Context:Opioids are being increasingly used these days as adjuvants to local anesthetics in spinal anesthesia.Aim:The aim of this study is to compare the effects of adding sufentanil or fentanyl to low dose bupivacaine in spinal anesthesia for endoscopic urological procedures.Settings and Design:Prospective, randomized, double-blind study.Materials and Methods:A total of 90 elective endoscopic urological surgery patients, 40-80 years old, received spinal anesthesia with 7.5 mg hyperbaric bupivacaine 0.5% (Group A) or by adding sufentanil 10 g (Group B) or fentanyl 25 g (Group C) to 5 mg hyperbaric bupivacaine 0.5%. These groups were compared in terms of the quality of spinal anesthesia as well as analgesia.Results:The onset of sensory and motor blockade was significantly rapid in Group A as compared with Groups B and C. The maximum upper level of sensory block was higher in Group A patients than Groups B and C patients. Quality of analgesia was significantly better and prolonged in sufentanil group as compared with other two groups. Motor block was more intense and prolonged in Group A as compared with Groups B and C patients. Request for post-operative analgesic was significantly delayed in Group B patients.Conclusions:Spinal anesthesia for endoscopic urological procedures in elderly patients using low dose bupivacaine (5 mg) combined with 10 μg sufentanil is associated with a lower incidence of hemodynamic instability, better quality and prolonged duration as compared to that by adding 25 μg fentanyl.

We present a case of severe autonomic dysreflexia (AD) progressing to cardiac arrest and death under isoflurane anesthesia. Though AD in chronic cervical spine injury is a common entity, occurrence of such an event in the stage of flaccid paralysis in lower dorsal spinal cord injury is rare, especially under general anesthesia. Manipulation of urinary bladder catheter under light plane of isoflurane anesthesia might be the precipitating factor. Increasing concentration of isoflurane failed to abort the episode or might have aggravated it. High level of suspicion and vigilance is necessary to prevent, diagnose and treat such a condition.

A bstract Introduction Snakebites are one of the commonest occupational hazards in tropical countries and viperine bites are potential to cause systemic toxicity. Coagulopathies and acute kidney injury (AKI) have been documented and easily dealt with in past, but pulmonary hemorrhage has been rarely seen and plasmapheresis has shown promising result for the same. This case reports highlight the effective use of plasmapheresis for pulmonary hemorrhage post-snakebite. Background Viperine snakebite has been associated with high morbidity and mortality due to its toxic systemic envenomization. The important systemic manifestations are coagulopathy, neuromuscular paralysis, AKI, myotoxicity, and cardiovascular collapse. Antivenomization, renal replacement therapy, steroids, and other supportive care are considered to be the mainstay of treatment till date. Pulmonary hemorrhage has been an unusual manifestation of viper bite and rarely reported and steroids have been used in such scenario but with mixed results. Role of plasmapheresis has been documented in the management of snakebite but especially for hematological problems and in limb preservation/salvage strategies. The use of same, for pulmonary hemorrhage has not been studied yet. Here, we present a rare case of pulmonary hemorrhage along with renal failure following viper bite which was successfully treated with plasmapheresis. To the best of our knowledge, it is a rare presentation and has not been reported in the literature reviewed till date. Case description A previously healthy, 36-year-old man presented to our hospital 48 hours after a viper bite. He developed local as well systemic manifestations evident as hemolysis and renal failure. Gradually, he started having hemoptysis followed by respiratory failure requiring ventilatory support. CT chest done was s/o bilateral pulmonary hemorrhages correlating clinically with ongoing tracheal bleed. He had no other bleeding manifestations and had normal coagulation profile. He was initially treated with methylprednisolone therapy, but then did not show any improvement and finally plasmapheresis was done as rescue therapy. Following this, he had improvement in respiratory parameters and settling tracheal bleed with resolution of radiological changes. He was successfully weaned off from the ventilation and also his renal failure also improved with near normalization of pulmonary and renal functions. Conclusion This case highlights the unusual presentation of pulmonary hemorrhage in a patient with viperine bite with normal coagulation and was aggressively managed with plasmapheresis. Hence, plasmapheresis can be used as life-saving modality in patients with systemic envenomization post-viperine bit. How to cite this article Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with R...

How to cite this article: Sampley S, Bhasin D, Singh H, Mishra S. Cerebral Aspergillosis Complicating COVID Recovery. Indian J Crit Care Med 2022;26(4):535–536.

Background Mortality and morbidity are highest in severe and critically ill patients with COVID -19 pneumonia. Recently corticosteroids have shown a definite mortality benefit in these patients. In this study we used interleukin -6 inhibitor, tocilizumab in patients who failed to show any clinical improvement after initial treatment with steroids. Patients and methods This is a retrospective observational study conducted at a tertiary care referral hospital in India. Severe and critical COVID 19 patients , who got admitted to intensive care unit and subsequently received tocilizumab were included . Patients who worsened clinically or had no change in oxygen requirement even after 24hrs of receiving Intravenous methylprednisolone at a dose of 1-2mg/kg/day received a maximum total dose of 800mg of intravenous tocilizumab. The day 28 all cause mortality and progression to mechanical ventilation were the primary outcome measures. Clinical improvement and oxygen requirements after tocilizumab administration along with trends in inflammatory markers were secondary outcome.Secondary infections rates and other drug related side effects were also noted. Results A total of 51 patients who did not show clinical improvement even after 24 hours of intravenous steroids and received tocilizumab were included. In these patients, there was a significant decrease in oxygen requirement by day 3 and clinical improvement by day 7 of tocilizumab administration. Among the inflammatory markers, we observed elevated median baseline values of CRP (114.2 mg/L) , IL-6 (55.4 pg/ml) and Neutrophil to Lymphocyte Ratio (12.4). Out of these only CRP showed a significant decrease after the drug administration. 13 (26.5%) of the 49 patients who were on non-invasive or conventional oxygen support progressed to mechanical ventilation. The day 28 all-cause mortality rate was 10/51(19.6%). 10(19.6%) of the 51 patients had life threatening infections, 5/51 had thrombocytopenia, 3/51 had pneumo-mediastenum/pneumothorax, 1 patient had colonic perforation and 1 patient had transaminitis following tocilizumab administration. Conclusion Early and timely administration of tocilizumab only in selected severe and critical covid patients not responding to initial steroids appears to increase the survival. This needs to be further confirmed by randomised controlled trials. When given along with steroids, incidence of life threatening infections seems to increase, hence a high suspicion of secondary infection should be kept.