients posted for elective surgery under general anesthesia. Based on the history of diabetes mellitus (DM), 50 patients were divided into two groups, i.e., group A (diabetic for > 5 years, n = 25) and group B (non-diabetic, n = 25). After standard fasting period of 8 h, bedside ultrasound was conducted to assess gastric antral cross-sectional area, gastric volume and contents. Results The mean gastric antral cross-sectional area (3.96 ± 2.07 versus 2.96 ± 1.88, P value 0.08), mean gastric volume (17.88 ± 19.48 versus 9.72 ± 12.29, P value 0.083) and the mean gastric volume per kg body weight (0.16 ± 0.374 versus 0.04 ± 0.20, P value 0.164) after 8 h fasting were higher in diabetics as compared to non-diabetics, but were statistically insignificant. Conclusions Diabetic patients had comparatively slower gastric emptying and hence higher mean effecting gastric volume and gastric volume/kg body weight, after fixed hours of fasting. However, no patient had gastric volume/kg body weight > 1.5 ml/kg or presence of any solid food was visualized in any of the groups. Hence, the fixed 8 h fasting guarantees the safety from the risk of aspiration in diabetic and non-diabetic adult population.

BACKGROUND Sub-arachnoid block (SAB) is often associated with hypotension due to changes in intravascular volume, tone of vessels and cardiac output. Sympatholytic effect of SAB causes hypotension which is exaggerated in elderly, hypovolemic and cardiac patients, thus increasing the incidence of myocardial ischemia. Perfusion index (PI), derived from pulse oximeter, is a relatively newer and non-invasive parameter to measure the vascular tone (1,2). Changes in baseline peripheral vascular tone may affect the degree of hypotension, and patients with low baseline vascular tone may be at an increased risk of hypotension (3-6). This study was conducted to investigate correlation between baseline PI and incidence of hypotension following SAB in patients undergoing lower-limb orthopedic surgeries and to determine a new baseline cut-off to assess the chances of developing hypotension. OBJECTIVE To investigate the correlation between baseline PI and incidence of hypotension following SAB, in patients undergoing lower-limb orthopedic surgeries. METHODS This single center, prospective, observational study was conducted between June 2018 and February 2020, at a tertiary care center, after obtaining Institutional Ethics Committee clearance. Adult patients (18-60 years) undergoing lower-limb orthopedic surgery under SAB and belonging to American Society of Anesthesiologists (ASA) grade I and II were included. Patient not willing for surgery under regional anesthesia (RA) or having contraindications to RA due to allergy to local anesthetics (LA), procedure site infection, any coagulation disorder, ASA grade III-IV, mental health issues were excluded. After detailed pre-anesthetic check-up, a written informed consent was taken. Standard fasting guidelines were followed. All the patients were given tablet lorazepam 2 mg in the night and morning before surgery. After wheeling the patient into the theatre, intravenous access was taken, standard monitors were attached. Each patient was pre-hydrated with 500 mL of Ringer Lactate before SAB followed by maintenance fluid. A total of 75 patients were enrolled in the study initially and 15 were excluded because of exclusion criteria. Remaining 60 patients were assessed for baseline PI and were divided into two groups. The PI was measured in the supine position using specific pulse oximeter probe attached to the left index finger of all patients to ensure uniformity in measured PI values. Patients with baseline PI ≤ 3.5 fell into group A and those with PI > 3.5 fell into group B. SAB was performed by an anesthesiologist blinded to the baseline PI values, using 25-gauge Quincke's spinal needle in sitting position with 15 mg of injection 0.5% bupivacaine (hyperbaric) at L3–L4 interspace. The level of sensory blockage was checked using a cold swab. Maximum cephalad spread was checked 20min after SAB. Non-invasive blood pressure (NIBP), heart rate (HR), Saturation (SpO2) and PI were recorded at 2 min intervals up to 20 minutes after SAB, followed by every 5 minutes interval for rest 40 minutes. Hypotension was defined as a decrease in Mean Arterial Pressure (MAP) of 20% from baseline and was treated with intra-venous bolus of injection Mephentermine 6 mg and 100 ml of Ringer lactate. Hypotension within first 60 min following SAB was considered for anesthesia-induced hypotension. Bradycardia (HR <55 beats/minutes), if any, was treated with injection atropine 0.6 mg. Statistical analysis was done by using Statistical Package for Social Sciences version 21.0 (IBM Corporation, Armonk, New York, USA). Data was entered in Microsoft excel 2016 for Windows. Statistical analysis was performed using unpaired t-test for comparison between the groups and Pearson’s chi-square test was applied to compare categorical variables (frequency and percentages). Receiver operating characteristic (ROC) curve was plotted for baseline PI and occurrence of hypotension. A P-value <0.05 was considered statistically significant. RESULTS A total of 75 patients were enrolled in the study initially. 15 patients were excluded as they were not following inclusion criteria, 3 patients were excluded due to inadequate level of spinal blockade. A total of 28 patients felt in Group A and 29 patients in Group B, for final analysis (figure 1). Systolic blood pressure (SBP), diastolic blood pressure (DBP) and MAP were significantly higher in group A as compared to group B for the first 25 minutes after SAB (figure 2, 3). Overall, incidence of post-SAB hypotension was 68.97% in group B and 10.71 % in group A (figure 4). Intra-operatively, heart rate was comparable between the two groups. The ROC analysis revealed that baseline PI was suitable for detecting risk for hypotension (AUC = 0.854, P < 0.001) (figure 5) (Table 2). The baseline PI cut-off point that predicted hypotension as determined by the ROC analysis was 3.1 with a sensitivity of 100% (95% CI= 85.20% - 100.00%), a specificity of 73.53% (95% CI = 55.60–87.10%), a positive predictive value of 71.88% (95% CI= 59.34% - 81.74%), and a negative predictive value of 100.00% (95% CI = NA) (figure 5). CONCLUSIONS In patients undergoing lower limb orthopedic surgeries, Perfusion index (PI) can be used as a tool for predicting hypotension following SAB. Baseline PI >3.5 is associated with higher incidence of developing hypotension than PI <3.5.