Sunaina T. Karna - Academia.edu (original) (raw)
Papers by Sunaina T. Karna
PubMed, Apr 1, 2019
Purpose of the study: Thromboelastography provides a holistic picture of blood coagulation includ... more Purpose of the study: Thromboelastography provides a holistic picture of blood coagulation including fibrin formation, cross, linking and fibrinolysis. Coagulaopathy in end stage renal disease (ESRD) is multifactorial. The present evaluated the thromboelastographic profile of ESRD patients and compared it to conventional tests of coagulation. Study design: In this observational case control study, fifty ESRD patients and 50 controls were recruited. Venous samples were withdrawn and platelet count, International Normalization Ratio and fibrinogen levels were measure. Simultaneously a thromboelastography (TEG) was performed. All samples were drawn prior to initiation of dialysis. Results: The fibrinogen concentration was higher in the ESRD group compared to control (455.51±83.39 vs. 233.84±71.71 mg/dl, P<0.05). The maximum amplitude in ESRD group was 76.94 ± 15.11 mm, which was significantly higher than control group 65.10±10.31 mm (P<0.05).Out of 50 ESRD patients,39 had maximum amplitude (MA) >73mm, 3 had MA <55 mm while 8 patients had normal MA. Further, it was seen that in four out if the five patients whose INR was greater than 1.5. TEG was hypercoaguable. Also, three patients whose platelet count was less than x105/dl had normal thromboelastographs. Two patients with normal platelet count, fibrinogen and INR had hypercoaguable thromboelastographs. Thromboelastography could detect fibrinolysis in 5 patients of end stage renal disease. Conclusion: The present study demonstrated that INR, platelet count and fibrinogen levels do not reflect the actual coagulation status in patients of ESRD. Thromboelastography is a better tool to detect coagulopathy in this group of patients.
Indian Journal of Anaesthesia, 2016
their names and initials will not be published and due efforts will be made to conceal their iden... more their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
The Journal of the Association of Physicians of India, 2014
Hepatorenal syndrome is a unique form of acute kidney injury seen in patients with acute liver fa... more Hepatorenal syndrome is a unique form of acute kidney injury seen in patients with acute liver failure or chronic liver disease in absence of any other identifiable cause of renal failure. It is primarily a diagnosis of exclusion. Despite of good pathophysiological understanding and better available therapeutic options for management of hepatorenal syndrome, it is still associated with significant morbidity and mortality. Liver transplantation forms the cornerstone for its management. In this review article, we have attempted to assimilate and summarise the advances made in the previous decade with regards to pathophysiology, classification and management of this entity.
Anaesthesia, 2021
SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...
Anaesthesia, 2021
SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...
Journal of Anesthesia & Critical Care: Open Access, Jan 3, 2017
The study was approved by the institute's ethical committee. Patient posted for elective surgery ... more The study was approved by the institute's ethical committee. Patient posted for elective surgery requiring NGT insertion were included. General Anaesthesia was standardized with induction using injection Propofol and maintenance of anaestheia using inhalational anaesthetic agent, Isoflurane in Oxygen. Neuromuscular blockade for endotracheal intubation and for surgical paralysis was achieved using injection Vecuronium Bromide which was reversed at the end of surgery using premixed injection Neostigmine with Glycopyrolate. All patients received antiemetic prophylaxis using Injection Ondansetron. Analgesia was ensured using Injection Fentanyl and Injection Paracetamol. Anaesthesia was provided by consultant anaesthesiologists, each with more than 10 years of work experience. Patients with upper airway deformity like deviated nasal septum and patients with perceived difficult intubation and coagulopathy were not included. Poor visualization of glottis opening upon direct laryngoscopy and resistance at level of posterior nares led to exclusion.
Research Square (Research Square), Jul 29, 2020
The COVID-19 disease caused by novel Coronavirus was rst reported in Wuhan, China in December 201... more The COVID-19 disease caused by novel Coronavirus was rst reported in Wuhan, China in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in thrombocytes in contrast to thrombocytopenia documented in cases of dissemination intravascular coagulation and sepsis. Early recognition of abdominal symptoms, diagnosis of pathology and timely surgical intervention may de nitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.
Journal of Postgraduate Medicine, 2014
Succinylcholine a depolarizing muscle relaxant with rapid onset, predictable course and short dur... more Succinylcholine a depolarizing muscle relaxant with rapid onset, predictable course and short duration of action is associated with myalgia. The aim of this study is to evaluate the efficacy of pregabalin, gabapentin and diclofenac on the incidence and severity of succinylcholine-induced myalgia. Tertiary Care Teaching Hospital. A total of 120 patients undergoing laparoscopic cholecystectomy were randomly assigned into three groups: Pregabalin group received 150 mg of pregabalin, gabapentin group received 600 mg of gabapentin and diclofenac group received 100 mg of diclofenac sodium orally 2 h prior to surgery. Anesthesia was induced with fentanyl 3 μg/kg, propofol 2-2.5 mg/kg and succinylcholine 1.5 mg/kg and was maintained with oxygen with sevoflurane in the air and intermittent vecuronium bromide. A blinded observer recorded post-operative pain scores on visual analog scale at different time intervals and myalgia at 24 h. Post-operative pain relief was provided with fentanyl based patient-controlled analgesia. Fentanyl consumption in 24 h was recorded as a primary outcome. Patients' characteristics and total fentanyl consumption were compared using one-way ANOVA followed by post-hoc test. Pain score was compared amongst the groups using Kruskal Wallis test. The myalgia occurred in 15, 14 and 13 patients in pregabalin, gabapentin and diclofenac sodium group respectively (P > 0.85). Patients in diclofenac group had significantly higher fentanyl consumption (674.85 ± 115.58 μg) compared with pregabalin group (601.87 ± 129.57 μg) (95% confidence interval [CI] = 34.8-120.7) and gabapentin group (612.29 ± 105.12 μg) (95% CI = 14.9-170.5). However, there was no significant difference in fentanyl consumption between pregabalin and gabapentin groups (95% CI = -34.8-120.7). There was a significant difference in visual analog score at time points 12, 18 and 24 h among the study groups. Pre-treatment with pregabalin, gabapentin and diclofenac had equal efficacy in reducing the incidence and severity of succinylcholine-induced myalgia. However, pre-treatment with pregabalin and gabapentin decreased post-operative pain scores and fentanyl consumption.
Ain-Shams Journal of Anesthesiology, Jan 20, 2022
Background: The world has been facing the novel coronavirus SARS-CoV-2 pandemic. The novel corona... more Background: The world has been facing the novel coronavirus SARS-CoV-2 pandemic. The novel coronavirus primarily affects the lungs but also affects multiple organ systems including the cardiovascular system causing myocarditis, cardiomyopathy, and arrhythmias. Cardiomyopathy has been reported in patients with COVID-19; however, prognosis of peripartum cardiomyopathy in a patient with COVID-19 is still unexplored. More knowledge is required to understand the incidence of cardiomyopathy due to novel coronavirus SARS-CoV-2. Case presentation: We report a case of peripartum cardiomyopathy gravida 2 parity 2 COVID-19 confirmed patient who underwent an emergency preterm lower segment caesarean section (LSCS) for severe pre-eclampsia and intrauterine growth retardation (IUGR) and landed up in acute congestive cardiac failure with pulmonary oedema. A postpartum 32 years female presented to our institute, a dedicated COVID-19 hospital with tachycardia, hypertension, anasarca, tachypnea with desaturation on room air. She had undergone emergency caesarean section for severe preeclampsia with intrauterine growth retardation. On post-operative day 2 (POD2), she complained of shortness of breath. On POD 3 she tested positive RT-PCR for COVID-19 infection. She responded to treatment with steroids. However, on POD6, She developed severe pulmonary oedema with poor ejection fraction necessitating endotracheal intubation and pressure control ventilation. Congestive cardiac failure was managed with diuretics and digoxin. Gradually oxygenation improved. She was electively ventilated for 3 days. Gradually, ejection fraction improved with the resolution of B lines. On the 9th POD, after a successful spontaneous breathing trial, she was extubated and non-invasive ventilation with bi-level positive airway pressure was attached. The patient was gradually tapered off of the non-invasive ventilation over 2 days. On the 11th post-operative day, she was maintaining oxygen saturation on nasal prongs and was sent to the ward. Conclusions: We recommend early use of bedside lung ultrasonography; echocardiography and close cardiovascular monitoring in severe COVID-19 infected pregnant patients who present with shortness of breath, tachypnea, and hypertensive disorders of pregnancy and previous cardiac abnormalities for expedite management and improved prognosis. An ideal case scenario for extubation may not be present, non-invasive ventilation with bi-level positive airway pressure post-extubation helps in patients with peripartum cardiomyopathy.
Journal of Postgraduate Medicine, 2022
Journal of Neurosciences in Rural Practice
Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoin... more Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoing craniotomy is usually done in perioperative period in intensive care unit. Invasive measurement of ICP, though considered as the gold standard, has its own limitations such as availability of expertise, equipment, and associated complications. Period of raised ICP in post-operative period may impact patient outcomes. Post-craniotomy computed tomography (CT) assessment is done routinely and may need to be repeated if indicated during post-operative stay. Utility of sonographic serial optic nerve sheath diameter (ONSD) assessment in post-operative monitoring of patients who have undergone elective craniotomy was explored in this study. The primary objective of the study was to measure the dynamic change in ONSD as compared to baseline pre-operative measurement in the first 3 postoperative days after elective craniotomy. The secondary objective of the study was to evaluate correlation bet...
BMJ Case Reports
Laryngoceles are rare dilated laryngeal saccules that can present as acute airway obstruction and... more 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.
Anesthesia: Essays and Researches
Background: Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeri... more Background: Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeries with free flap reconstruction (HNS-FFR). Studies to guide regarding association of intraoperative fluid with metabolic parameters during such surgeries are infrequent. Aim: This study aimed to compare plasmalyte (PL) and normal saline (NS) (0.9%) in terms of acid–base balance and electrolytes in the peri-operative period along with graft viability during above-mentioned surgeries. Settings and Design: Prospective, observational cohort study was conducted in patients, 18–65 years, undergoing HNS-FFR at a tertiary care center. Materials and Methods: The cohort was categorized into two groups based on the intraoperative fluid used, i.e., PL (Group A) and NS (Group B) group. The primary objective was to compare arterial blood gas parameters at seven time points till the 3rd postoperative day. We studied the effect on graft viability and length of hospital stay. Statistical Analysis Used: The independent t-tests, Chi-square, or Fisher's exact test were used to evaluate the categorical variables with a repeated measures analysis of variance for inter-group comparison with P < 0.05 as significant. Results: Seventy-one (36 in Group A and 35 in Group B) patients were included in the study with comparable baseline characteristics. Group A had a better acid–base status, especially after the conclusion of vascular anastomosis (pH 7.37 ± 0.06 vs. 7.33 ± 0.04, P = 0.014) and in the postoperative period (pH 7.35 ± 0.07 vs. 7.31 ± 0.05, P = 0.013). No statistically significant difference was observed in outcome parameters between the groups. Conclusions: PL may be preferred over NS due to better metabolic milieu during HNS-FFR surgery.
Turkish Journal of Anaesthesiology and Reanimation
Thromboelastography and rotational thromboelastometry are the viscoelastic point of care devices ... more Thromboelastography and rotational thromboelastometry are the viscoelastic point of care devices that use whole blood samples to assess coagulation and fibrinolysis. These devices give information from initiation of the coagulation cascade, activation of clotting factors to fibrin cross-linking, and contribution of fibrinogen and platelet to clot strength and clot lysis. Viscoelastic point of care tests are well established in hypocoaguable states like trauma, cardiac surgery, liver transplantation, and their use in critical care settings with coronavirus disease 2019 (COVID-19) is not so well-known. We performed a systematic review of studies on thromboelastography and rotational thromboelastometry and their modifications to assess their role in critically ill patients with COVID-19. Inclusion criteria were any kind of studies using thromboelastography or rotational thromboelastometry during coronavirus disease critical illness published in English. Ninety-three articles, from December 1, 2019, to August 31, 2020, were identified in the initial search, out of which 12 articles (a total of 380 patients) satisfied the inclusion and exclusion criteria. Thromboelastography and rotational thromboelastometry were observed to detect the hypercoagulable changes and fibrinolysis shutdown associated with COVID-19. Hypercoagulability is associated with an increased risk of venous thrombosis and micro-thrombosis. This review identifies the role of thromboelastography and rotational thromboelastometry in studying the mechanisms contributing to coagulopathy and incidence of thrombosis in COVID-19.
Indian Journal of Critical Care Medicine, 2021
Background: Tracheostomy is integral in long-term intensive care of COVID-19 patients. There is a... more Background: Tracheostomy is integral in long-term intensive care of COVID-19 patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. 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.
Indian Journal of Critical Care Medicine, 2021
Background: Coronavirus disease 2019 (COVID-19) commonly presents with respiratory symptoms. Howe... more Background: Coronavirus disease 2019 (COVID-19) commonly presents with respiratory symptoms. However, symptoms involving the digestive system may be present, significance of which is not well studied in the Indian scenario. Methods: This prospective observational cohort study included consecutive patients with severe COVID-19 admitted to intensive care unit of our tertiary care hospital from September 9, 2020, to March 14, 2021. We evaluated the frequency of preadmission digestive symptoms and compared the demographic, clinical, laboratory parameters, and organ failure at admission and during intensive care along with mortality between those with and without digestive symptoms. In the digestive group, we sought to find predictors of mortality. Results: Digestive symptoms were present in 76/234 (32.4%) with severe COVID-19 infection. In comparison to nondigestive group, digestive patients had higher need for noninvasive ventilation (p 0.028), invasive lines (68%, p 0.003), vasopressors (64%, p 0.01), blood product transfusion (21.1%, p <0.001), and heart failure (55.4%, p 0.041). Confounding factors of alcohol abuse, smoking, sedentary lifestyle as a causative agent for heart failure could not be ruled out. Proportional mortality rate is higher in the digestive group (65.8%, p = 0.015). Mortality is multifactorial with preadmission abdominal pathologies (HR 4.3) or central nervous system (CNS)-related comorbidities (HR 2.829), presentation with multiple digestive symptoms (HR 6.9), higher sequential organ failure assessment score (SOFA) score at admission (HR 1.258) and discharge (HR 1.162), and presence of acute kidney injury (AKI) Grade 3 (HR 2.95) as predictors of mortality. After adjusting for all confounders, need for vasopressor was observed to be associated with 11.58 times higher risk of mortality. Conclusion: Preadmission digestive symptoms may be associated with a turbulent illness with invasive interventions, heart failure, and greater proportional mortality in severe COVID-19. AKI Grade 3 is identified as a preventable risk factor predicting mortality. CTRI/2021/03/032325.
Indian Journal of Surgery, 2020
The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December ... more The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in prothrombin time, fibrinogen, and D-dimers. Early recognition of abdominal symptoms, diagnosis of pathology, and timely surgical intervention may definitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.
PubMed, Apr 1, 2019
Purpose of the study: Thromboelastography provides a holistic picture of blood coagulation includ... more Purpose of the study: Thromboelastography provides a holistic picture of blood coagulation including fibrin formation, cross, linking and fibrinolysis. Coagulaopathy in end stage renal disease (ESRD) is multifactorial. The present evaluated the thromboelastographic profile of ESRD patients and compared it to conventional tests of coagulation. Study design: In this observational case control study, fifty ESRD patients and 50 controls were recruited. Venous samples were withdrawn and platelet count, International Normalization Ratio and fibrinogen levels were measure. Simultaneously a thromboelastography (TEG) was performed. All samples were drawn prior to initiation of dialysis. Results: The fibrinogen concentration was higher in the ESRD group compared to control (455.51±83.39 vs. 233.84±71.71 mg/dl, P<0.05). The maximum amplitude in ESRD group was 76.94 ± 15.11 mm, which was significantly higher than control group 65.10±10.31 mm (P<0.05).Out of 50 ESRD patients,39 had maximum amplitude (MA) >73mm, 3 had MA <55 mm while 8 patients had normal MA. Further, it was seen that in four out if the five patients whose INR was greater than 1.5. TEG was hypercoaguable. Also, three patients whose platelet count was less than x105/dl had normal thromboelastographs. Two patients with normal platelet count, fibrinogen and INR had hypercoaguable thromboelastographs. Thromboelastography could detect fibrinolysis in 5 patients of end stage renal disease. Conclusion: The present study demonstrated that INR, platelet count and fibrinogen levels do not reflect the actual coagulation status in patients of ESRD. Thromboelastography is a better tool to detect coagulopathy in this group of patients.
Indian Journal of Anaesthesia, 2016
their names and initials will not be published and due efforts will be made to conceal their iden... more their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
The Journal of the Association of Physicians of India, 2014
Hepatorenal syndrome is a unique form of acute kidney injury seen in patients with acute liver fa... more Hepatorenal syndrome is a unique form of acute kidney injury seen in patients with acute liver failure or chronic liver disease in absence of any other identifiable cause of renal failure. It is primarily a diagnosis of exclusion. Despite of good pathophysiological understanding and better available therapeutic options for management of hepatorenal syndrome, it is still associated with significant morbidity and mortality. Liver transplantation forms the cornerstone for its management. In this review article, we have attempted to assimilate and summarise the advances made in the previous decade with regards to pathophysiology, classification and management of this entity.
Anaesthesia, 2021
SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...
Anaesthesia, 2021
SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...
Journal of Anesthesia & Critical Care: Open Access, Jan 3, 2017
The study was approved by the institute's ethical committee. Patient posted for elective surgery ... more The study was approved by the institute's ethical committee. Patient posted for elective surgery requiring NGT insertion were included. General Anaesthesia was standardized with induction using injection Propofol and maintenance of anaestheia using inhalational anaesthetic agent, Isoflurane in Oxygen. Neuromuscular blockade for endotracheal intubation and for surgical paralysis was achieved using injection Vecuronium Bromide which was reversed at the end of surgery using premixed injection Neostigmine with Glycopyrolate. All patients received antiemetic prophylaxis using Injection Ondansetron. Analgesia was ensured using Injection Fentanyl and Injection Paracetamol. Anaesthesia was provided by consultant anaesthesiologists, each with more than 10 years of work experience. Patients with upper airway deformity like deviated nasal septum and patients with perceived difficult intubation and coagulopathy were not included. Poor visualization of glottis opening upon direct laryngoscopy and resistance at level of posterior nares led to exclusion.
Research Square (Research Square), Jul 29, 2020
The COVID-19 disease caused by novel Coronavirus was rst reported in Wuhan, China in December 201... more The COVID-19 disease caused by novel Coronavirus was rst reported in Wuhan, China in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in thrombocytes in contrast to thrombocytopenia documented in cases of dissemination intravascular coagulation and sepsis. Early recognition of abdominal symptoms, diagnosis of pathology and timely surgical intervention may de nitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.
Journal of Postgraduate Medicine, 2014
Succinylcholine a depolarizing muscle relaxant with rapid onset, predictable course and short dur... more Succinylcholine a depolarizing muscle relaxant with rapid onset, predictable course and short duration of action is associated with myalgia. The aim of this study is to evaluate the efficacy of pregabalin, gabapentin and diclofenac on the incidence and severity of succinylcholine-induced myalgia. Tertiary Care Teaching Hospital. A total of 120 patients undergoing laparoscopic cholecystectomy were randomly assigned into three groups: Pregabalin group received 150 mg of pregabalin, gabapentin group received 600 mg of gabapentin and diclofenac group received 100 mg of diclofenac sodium orally 2 h prior to surgery. Anesthesia was induced with fentanyl 3 μg/kg, propofol 2-2.5 mg/kg and succinylcholine 1.5 mg/kg and was maintained with oxygen with sevoflurane in the air and intermittent vecuronium bromide. A blinded observer recorded post-operative pain scores on visual analog scale at different time intervals and myalgia at 24 h. Post-operative pain relief was provided with fentanyl based patient-controlled analgesia. Fentanyl consumption in 24 h was recorded as a primary outcome. Patients' characteristics and total fentanyl consumption were compared using one-way ANOVA followed by post-hoc test. Pain score was compared amongst the groups using Kruskal Wallis test. The myalgia occurred in 15, 14 and 13 patients in pregabalin, gabapentin and diclofenac sodium group respectively (P > 0.85). Patients in diclofenac group had significantly higher fentanyl consumption (674.85 ± 115.58 μg) compared with pregabalin group (601.87 ± 129.57 μg) (95% confidence interval [CI] = 34.8-120.7) and gabapentin group (612.29 ± 105.12 μg) (95% CI = 14.9-170.5). However, there was no significant difference in fentanyl consumption between pregabalin and gabapentin groups (95% CI = -34.8-120.7). There was a significant difference in visual analog score at time points 12, 18 and 24 h among the study groups. Pre-treatment with pregabalin, gabapentin and diclofenac had equal efficacy in reducing the incidence and severity of succinylcholine-induced myalgia. However, pre-treatment with pregabalin and gabapentin decreased post-operative pain scores and fentanyl consumption.
Ain-Shams Journal of Anesthesiology, Jan 20, 2022
Background: The world has been facing the novel coronavirus SARS-CoV-2 pandemic. The novel corona... more Background: The world has been facing the novel coronavirus SARS-CoV-2 pandemic. The novel coronavirus primarily affects the lungs but also affects multiple organ systems including the cardiovascular system causing myocarditis, cardiomyopathy, and arrhythmias. Cardiomyopathy has been reported in patients with COVID-19; however, prognosis of peripartum cardiomyopathy in a patient with COVID-19 is still unexplored. More knowledge is required to understand the incidence of cardiomyopathy due to novel coronavirus SARS-CoV-2. Case presentation: We report a case of peripartum cardiomyopathy gravida 2 parity 2 COVID-19 confirmed patient who underwent an emergency preterm lower segment caesarean section (LSCS) for severe pre-eclampsia and intrauterine growth retardation (IUGR) and landed up in acute congestive cardiac failure with pulmonary oedema. A postpartum 32 years female presented to our institute, a dedicated COVID-19 hospital with tachycardia, hypertension, anasarca, tachypnea with desaturation on room air. She had undergone emergency caesarean section for severe preeclampsia with intrauterine growth retardation. On post-operative day 2 (POD2), she complained of shortness of breath. On POD 3 she tested positive RT-PCR for COVID-19 infection. She responded to treatment with steroids. However, on POD6, She developed severe pulmonary oedema with poor ejection fraction necessitating endotracheal intubation and pressure control ventilation. Congestive cardiac failure was managed with diuretics and digoxin. Gradually oxygenation improved. She was electively ventilated for 3 days. Gradually, ejection fraction improved with the resolution of B lines. On the 9th POD, after a successful spontaneous breathing trial, she was extubated and non-invasive ventilation with bi-level positive airway pressure was attached. The patient was gradually tapered off of the non-invasive ventilation over 2 days. On the 11th post-operative day, she was maintaining oxygen saturation on nasal prongs and was sent to the ward. Conclusions: We recommend early use of bedside lung ultrasonography; echocardiography and close cardiovascular monitoring in severe COVID-19 infected pregnant patients who present with shortness of breath, tachypnea, and hypertensive disorders of pregnancy and previous cardiac abnormalities for expedite management and improved prognosis. An ideal case scenario for extubation may not be present, non-invasive ventilation with bi-level positive airway pressure post-extubation helps in patients with peripartum cardiomyopathy.
Journal of Postgraduate Medicine, 2022
Journal of Neurosciences in Rural Practice
Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoin... more Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoing craniotomy is usually done in perioperative period in intensive care unit. Invasive measurement of ICP, though considered as the gold standard, has its own limitations such as availability of expertise, equipment, and associated complications. Period of raised ICP in post-operative period may impact patient outcomes. Post-craniotomy computed tomography (CT) assessment is done routinely and may need to be repeated if indicated during post-operative stay. Utility of sonographic serial optic nerve sheath diameter (ONSD) assessment in post-operative monitoring of patients who have undergone elective craniotomy was explored in this study. The primary objective of the study was to measure the dynamic change in ONSD as compared to baseline pre-operative measurement in the first 3 postoperative days after elective craniotomy. The secondary objective of the study was to evaluate correlation bet...
BMJ Case Reports
Laryngoceles are rare dilated laryngeal saccules that can present as acute airway obstruction and... more 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.
Anesthesia: Essays and Researches
Background: Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeri... more Background: Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeries with free flap reconstruction (HNS-FFR). Studies to guide regarding association of intraoperative fluid with metabolic parameters during such surgeries are infrequent. Aim: This study aimed to compare plasmalyte (PL) and normal saline (NS) (0.9%) in terms of acid–base balance and electrolytes in the peri-operative period along with graft viability during above-mentioned surgeries. Settings and Design: Prospective, observational cohort study was conducted in patients, 18–65 years, undergoing HNS-FFR at a tertiary care center. Materials and Methods: The cohort was categorized into two groups based on the intraoperative fluid used, i.e., PL (Group A) and NS (Group B) group. The primary objective was to compare arterial blood gas parameters at seven time points till the 3rd postoperative day. We studied the effect on graft viability and length of hospital stay. Statistical Analysis Used: The independent t-tests, Chi-square, or Fisher's exact test were used to evaluate the categorical variables with a repeated measures analysis of variance for inter-group comparison with P < 0.05 as significant. Results: Seventy-one (36 in Group A and 35 in Group B) patients were included in the study with comparable baseline characteristics. Group A had a better acid–base status, especially after the conclusion of vascular anastomosis (pH 7.37 ± 0.06 vs. 7.33 ± 0.04, P = 0.014) and in the postoperative period (pH 7.35 ± 0.07 vs. 7.31 ± 0.05, P = 0.013). No statistically significant difference was observed in outcome parameters between the groups. Conclusions: PL may be preferred over NS due to better metabolic milieu during HNS-FFR surgery.
Turkish Journal of Anaesthesiology and Reanimation
Thromboelastography and rotational thromboelastometry are the viscoelastic point of care devices ... more Thromboelastography and rotational thromboelastometry are the viscoelastic point of care devices that use whole blood samples to assess coagulation and fibrinolysis. These devices give information from initiation of the coagulation cascade, activation of clotting factors to fibrin cross-linking, and contribution of fibrinogen and platelet to clot strength and clot lysis. Viscoelastic point of care tests are well established in hypocoaguable states like trauma, cardiac surgery, liver transplantation, and their use in critical care settings with coronavirus disease 2019 (COVID-19) is not so well-known. We performed a systematic review of studies on thromboelastography and rotational thromboelastometry and their modifications to assess their role in critically ill patients with COVID-19. Inclusion criteria were any kind of studies using thromboelastography or rotational thromboelastometry during coronavirus disease critical illness published in English. Ninety-three articles, from December 1, 2019, to August 31, 2020, were identified in the initial search, out of which 12 articles (a total of 380 patients) satisfied the inclusion and exclusion criteria. Thromboelastography and rotational thromboelastometry were observed to detect the hypercoagulable changes and fibrinolysis shutdown associated with COVID-19. Hypercoagulability is associated with an increased risk of venous thrombosis and micro-thrombosis. This review identifies the role of thromboelastography and rotational thromboelastometry in studying the mechanisms contributing to coagulopathy and incidence of thrombosis in COVID-19.
Indian Journal of Critical Care Medicine, 2021
Background: Tracheostomy is integral in long-term intensive care of COVID-19 patients. There is a... more Background: Tracheostomy is integral in long-term intensive care of COVID-19 patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. 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.
Indian Journal of Critical Care Medicine, 2021
Background: Coronavirus disease 2019 (COVID-19) commonly presents with respiratory symptoms. Howe... more Background: Coronavirus disease 2019 (COVID-19) commonly presents with respiratory symptoms. However, symptoms involving the digestive system may be present, significance of which is not well studied in the Indian scenario. Methods: This prospective observational cohort study included consecutive patients with severe COVID-19 admitted to intensive care unit of our tertiary care hospital from September 9, 2020, to March 14, 2021. We evaluated the frequency of preadmission digestive symptoms and compared the demographic, clinical, laboratory parameters, and organ failure at admission and during intensive care along with mortality between those with and without digestive symptoms. In the digestive group, we sought to find predictors of mortality. Results: Digestive symptoms were present in 76/234 (32.4%) with severe COVID-19 infection. In comparison to nondigestive group, digestive patients had higher need for noninvasive ventilation (p 0.028), invasive lines (68%, p 0.003), vasopressors (64%, p 0.01), blood product transfusion (21.1%, p <0.001), and heart failure (55.4%, p 0.041). Confounding factors of alcohol abuse, smoking, sedentary lifestyle as a causative agent for heart failure could not be ruled out. Proportional mortality rate is higher in the digestive group (65.8%, p = 0.015). Mortality is multifactorial with preadmission abdominal pathologies (HR 4.3) or central nervous system (CNS)-related comorbidities (HR 2.829), presentation with multiple digestive symptoms (HR 6.9), higher sequential organ failure assessment score (SOFA) score at admission (HR 1.258) and discharge (HR 1.162), and presence of acute kidney injury (AKI) Grade 3 (HR 2.95) as predictors of mortality. After adjusting for all confounders, need for vasopressor was observed to be associated with 11.58 times higher risk of mortality. Conclusion: Preadmission digestive symptoms may be associated with a turbulent illness with invasive interventions, heart failure, and greater proportional mortality in severe COVID-19. AKI Grade 3 is identified as a preventable risk factor predicting mortality. CTRI/2021/03/032325.
Indian Journal of Surgery, 2020
The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December ... more The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in prothrombin time, fibrinogen, and D-dimers. Early recognition of abdominal symptoms, diagnosis of pathology, and timely surgical intervention may definitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.