Anaesthesia, Pain & Intensive Care

Lisa Stearns, MD, Founder & Medical Director at Center for Pain and Supportive Care, Phoenix, USA, breathed her last on 31 May 2020 at her home in Mexico.As a physician, she was a valiant warrior. Her pursuit of novel methods, innovation, and creative approaches contributed widely to the practice of pain medicine globally. Courageous, stubbornly committed, and always compassionate, she was one of the heroes in the epidemic of pain and suffering.

The incidence of transfusion has increased day by day due to many factors, including increasing population, enhanced expertise and facilities to operate once inoperable conditions and the willingness of the public to pay high cost of advanced surgical procedures. Trauma services have been well-organized now and victims may have massive transfusion. Many authors have pointed out the need of protocols and guidelines to be followed to avoid transfusion associated risks and complications. Under-transfusion has been preferred to over-transfusion and a need to have a ‘Maximum Surgical Blood Order Schedule’ has been stressed. Citation: Khan TH. Transfusion, under-transfusion and over-transfusion. Anaesth Pain & Intensive Care 2013;17(1):1-3

The number of cancer patients has been steadily increasing and with it the number of cancer related pain patients is also increasing. Cancer pain (CP) is the most unique and versatile pain, regarding type, intensity, site, variations and the needed management modalities. No one pain specialist or the pain center can be capable of adequately manage every cancer patient. In this background, an idea to confront this menace at a national level with a combined effort is presented. If implemented it is hoped that the CP patients will get rid of at least the worry about their excruciating pain. The idea of the 'Cancer Pain Initiative' has been in circulation for quite some time, but needs to be discussed at various levels.

We encountered a case of malignant hyperthermia in a 52 year old male undergoing open reduction/internal fixationof humerus fracture under general anesthesia. Isoflurane has been reported as a potent triggering agent of malignanthyperthermia. Dantrolene remains the gold standard for treating this life threatening syndrome but it is not availablein many countries including Pakistan. However, we successfully managed our patient by timely recognition of thissyndrome and administering prompt and effective symptomatic treatment.

Rheo Probe is a minimally invasive device, implanted in the brain matter for patients in a coma following brain haemorrage or traumatic brain injuries to measure cerebral blood flow, intracranial pressure, temperature and oxygenation parameters. Nearinfrared sensors assess levels of tissue oxygenation as well as cerebral blood flow by measuring oxygenated and deoxygenated hemoglobin based on spectrometry.

Following the publication of the article entitled, ‘Lignocaine’s substantial role in COVID-19 management: potential remedial and therapeutic implications’, authored by Nasser Ali Malik, Amjid Hammodi and Dayanidhi Jaiswara, published in the Anaesthesia, Pain and Intensive Care; 21(1);59-63, 2020, I would like to suggest a revolutionary idea that could help control the spread of respiratory viruses from person to person, achieve potential prophylaxis against them and even could be used as a treatment for mild to moderately infected cases.

Following the publication of the article entitled, ‘Lignocaine’s substantial role in COVID-19 management: potential remedial and therapeutic implications’, authored by Nasser Ali Malik, Amjid Hammodi and Dayanidhi Jaiswara, published in the Anaesthesia, Pain and Intensive Care; 21(1);59-63, 2020, I would like to suggest a revolutionary idea that could help control the spread of respiratory viruses from person to person, achieve potential prophylaxis against them and even could be used as a treatment for mild to moderately infected cases.

Background: It has been observed that some candidates do very well in postgraduate examinations and get through in the very first attempt, whereas the others may not do very well and have to go for multiple attempts to get through the same examination. This study aimed to determine the factors affecting the performance and the success rate in the first attempt in the Master of Medicine (Anesthesiology) Part-1 examination. Methodology: This was a cross-sectional study involving 73 postgraduate candidates who passed the Master of Medicine (Anesthesiology) Part-1 examination between 2016 and 2017. The candidates were required to respond to various questions about various factors assumed to be affecting their performance, including sociodemographic factors, pre-training, and in-training factors. Statistical analysis of the received responses was done and linked to the performance in the Part-1 examination. Results: The candidates with more than 5 y of medical service had 85% lower odds than those with 5 or fewer years (adjusted OR 0.15; 95% CI 0.03-0.81; p = 0.027). Those who passed the entrance examination after 2 or more attempts also had 80% lower odds than those who passed at the first attempt (adjusted OR 0.20; 95% CI 0.06-0.70; p = 0.011). The odds of the candidates who often had small-group discussions during their study leave were 16.21 times higher to pass than those who seldom had any discussion (adjusted OR 16.21; 95% CI 1.81-145.41; p = 0.013). Conclusions: The success in the Master of Medicine (Anesthesiology) Part-1 examination in first attempt was determined by a shorter duration of medical service, single attempt at the entrance examination, and regular smallgroup discussions.

Cancer is a global health issue. Approximately 40% of the world population faces cancer at some point of their lives. Even though various cancer treatment modalities, such as chemotherapy, radiotherapy or surgery, have been improved during the recent past, they still can cause many undesirable side effects. In order to administer a good and safe anesthesia in these patients, the acute and chronic side effects of the cancer treatment must be well understood by the anesthesiologist. Regional anesthesia has been thought to have a positive effect on the postoperative healing by decreasing the stress response to surgery. Some studies even show beneficial effects of regional anesthesia in oncological cases. We present a report of spinal anesthesia in a patient with high-grade Bcell lymphoma, scheduled for amputation of necrotic toes of feet.

New Resuscitation guidelines have been published this year by Resuscitation Council UK (RCUK). Its the commentary and comparison of changes to the previous guidelines of BLS, ALS, PLS and PALS The new topics are also added in new guidelines and details are in full text

Background & objective: Despite available data from developed countries, suggesting a high incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19), there is scarce data from African countries, including Nigeria. We conducted this study to determine and document the incidence, the associated factors and the outcome (in-hospital mortality) of AKI among COVID-19 patients managed in a center in Nigeria. Methodology: It was a retrospective review of confirmed COVID-19 cases managed at a center in Nigeria. AKI was defined using 2012 Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. We extracted relevant data from the electronic records of the COVID-19 patients admitted to our hospital and analyzed. Fischer's exact tests were used to test factors associated with AKI for discrete variables, Mann-Whitney U test was used for skewed continuous data, and T-test for continuous normal distribution variables. Results: This study involved 41 of the 56 confirmed COVID-19 cases. The mean age was 45 ± 17.94 y. A majority of the patients were males (33; 80.5%). AKI occurred in 6 (14.6%) of the patients. Of the 6 AKI; 4 (66.7%) and 2 (33.3%) were in stages 1 and 3 respectively. One patient (16.7%) had had hemodialysis. Of the 6 with AKI, 3 died with a mortality rate of 50.0%. Factors associated with AKI included age above 45 years, body weakness, severe and critical COVID, urea > 10 mmol/l, and serum creatinine > 1.5 mg/dl. Only severe and critical disease was predictive of AKI (adjusted odds ratio 1.777, 95% CI 1.028, 3.074). Conclusion: The results of our study show that AKI is common in severe and critical COVID-19 and is associated with a poor outcome.

Guillain-Barre syndrome (GBS) is one of the leading causes of non-trauma induced paralysis in the world. We present the anesthetic management of a 43-year-old breast cancer female patient who recently suffered from GBS. The patient had complete motor loss with power of 3/5 in all four limbs and she fully recovered after successful treatment with intravenous immunoglobulin. Keeping in view the nature of surgery and her clinical condition, her breast surgery was planned with para-vertebral block and sedation with target controlled infusion (TCI) plus entropy monitoring. The literature search for the anesthetic management for such type of cases revealed no common agreement regarding management, which prompted us to report this case.

is a name that stands out amongst others as the most significant anesthesiologist and intensivist of the country. He was the first to commission an intensive care unit (ICU), at Nishtar Hospital Multan (Pakistan) in 1981. It was first such unit in the country He was the founder president of Pakistan Society of Intensive Care. He innovated the technique of combined spinal epidural (CSE-SST), also called Epispinal, in 1982. This technique has been used all over the world now. Dr. Mehdi is one of the finest teachers in anesthesiology today. He trained a lot many anesthesiologists who are holding key positions in anesthesiology departments in the country as well as abroad, and continuing his hard work.

Anesthetic management of patients with mitochondrial disorders is challenging due to their rare nature, and difficulties to develop evidence-based protocols for general anesthesia. We report a case of a 52-year-old male with hypertension, congenital deafness, optic neuritis, hypogonadism and myotonia, who developed severe refractory hypotension and bradycardia, and intractable severe lactic acidosis during induction of general anesthesia with fentanyl, propofol, and succinylcholine. The surgery had to be postponed and supportive management started. After extensive work-up, the patient was diagnosed with probable mitochondrial dysfunction. Patient returned for surgery under a different anesthetic regimen consisting of ketamine, fentanyl, ephedrine and dexmedetomidine; yielding a successful perioperative course and highlighting potential alternative strategies to manage anesthesia in patients with such disorders.

Introduction: Evaluating the success rate of regional anesthesia is performed with pinprick test, Bromage score and pain scales, where they act as indicators of success or otherwise of motor, sensory and nociceptive blockade. The sympathetic system is also affected by the regional anesthesia blockade. The present study evaluated the relationship of peripheral venous dilatation and the skin temperature of the block area, to be used as an additional tool. Methodology: An analytic, observational study was conducted in Dr. Soetomo Surabaya Hospital. 18 patients received peripheral nerve block (PNB) and 16 patients received subarachnoid block (SAB). Informed consent was obtained from all the participants. The peripheral venous circumference was measured by using linear probe of Sonosite® M-Turbo ultrasound, before the blocks and then one hour after PNB and SAB to assess the venous dilatation. The peripheral skin temperature was measured with a thermometer (Microlife NC-150 Bluetooth®) infrared thermometer before the blocks, and within the range of 5 min from the zero min after the block until the 30th min. The success rate of the blocks was performed with pain scale (VAS) and absence of motor, sensory and nociceptive response Results: No relationship was found of sex, age, weight and type of block with increased peripheral venous circumference and peripheral skin temperature (p > 0.05). The block's success was associated with the increased peripheral venous circumference and peripheral skin temperature (p ≤ 0.001) in both PNB and SAB blocks. The average PNB block succeeded in 20 min while SAB took only 5 min (p < 0.05) to affect both of the parameters. The delta value of the increased temperature's successful block was 0.7 o C in the PNB, and 0.275 o C in the SAB group. Conclusions: The success of the peripheral nerve block and the subarachnoid block is associated with an increase in the peripheral venous circumference and in the peripheral skin temperature in the block area.

Background & objective: Appropriate decisions regarding admission of potential patients to intensive care unit (ICU) postoperatively are considered very important for the patient care. We evaluated the reasons and the risk factors for postoperative ICU admissions in our hospital. Methodology: This is a case-control study, that was done at Security Forces Hospital, Riyadh, during the period from July 2019 to December 2019. We included all patients who needed ICU admission postoperatively in the study as cases. The controls were the patients who had any surgical procedure during the same study period. Patients' demographics, ASA status, medical co-morbidities and operation details were recorded. We then did univariate and multivariate logistic regression to analyze the data. A p-value of less than 0.05 was considered as significant. Results: We enrolled a total of 140 patients in the study, with 46 cases and 94 controls. In univariate analysis, age, ASA status, presence of hypertension, diabetes, ischemic heart disease, respiratory disease, renal dysfunction and neurological abnormalities were found to be statistically significant predictors for postoperative ICU admission. In multivariate analysis, ASA status and perioperative neurological abnormalities were the most significant risk factors for ICU admission. Conclusion: ASA status and presence of neurological abnormalities are the most significant risk factors associated with ICU admission in the postoperative period.

Pain is a universal human experience. By virtue of its complex and variable nature, it is perceived differently by different individuals, over time, and among the different populations. To understanding pediatric pain requires considerable judgment, integration of different sources of information, such as self-report and nonverbal expression.

Background & Objective: The spinal anesthesia in cesarean sections is still marred by post dural puncture headache (PDPH) and low backache. Both complaints sometimes becomes very troublesome for the patient and the anesthesiologists. This study evaluated the incidence of PPDH with modified paraspinous paramedian and median traditional approaches for spinal anesthesia during cesarean sections. Methodology: For this randomized, controlled double-blind study, 60 primigravida parturients undergoing cesarean section under spinal anesthesia were randomized into 2 groups (30 each). Group 1 received spinal anesthesia with the classic median approach and Group 2 received spinal anesthesia with the modified paraspinous paramedian approach. All the patients were followed up to 7 days postoperatively. The incidence of PDPH and low backache was observed in each group. Results: The present study showed a statistically significant lower incidence and lower severity of PDPH in Group 2 in which a modified paraspinous paramedian approach was used, compared to Group 1 (p < .05) in which median classic approach was used. The difference in the incidence of back pain was non-significant. Conclusion: Spinal anesthesia with the modified paraspinous/ paramedian approach for cesarean section is associated with a lower incidence of PDPH when compared to the standard median approach.

Background: Lumbosacral radicular pain is one of the most common clinical features which accounts for more than 10% of the hospital visits annually. Multiple treatment strategies have been in use to manage it. This study aimed to assess the efficacy of pulsed radiofrequency (PRF) in treating pain and physical disturbances in chronic lumbosacral radicular pain. Methodology: Forty patients, suffering from lumbosacral neuropathic pain were treated by PRF at the corresponding level (ranging from L3 to S1). Outcome measures included the pain intensity score on a 0-10 numeric rating scale (NRS) at pretreatment, after two months and six months post-treatment. Results: A significant reduction in pain scores was observed in mean NRS at two and six month duration (p < 0.001). The NRS after treatment with PRF was significantly reduced compared to that before PRF treatment (3.28 vs. 8.38 and 4.25 vs. 8.38 respectively) after two and six months. Conclusion: The PRF is effective in the treatment of chronic lumbosacral radicular pain of neuropathic features.

Peroral endoscopic myotomy (POEM) is a newly developed endoscopic intervention for esophageal achalasia. We present a case of a patient undergoing POEM, who suffered intra operative hemodynamic collapse due to massive pneumomediastinum as well as massive pneumoperitoneum requiring emergent needle decompression.

Persistence of symptoms or development of new symptoms, late in the course of COVID-19 puts a constant burden on our healthcare facilities. In its severe form, COVID-19 patient may present as acute respiratory distress syndrome (ARDS), shock, and multiorgan failure and other immunological disharmony. With extensive parenchymal and vascular endothelial damage to lung vasculature, some patient may develop extensive fibrosis and pulmonary hypertension. Our patient a 60-year-old male, slightly overweight (BMI = 28.3) with history of IGT suddenly developed fever, sore throat and anosmia with myalgia. At 7 th day of symptom his saturation fell down and patient was admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU) for advance management. Initially patient was treated in COVID-19 ward, latter he was shifted to ICU as oxygen saturation was not maintained by HFNC. After a long battle of 56 days in ICU and 19 days stay in post COVID ward patient was discharged home with intermittent oxygen therapy only to develop pulmonary hypertension as a sequelae of post COVID syndrome. A holistic approach to management of post COVID syndrome is needed for such multisystem involvement of severe COVID patients.

This is a century of corona virus. The world is still coping up with the third wave of COVID-19, while the scientists have already warned that a fourth wave is imminent. This wave is expected to be more lethal due to multiple mutated variety of the corona virus, including one of the most lethal one known as Indian variant or delta variant. Meanwhile, the health staff has to deal with those patients who survived COVID-19, but continued to have a variety of new complaints, including respiratory distress, dysautonomia, intravascular thrombosis and endocardial myocarditis etc. Anti-corona therapy, in itself lead to multiple syndromes including acute kidney injury, bone marrow depression and deranged blood sugar levels. One of the more lethal complication is mucormycosis-a fungal disease. It has effected thousands of recovering or recovered corona patients in India. This editorial highlights the salient features of post-corona syndrome or long covid.

The COVID-19 pandemic has affected the lives and health of people all around the world. Although majority of patients with COVID-19 experience respiratory symptoms, pain is also a very important symptom. The condition of 15-20% of patients is serious and requires hospitalization. Despite the fact that the disease was initially referred to as a respiratory disease, it often affects other systems as well; the most common are the cardiovascular, urologic and nervous system. Multi-organ involvement increases the need for intensive care and treatment of several consequences caused by the disease. Due to severity of the disease, the management of complications following release from hospital should also be considered. The provision of multidisciplinary care that supports both physical and mental recovery in the initial stages of hospitalization can minimize the damage. Cognitive, physical and mental dysfunction reported by COVID-19 patients after discharge may have significant impact on the quality of human life. Pain is usually part of the dysfunction. The post-COVID-19 pain syndrome is still not completely understood, in particular the way it affects patients after they have recovered from COVID-19. There is limited information on the clinical characteristics, treatment, results and pain management in COVID-19 patients. The aim of our article is to provide an overview of the impact COVID-19 has on conditions associated with acute and chronic pain.

Background & objective: There have been a lack of consensus among the anesthetists regarding the utility of different opioids as adjuvants in brachial plexus blockade (BPB). The results vary and there is no agreement. We studied the utility of fentanyl versus tramadol as an adjunct to local anesthetic bupivacaine in ultrasound-guided supraclavicular BPB. Methodology: The study was conducted on 71 patients who were randomized in three groups for ultrasound-guided supraclavicular brachial plexus block. Group B: received 20 ml bupivacaine 0.5% plus normal saline 2 ml; Group F received 20 ml of bupivacaine 0.5% plus fentanyl 100 µg in 2 ml and Group T received 20 ml bupivacaine 0.5% plus tramadol 100 mg in 2 ml. Data was collected for the onset and duration of sensory and motor block, time to first request for rescue analgesia and the total analgesic consumption in first 24 h postoperatively. Results: The onset of sensory blockade in Group T (8.36 ± 1.59 min) was significantly shorter compared to Group B [15.91 ± 3.21 min (p = 0.011)] and to Group F [10.64 ± 1.86 min (p = 0.011)]. The onset of motor blockade was also shorter in Group T (10.36 ± 1.92) compared to Group B [20.91 ± 3.22 min (p = 0.001)] and Group F [13.36 ± 1. 29 (p = 0.001) respectively. The time to first analgesic requests was significantly longer in the Groups T and F than in the Group B (p = 0.001 and p = 0.021, respectively) and significantly longer in the tramadol group compared to the fentanyl group (p = 0.041). Conclusion: Tramadol as an adjuvant to bupivacaine in ultrasound-guided supraclavicular BPB, when compared to bupivacaine alone or with fentanyl, has a shorter onset of sensory and motor blockade and produces a significantly prolonged analgesia.

Background: Emergence of current pandemic caused by novel SARS-COV-2 has already caused over 963000 deaths. Case fatality rate (CFR) estimation helps understanding the disease severity and the lethality trend, high risk population and subsequently, optimization of quality healthcare facilities. Our observational study aimed to find out existing trends in treating the most vulnerable group with scarce medical resource allocation and to implement necessary support services to comply with the ensuing need for best possible outcomes in our ICU. Methodology: In this observational study, all COVID-19 diagnosed patients admitted in our ICU from July 4, 2020 to September 22, 2020, were enrolled. Data were obtained from the core ICU register of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Information accumulated on predesigned data sheets comprised of particulars of patients, co-morbidities, duration of ICU stay, mode of oxygenation, organ support and quick SOFA scores. Total deaths in ICU (in hospital or referred from outside of BSMMU) were recorded. Results: The results revealed that all patients were either very severe or critically sick with COVID-19 pneumonia at the time of ICU admission. Out of 174 patients, 46 (26.44%) were put on invasive ventilation and the rest received noninvasive ventilation in the form of NRM, high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP or BiPAP), CTEX CPAP and non-invasive ventilation (NIV) as appropriate. Male and female ratio was 74:26. Age of patients ranged between 19-95y. The median age of patients was 65 y (IQR: 57-70).Quick SOFA scores were more than 2 in 65.37% of patients. Regarding co-existing organ dysfunction 13.8% had 3 or more co-morbidities; while 74.1% had 2 and 9.8% had a single systemic illness along with COVID-19. Most common diseases encountered among 135 deceased were hypertension (64%), IHD (49%), diabetes mellitus (45%), bronchial asthma or COPD (32%), renal failure (either ARF or CRF) (20%). Overall CFR due to COVID-19 pneumonia associated with co-morbidities was 77.6%. Relatively higher CFR (82.6%) was evident harboring multi-organ dysfunction especially among COVID-19 patients aged 50y or more. Gender linked CFR were 81.4% and 66.7% in males and females respectively. Conclusion: High CFR demonstrates significant correlation with increasing age and co-morbidities and survival functions. Late presentation to the hospital and invasive mechanical ventilation also contributed to high CFR. Islam MS et al case fatality rate, survival functions and corona

Background: Antibiotic resistance remains a major problem in the intensive care units (ICU). Various risk factors have been documented by various researchers. Similarly some factors have been identified to influence the outcome after the antibiotic resistance has been developed in the patients. This retrospective study aimed to identify and document the risk factors and outcomes in ICU of our hospital. Methodology: This retrospective, single-centre cohort study, involved 440 patients, treated in the ICU during January 2017 to December 2019. The medical records of the enrolled patients were reviewed to identify the risk factors and outcomes of antibiotic resistance. The data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 26 (SPSS Inc., USA). Statistical tests used included chi-square test, Fisher's exact test, independent ttest, the Mann-Whitney test and simple or multiple logistic regression tests as per requirement. Results: The prevalence of antibiotic resistance was 22.3%. The odds for antibiotic resistance were increased 2.90 times with medical admission [Odds ratio (OR) 2.897; 95% confidence interval (CI) 1.560, 5.379; p = 0.01] and 3.42 times with carbapenem usage (OR 3.418; 95% CI 1.790, 6.526; p < 0.001). The odds were 73.2% lower with nitroimidazole usage (β =-1.318, OR 0.268; 95% CI 0.131, 0.546; p < 0.001) and 62.2% lower with macrolide usage (β =-0.973, OR 0.378; 95% CI 0.150, 0.950; p = 0.039). Each day of antibiotic usage increased the odds of antibiotic resistance by 1.07 times (OR 1.072; 95% CI 1.037, 1.111; p < 0.001), and each additional antibiotic prescribed increased the odds of antibiotic resistance by 1.72 times (OR 1.717; 95% CI 1.218, 2.423; p = 0.02). The antibiotic resistance mortality rate was 68.4%. Conclusions: Antibiotic resistance increased the mortality rate in the ICU, and the risk factors increased with medicalrelated admission, carbapenem usage, longer antibiotics duration and more antibiotic usage.

A pandemic is defined as an epidemic of an infectious etiology that crosses the international boundaries and infects a large number of people. This has happened several times in the human history; influenza, smallpox, bubonic plaque and cholera being some of the examples. Smallpox alone has resulted in death of 300-500 million people. As a frontline healthcare professional fighting against the COVID-19 pandemic, the author has experienced its socioeconomic and psychological consequences. In addition, critical care units faced ethical challenges to meet with the bed requirement. Dedicated and modified COVID-19 critical care services were started in both the public and private sectors. Because of high workload and lack of trained medical and nursing staff, extra staff ha to be recruited on temporary basis. Some commonly performed procedures were modified to decrease the risk of infection spread. ICUs faced shortage of personal protective equipment and ventilators. Training programs were developed to help improve the understanding of novel COVID-19 infection. ICU staff was probably at lower risk of acquiring this infection as compared to other hospital staff.

Hemorrhagic shock is a form of hypovolemic shock in which severe blood loss leads to inadequate oxygen delivery at the cellular level. Death from hemorrhage represents a substantial global problem, with more than 60,000 deaths per year in the United States and an estimated 1.9 million deaths per year worldwide, 1.5 million of which result from physical trauma. This case report aims to stress the need of handling cases of hemorrhagic shock in accordance with damage control protocol. Hemorrhagic shock management using permissive hypotension management, bleeding control, massive transfusion protocol (MTP), minimal crystalloid therapy, and adjuvant therapy is the best approach to get optimal outcome to prevent triad of death. In this case, the application of damage control resuscitation has not been fully implemented because of several constraints.

The number of cancer patients has been steadily increasing and with it the number of cancer related pain patients is also increasing. Cancer pain (CP) is the most unique and versatile pain, regarding type, intensity, site, variations and the needed management modalities. No one pain specialist or the pain center can be capable of adequately manage every cancer patient. In this background, an idea to confront this menace at a national level with a combined effort is presented. If implemented it is hoped that the CP patients will get rid of at least the worry about their excruciating pain. The idea of the 'Cancer Pain Initiative' has been in circulation for quite some time, but needs to be discussed at various levels.

Background & Objectives: Neurosurgical operations involve major fluid shifts. Fluid management in such critical brain-injured patients is aimed at maintaining sufficient cerebral blood flow and oxygenation. Goal directed fluid strategies are beneficial in rationalization of the way the patients are treated. With availability of less invasive methods for monitoring, use of parameters like Stroke Volume Variation (SVV) and Pulse Pressure Variation (PPV) have been used to guide fluid management as these are more useful than central venous pressure (CVP) measurement. This study correlated an easily established monitoring technique like PPV with CVP for intra-operative fluid management in adult neurosurgical patients undergoing elective craniotomies. Methodology: This prospective, observational study was carried out in 60 patients of either sex, age group 18 to 65 y, planned for elective craniotomies conducted in neurosurgical operation theatre. After anesthesia induction radial arterial cannulation was carried out to monitor the invasive arterial blood pressure and PPV (normal less than 13%). Central venous cannulation was carried out and transduced to measure the CVP. Results: The sensitivity of CVP after calculating entirely was 5.0% and the specificity was 90%. The positive predictive value of CVP was 50.0% and the negative predictive value was a mere 32.14 %. The sensitivity of PPV was 50.0% and specificity was 32.14%. The positive predictive value was 5.00% and negative predictive value was 90%. Conclusion: PPV is a reliable index of fluid management guidance in adult neurosurgical patients undergoing elective craniotomies as compared to CVP, which can lead to excessive administration of fluids.

In the early days of the Coronavirus disease 2019 (COVID-19) pandemic, several countries had policies to postpone elective surgical services. By reducing or suspending elective surgery, they aimed to maximize existing resources to deal with patients with COVID-19. However, the delay and/or termination of elective surgery created additional problems, both for patients and the healthcare system. Discontinuation of elective surgery can cause a risk of a backlog; increasing patient morbidity and mortality; poorer quality of life; affecting finances and hospital resources, as well as training and research programs. Based on all these considerations, elective surgery during the COVID-19 pandemic must be restarted with several requirements and provisions, which provide safety for the patients as well as the healthcare workers. The COVID-19-free pathway has been shown to minimize the risk of SARS-CoV-2 transmission in hospitals for patients undergoing elective surgery. We can use this strategy as a protocol in the future pandemics.

Assessment and management of patients with chronic pain is a challenging task due to its complex multidimensional nature and biopsychosocial impact. It requires a collaborative effort by an interdisciplinary team. Evidence showed that in low and middle-income countries (LMICs), 33% patients among general adult population, and 56% of general elderly population, suffer from chronic painful conditions. Women are more likely to report chronic pain than men. In this narrative review, we attempted to search published literature to know the status of assessment and management of patients with chronic pain in low resource countries and to know the most appropriate chronic pain management strategies used in developed countries. We used broad electronic database (January 2010-December 2020) through common search engines. Lack of trained pain physicians and staffs, lack of interest, empathy and lack of integrated multidisciplinary approach are some of the barriers to achieve teamwork in chronic pain management. Authors strongly recommend the need of further research in this area, improvement in training programs for physicians and nursing staff for proper pain assessment and management of patients with chronic pain in low resource countries.

Anesthesia Preoperative evaluation holds a prime importance in improving overall patient outcomes and decreases hospital expenditure. The American Society of Anesthesiologists Physical Status scoring system ASA-PS was introduced 70 years back in clinical practice and it still holds the lime light for stratifying patient population and considering the risk index and mortality outcomes to warn the surgeon. How has it evolved since the passing years? We will see how over centuries it has evolved. ASA PS has been a significant predictor in depicting morbidity and mortality and evaluating peri-operative risks in patients going for surgery for clinicians, researchers, hospital administrators and government. Further addition of examples of modifying ASA PS status is necessary to make it more comprehensive and easier to use even for non-anesthetists to improve overall peri-operative morbidity and mortality.

Morgagni hernia in adults is a rare condition and is associated with complications such as recurrent chest infections, respiratory failure and cardiac tamponade. Its correction represents an anesthetic challenge. Intraoperative esophageal Doppler provides important information in real time about the patient's cardiac function and vascular filling, aiding in decision making by the anesthesiologist. We report a case of a 70-year-old woman, ASA Physical Status-III, and presented with chest pain, dyspnea and hypoxemia. Her chest x-ray revealed opacification of 2/3 of the left hemithorax and 1/2 of the right. Computed tomography confirmed a bilateral Morgagni hernia. The patient underwent immediate corrective surgery. Intraoperative cardiovascular function was monitored with esophageal Doppler. Compression and decompression of thoracic structures produces enormous hemodynamic and respiratory impact. After herniated contents removal it showed an increase in systolic volume and cardiac index and a correction of flow time. Transient arterial hypotension was verified, requiring fluid therapy and vasopressor support. Diaphragmatic defect was corrected and general hemodynamic stabilization was achieved. Patient was discharged asymptomatic. The esophageal Doppler was important in this case because it allowed us to measure fundamental hemodynamic variables in real time, such as cardiac index or systolic volume, and to subsequently act accordingly.

Aim: Blood stream infections are common in critically sick patients and the clinicians have to use antibiotics to manage. The susceptibility of the microorganisms varies widely from institution to institution, and from country to country. This study was carried out to document the distribution and antimicrobial susceptibility patterns of bloodstream bacterial infections over a six-month period in the medical and surgical intensive care units (ICUs) at NRI Academy of Medical Sciences, in the Southern Region of India. Methodology: This was a retrospective study conducted from June 2020 to December 2020. The study included all patients of either gender, aged above 18 years, admitted in the medical and surgical ICUs for whom blood specimens for culture were positive for BSI. The data for each of the ICUs was compared separately for the type and the number of isolates. The antibiotic susceptibility was assessed for both the ICUs together. The data was analysed using the Medcalc® software. Results: Medical and surgical intensive care units had 103 and 30 culture positive cases respectively. Among the culture positive cases, fermentive and non-fermentive gram-negative were equally isolated at 51 (38.3%) samples each and 31(23.3%) were gram-positive organisms. Altogether, Acinetobacter (20.3%) was the major isolate followed by E. coli (14.2%) and Klebsiella (13.5%). Acinetobacter was most sensitive to colistin (70.4%) followed by levofloxacin (63.0%) and tigecycline (55.6%). E. coli were sensitive to colistin and tigecycline, (100%), followed by amikacin (78.9%), meropenem (68.4%), gentamicin (63.2%). Similar sensitivity was observed for Klebsiella. Conclusion: This study highlights the predominance of gram-negative bacteria in the ICUs and the emergence of multidrug resistant organisms and higher rate of antimicrobial resistance among gram-negative and gram-positive organisms which is an alarming issue. The knowledge of the pathogens causing BSIs in the ICUs and their antibiotic sensitivity patterns can be of help to the clinicians in choosing appropriate empiric antimicrobial therapy. Appropriate empiric therapy is key for decreasing the length of hospital stay and mortality associated with severe sepsis and septic shock associated with blood stream infection in the ICUs.

Background: Inflammation and postoperative pain plays an important role in the causation of postoperative cognitive dysfunction (POCD). Celecoxib-a COX-2 inhibitor, because of its anti-inflammatory and analgesic effects is used for the treatment of acute pain. In this study, we evaluated the effects of celecoxib on POCD and the postoperative pain in the elderly patients undergoing surgical reduction of fracture neck of femur under spinal anesthesia. Methodology: We enrolled 84 patients of either sex, age more than 65 y, ASA grade I to III, who were planned for surgical reduction of fracture neck femur under spinal anesthesia. The patients were randomly divided into two groups and treated with either celecoxib (Group-A) or placebo (Group-B) for one week starting from one day before surgery. Mini-Mental State Examination (MMSE) was done at one day before the surgery and at day seven after surgery. POCD was diagnosed if MMSE score was below 24 (out of 30). Numerical rating scale (NRS) was used to measure pain intensity one day before surgery and at postoperative days one, three and seven. The results were analysed using descriptive statistics and making comparisons among various groups.