Mukul Chandra Kapoor

Nutrition in intensive care.

Nutritional support has now come to be recognized as sine qua non in management of critically ill.[1] It has gained importance with better understanding of the pathophysiology of protein energy malnutrition (PEM) in intensive care unit (ICU) patients and optimal modalities in administration of nutritional therapy.[2,3] Its status has changed from being adjunct in critical care to that of definitive therapy. Vincent has emphasized the importance of feeding the ICU patient in a simple but appealing pneumonic – “FAST HUG” (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head end elevation, Ulcer prophylaxis, and Glucose control).[4]

Violence against the medical profession

Violence is increasingly being used against doctors and other medical personnel. More than 75% of doctors face violence during their practice. Almost half of the violent incidents occur in critical care units. Anesthesiologists, especially those working in intensive care units (ICUs), face it almost every day. There are regular reports of doctors being abused, threatened, bullied, manhandled, and even killed. The issue is not restricted to our country but is a worldwide phenomenon. Multiple reviews and studies have been published in contemporary literature, with the largest number originating in China.[1‐3] The World Health Organization has drawn out a global action plan to prevent this violence.[4]

Nasal mask ventilation is better than face mask ventilation in edentulous patients

Background and Aims: Face mask ventilation of the edentulous patient is often difficult as ineffective seating of the standard mask to the face prevents attainment of an adequate air seal. The efficacy of nasal ventilation in edentulous patients has been cited in case reports but has never been investigated. Material and Methods: Consecutive edentulous adult patients scheduled for surgery under general anesthesia with endotracheal intubation, during a 17-month period, were prospectively evaluated. After induction of anesthesia and administration of neuromuscular blocker, lungs were ventilated with a standard anatomical face mask of appropriate size, using a volume controlled anesthesia ventilator with tidal volume set at 10 ml/kg. In case of inadequate ventilation, the mask position was adjusted to achieve best-fit. Inspired and expired tidal volumes were measured. Thereafter, the face mask was replaced by a nasal mask and after achieving best-fit, the inspired and expired tidal volumes were recorded. The difference in expired tidal volumes and airway pressures at best-fit with the use of the two masks and number of patients with inadequate ventilation with use of the masks were statistically analyzed. Results: A total of 79 edentulous patients were recruited for the study. The difference in expiratory tidal volumes with the use of the two masks at best-fit was statistically significant (P = 0.0017). Despite the best-fit mask placement, adequacy of ventilation could not be achieved in 24.1% patients during face mask ventilation, and 12.7% patients during nasal mask ventilation and the difference was statistically significant. Conclusion: Nasal mask ventilation is more efficient than standard face mask ventilation in edentulous patients.

Types of studies and research design

Medical research has evolved, from individual expert described opinions and techniques, to scientifically designed methodology-based studies. Evidence-based medicine (EBM) was established to re-evaluate medical facts and remove various myths in clinical practice. Research methodology is now protocol based with predefined steps. Studies were classified based on the method of collection and evaluation of data. Clinical study methodology now needs to comply to strict ethical, moral, truth, and transparency standards, ensuring that no conflict of interest is involved. A medical research pyramid has been designed to grade the quality of evidence and help physicians determine the value of the research. Randomised controlled trials (RCTs) have become gold standards for quality research. EBM now scales systemic reviews and meta-analyses at a level higher than RCTs to overcome deficiencies in the randomised trials due to errors in methodology and analyses.

Interdisciplinary position statement on management of hyperglycemia in peri-operative and intensive care.

Hospitalized patients with diabetes pose numerous clinical challenges, including hyperglycemia, which may often be difficult to control. The therapeutic challenges are further accentuated by the difficulty in practical application of existing guidelines among Indian and South Asian patients. The present review highlights the various clinical challenges encountered during management of different diabetic hospitalized populations, and attempts to collate a set of practical, patient and physician friendly recommendations to manage hyperglycemia in such patients.

Self-knotting of a nasogastric tube passed through i-gel™.

Sir, A 55 kg, 35-year-old lady, was anaesthetised for laparoscopic cholecystectomy. A no. 3 i-gel™ (Intersurgical Ltd., Wokingham, Berkshire, UK) supraglottic airway device was used to maintain airway and a 12FG nasogastric tube (NGT) (Romsons, Agra, Uttar Pradesh, India) passed through its gastric channel, for decompression of the stomach, in one attempt without encountering any resistance. On completion of the surgery, the NGT could not be pulled out of the channel. The i-gel™ and the NGT were removed en masse. The NGT was found to have a lariat loop knot at its gastric end [Figure 1]. Figure 1 Knotted gastric end of the nasogastric tube removed along with the i-gel™ i-gel™ is a supraglottic airway device made of medical grade thermoplastic elastomer, which has an integrated gastric channel to facilitate venting of stomach gas and allowing passage of NGT to empty the stomach contents. Although there are reports of self-knotting of NGT,[1] there are no reports of such an occurrence in NGT passed through i-gel™, possibly because its channel prevents the bending of the NGT and facilitates its entry into the oesophagus. The incidence of self-knotting of NGT appears to be low.[1] Risk factors include smaller diameter NGT, insertion deep into the stomach, and repetitive advancement of the NGT, pushing or pulling of NGT after it has been placed and interference with an endotracheal tube in the intubated patient.[2,3,4,5] The diameter of the NGT in the case was small due to restrictions of the i-gel channel dimension. Once knotted, the traction during retrieval tightens the knot.[1] NGTs are generally made up of polyvinyl chloride, which tends to soften when exposed to body temperature. The soft tubes tend to roll up and this may promote knot formation. Mechanism of knot formation is similar to that of supercoiling. Knotting of NGT during both insertion and removal can lead to serious complications, which include respiratory distress,[5] severe laryngeal injury,[5] and tracheoesophageal puncture,[6] in both intubated and non-intubated patients. Knotting of NGT can be prevented by using large bore tubes, avoiding repeated insertion attempts, using NGT made of stiffer material and avoiding NGT insertion deeper than that optimum for that size.

A prospective observational study of the use of desflurane anesthesia in Indian adult inpatients undergoing surgery: The Registry in India on Suprane Emergence registry

Background and Aims: Limited registry studies are available on the use of anesthetic agents. This registry was conducted to evaluate emergence outcomes in Indian adult patients undergoing surgery with desflurane anesthesia. Material and Methods: This multicenter, prospective, non-interventional, observational study (Registry in India on Suprane Emergence [RISE] registry) included adult inpatients who received desflurane as general anesthetic for surgical procedure of ≥2 h. Patients were stratified by age into three groups: ≥18–40 years, ≥41–65 years, and >65 years. Data on patients’ demographics, practice, and usage pattern of medications were collected. The primary efficacy outcomes were time to extubation, time to response to verbal command, and time to orientation. Results: Of 236 patients screened, 201 (≥18–40 years, n = 70; ≥41–65 years, n = 65; >65 years, n = 66) were enrolled in the study. Mean time to extubation observed in ≥18–40 years group was 7.2 ± 4.1 min, ≥41–65 years was 11.6 ± 8.99 min, and >65 years was 12.0 ± 10.5 min. Mean time to response to verbal command was 7.4 ± 4.3 min for ≥18–40 years, 10.9 ± 8.5 min for ≥41–65 years, and 10.0 ± 5.4 min for >65 years. Mean time to orientation was 13.0 ± 7.0 min for ≥18–40 years, 16.1 ± 12.0 min for ≥41–65 years, and 17.0 ± 8.6 min for >65 years. Incidence of nausea and retching/vomiting was observed in 8% of patients each in the postoperative period, and these complications were seen more in the >65 years age group. Overall, desflurane treatment maintained hemodynamic stability and no major airway events were reported. Conclusions: The RISE registry data suggest that desflurane-based anesthesia provides early recovery with stable hemodynamics without any airway adverse events, in a wide variety of surgical procedures.

Basic cardiopulmonary life support (BCLS) for cardiopulmonary resuscitation by trained paramedics and medics outside the hospital

The cardiopulmonary resuscitation guideline of Basic Cardiopulmonary Life Support (BCLS) for management of adult victims with cardiopulmonary arrest outside the hospital provides an algorithmic stepwise approach for optimal outcome of the victims by trained medics and paramedics. This guideline has been developed considering the need to have a universally acceptable practice guideline for India and keeping in mind the infrastructural limitations of some areas of the country. This guideline is based on evidence elicited in the international and national literature. In the absence of data from Indian population, the excerpts have been taken from international data, discussed with Indian experts and thereafter modified to make them practically applicable across India. The optimal outcome for a victim with cardiopulmonary arrest would depend on core links of early recognition and activation; early high-quality cardiopulmonary resuscitation, early defibrillation and early transfer to medical facility. These links are elaborated in a stepwise manner in the BCLS algorithm. The BCLS also emphasise on quality check for various steps of resuscitation.

Compression-only life support (COLS) for cardiopulmonary resuscitation by layperson outside the hospital

The cardiopulmonary resuscitation (CPR) guidelines of compression-only life support (COLS) for management of the victim with cardiopulmonary arrest in adults provide a stepwise algorithmic approach for optimal outcome of the victim outside the hospital by untrained laypersons. These guidelines have been developed to recommend practical, uniform and acceptable resuscitation algorithms across India. As resuscitation data of the Indian population are inadequate, these guidelines have been based on international literature. The guidelines have been recommended after discussion among Indian experts and the recommendations modified to ensure its practical applicability across the country. The COLS emphasises on early recognition of cardiac arrest and activation, early chest compression and early transfer to medical facility. The guidelines emphasise avoidance of any interruption of chest compression, and thus relies primarily on chest compression-only CPR by laypersons.