Critical Care Department Research Articles

Vasopressor weaning in sepsis: Debate is being continued!

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Souvik Maitra, Department of Anaesthesiology, Pain Medicine and Critical Care, Room No: 5013, Teaching Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 019, India. E-mail: [email protected] Received December 18, 2021 Received in revised form January 16, 2022 Accepted January 24, 2022 This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Facial pressure ulcer ensuing use of eye protection goggles: Secure your hatches before proning!

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India Address for correspondence: Dr. Anju Gupta, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail: [email protected] Received January 02, 2022 Received in revised form January 18, 2022 Accepted January 20, 2022 This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Does Masked Interviewing Encourage Holistic Review in Residency Selection? A Mixed-Methods Study

Problem: Medical educators increasingly champion holistic review. However, in U.S. residency selection, holistic review has been difficult to implement, hindered by a reliance on standardized academic criteria such as board scores. Masking faculty interviewers to applicants’ academic files is a potential means of promoting holistic residency selection by increasing the interview’s ability to make a discrete contribution to evaluation. However, little research has directly analyzed the effects of masking on how residency selection committees evaluate applicants. This mixed-methods study examined how masking interviews altered residency selection in an anesthesiology program at a large U.S. academic medical center. Intervention: During the 2019–2020 residency selection season in the University of Pennsylvania’s Department of Anesthesiology & Critical Care, we masked interviewers to the major academic components of candidates’ application files (board scores, transcripts, letters) on approximately half of interview days. The intent of the masking intervention was to mitigate the tendency of interviewers to form predispositions about candidates based on standardized academic criteria and thereby allow the interview to make a more independent contribution to candidate evaluation. Context: Our examination of the masking intervention used a concurrent, partially mixed, equal-status mixed-methods design guided by a pragmatist approach. We audio-recorded selection committee meetings and qualitatively analyzed them to explore how masking affected the process of candidate evaluation. We also collected independent candidate ratings from interviewers and consensus committee ratings and statistically compared ratings of candidates interviewed on masked days to ratings from conventional days. Impact: In conventional committee meetings, interviewers focused on how to reconcile academic metrics and interviews, and their evaluations of interviews were framed according to predispositions about candidates formed through perusal of application files. In masked meetings, members instead spent considerable effort evaluating candidates’ “fit” and whether they came off as tactful. Masked interviewers gave halting opinions of candidates and sometimes pushed for committee leaders to reveal academic information, leading to masking breaches. Higher USMLE Step 1 score and higher medical school ranking were statistically associated with more favorable consensus rating. We found no significant differences in rating outcomes between masked and conventional interview days. Lessons learned: Elimination of academic metrics during the residency interview phase does not straightforwardly promote holistic review. While critical reflection among medical educators about the fairness and utility of such metrics has been productive, research and intervention should focus on the more proximate topic of how programs apply academic and other criteria to evaluate applicants.

Pulse Oximetry: A Necessary Imperfect Tool in Critical Care.

1 Critical Care Department, Mayo Clinic Arizona, Phoenix, AZ. 2 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD. Drs. Athale and Suffredini received support for article research from the National Institutes of Health. Dr. Suffredini disclosed government work. For information regarding this article, E-mail: [email protected]

Healthcare Management Challenges and Opportunities during COVID Pandemic

This review aimed to analyze some problems and challenges that emerged from the COVID-19 pandemic since it has affected all global business sectors. During the pandemic, remote work was increased in response to social distance requirements to decrease the transmission of disease. In addition, increased delegation, teamwork, supply chains, sales activities, and business operations have all been disrupted. Many challenges have emerged in the management of organizations due to the pandemic including the lack of direct contact as the lockdown made many people work from home and placed restrictions on movement and travel and uncertainty about the future. The healthcare system was also affected by the COVID-19 pandemic and faced several difficulties including increased demand for medical supplies and personal protective equipment, a greater need for nurses and other skilled healthcare professionals, and increased pressure on healthcare facilities, emergency services, and critical care departments. These challenges have created some opportunities in the management systems of healthcare organizations and other sectors. It is recommended for leaders prepare and continuously work proactively to be ready for unexpected future crises. Risk management and planning for any unexpected situation are among the very important aspects of organizational management.

A Comparison of Long-Term Outcomes in Patients Managed With Venovenous Extracorporeal Membrane Oxygenation in the First and Second Waves of the COVID-19 Pandemic in the United Kingdom.

Early studies of venovenous extracorporeal membrane oxygenation (ECMO) in COVID-19 have revealed similar outcomes to historical cohorts. Changes in the disease and treatments have led to differences in the patients supported on venovenous ECMO in the first and second waves. We aimed to compare these two groups in both the acute and follow-up phase. Retrospective single-center cohort study comparing mortality at censoring date (November 30, 2021) and decannulation, patient characteristics, complications and lung function and quality of life (QOL-by European Quality of Life 5 Dimensions 3 Level Version) at first follow-up in patients supported on venovenous ECMO between wave 1 and wave 2 of the COVID-19 pandemic. Critical care department of a severe acute respiratory failure service. Patients supported on ECMO for COVID-19 between wave 1 (March 17, 2020, to August 31, 2020) and wave 2 (January 9, 2020, to May 25, 2021). None. One hundred twenty-three patients were included in our analysis. Survival at censoring date (χ 2 , 6.35; p = 0.012) and decannulation (90.4% vs 70.0%; p < 0.001) was significantly lower in the second wave, while duration of ECMO run was longer (12.0 d [18.0-30.0 d] vs 29.5 d [15.5-58.3 d]; p = 0.005). Wave 2 patients had longer application of noninvasive ventilation (NIV) prior to ECMO and a higher frequency of barotrauma. Patient age and NIV use were independently associated with increased mortality (odds ratio 1.07 [1.01-1.14]; p = 0.025 and 3.37 [1.12-12.60]; p = 0.043, respectively). QOL and lung function apart from transfer coefficient of carbon monoxide corrected for hemoglobin was similar at follow-up across the waves. Most patients with COVID-19 supported on ECMO in both waves survived in the short and longer term. At follow-up patients had similar lung function and QOL across the two waves. This suggests that ECMO has an ongoing role in the management of a carefully selected group of patients with COVID-19.

Nebulized ketamine in minor bronchoscopy procedures: A possibility.

Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India Address for correspondence: Dr. Manbir Kaur, Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan - 342 005, India. E-mail: [email protected] Received August 17, 2021 Received in revised form December 06, 2021 Accepted January 03, 2022 This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

COMPARISON OF EFFICACY OF ATRACURIUM AND CISATRACURIUM IN PATIENTS UNDERGOING SURGERIES UNDER GENERALANAESTHESIA

Background: Neuromuscular blocking drugs (NMB) are very important adjuvant to general anaesthesia . Cisatracurium is a puried 1R cis-1'R cis isomer of atracurium introduced for clinical use in 1995 which is 3 to 5 times more potent and it provides faster onset, longer duration of action with good intubating conditions and is devoid of histamine release. The aim of the study was to compare the efcacy of Atracurium (0.5mg/kg) versus Cisatracurium (0.3mg/kg) as regard to onset of action, duration of action, intubating conditions, haemodynamic effects and signs of histamine release. Material and Methods: The study was designed as a prospective randomized single blinded study conducted in the Department of Anaesthesiology and Critical care, Silchar Medical College, Silchar, Assam after obtaining institutional ethical committee clearance. Only ASAI and II without any anticipated difcult airway (MPS-I) and who had given valid informed consent were included. 100 ASA I&amp; II of age 18-60 years were divided into Group-A and Group-B of 50 in each group (n=50). Group-A received inj atracurium 0.5 mg/kg IV &amp; group-B received inj cisatracurium 0.3 mg/ kg IV. Patients with cardiovascular or neuromuscular disease or on drugs known to interact with muscle relaxants, history of allergy to study drugs were excluded from the study. Results: Onset time, duration of action,intubating conditions, haemodynamic effects and signs of histamine release in both groups were recorded.In Group-A, mean onset time and duration of actions were 178.72±12.7 (sec) and 38.72±3.36(min), whereas in Group-B, it was 143.82±5.36(sec) and 56.78±1.93(min) respectively and statistically signicant (p&lt;0.05). In Group-A, 70%(35) had excellent and 30%(15) good intubation grade whereas 92% (46) had excellent and 8% (4) good in Group-B with better haemodynaemic stability &amp; no histamine release. Conclusion: In this study,we concluded that cistracurium 0.3mg/kg provided rapid onset, longer duration of action with excellent intubating conditions, better haemodynamic stability and was devoid of histamine release as compared to atracurium 0.5mg/kg .

Mycobacterium avium Complex-associated Pleural Effusion in an Immunocompetent Host : A Rare Case Report and Literature Review.

*Department of Medicine †Division of Pulmonary and Critical Care Department of Medicine, Mount Sinai School of Medicine/Elmhurst Hospital Elmhurst Hospital, Elmhurst, NY Disclosure: There is no conflict of interest or other disclosures.

Obesity and Critical Illness-Associated Mortality: Paradox, Persistence and Progress.

Both authors: Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA. *See also p. 484. The authors have disclosed that they do not have any potential conflicts of interest.

COMPARISON BETWEEN PRE-EMPTIVE THORACIC EPIDURALANALGESIA VS CONVENTIONAL THORACIC EPIDURALANALGESIA IN PATIENTS UNDERGOING THORACOTOMY IN A TERTIARY CARE CENTRE

Background: Relative effects of timing of providing analgesia, type of surgery of local anaesthetics used for postoperative thoracic epidural analgesia and the possibility of establishment of pre-emptive analgesia as a superior mode for thoracic epidural analgesia are still in grey zone. In this observational study, we evaluated the idea of Pre-emptive thoracic epidural analgesia which can counter the post thoracotomy pain through pain scoring. Objective: To nd out whether pre-emptive thoracic epidural analgesia is superior to conventional postoperative epidural analgesia for post-thoracotomy pain. Study Design: Observational study. Place and Duration of Study: Department of Anesthesiology and Critical Care, Assam Medical College and Hospital, from Januray 2022 to January 2023. Methodology:After ethical committee approval and informed consent from patients, 22 patients undergoing thoracotomy were included in study. Preoperatively thoracic epidural catheter was inserted at T8-9 intervertebral space level. Group P was given 0.5ml/kg of 0.125% bupivacaine before induction of anesthesia; whereas group C was administered 0.5 ml 0.125% bupivacaine after closure of wound in supine position. All patients received thoracic epidural analgesia with a bolus dose of 0.1 ml/kg of 0.125% bupivacaine every 6 hourly post operatively .Visual analog scale (VAS) was used to assess pain severity at 1 and 24 hours postoperatively, both at rest and after cough (R1, R24, C1 and C24 respectively). Data were analyzed with SPSS and Microsoft Excel 2010. Results: There was no statistical difference in demographic prole of both groups in terms of age, gender, American Society of Anaesthesiologists (ASA) status or type of surgery, complications. Pain was signicantly less in group P at 1hour postoperatively (p=0.0001). However, there was no difference in pain severity at rest at 24 hours and with cough at 01 hour or 24 hours postoperatively. Conclusion: Pre-emptive thoracic epidural analgesia provides better pain control in immediate post operative period at rest. However, no such differences were observed in pain scores in immediate post operative period on coughing. No differences were observed at 24 hours at rest or coughing in both the groups

Surveying the changes in serum ubiquitin C-terminal hydrolase-L1 levels in severe traumatic brain injury patients

Objective: To investigate the change in serum ubiquitin C-terminal hydrolase-L1 protein (UCH-L1) levels in severe traumatic brain injury patients. Subject and method: Thirty-nine patients with severe traumatic brain injury were treated at the surgical critical care department, 103 Military Hospital. The patients were treated to the protocol, and information was collected in the medical records for research and testing. UCH-L1 at time T0, T1, T2, T3, T4 and T5. A prospective cohort study. Result: Serum UCH-L1 concentration gradually increased from T0 (9.18ng/mL) to T1 (11.59ng/mL) and peaked at T2 (19.9ng/mL), then gradually decreased over time. The median serum UCH-L1 concentration in the surviving group was constantly lower than in the death group. The biggest difference observed at T1 (10.47ng/mL and 46.76ng/mL), however, was not statistically significant with p=0.063, while the difference was statistically significant at T3, T4, and T5. Conclusion: Serum UCH-L1 levels in patients with severe TBI increased gradually from T0 to T1 and peaked at T2, then gradually decreased at T5. Serum UCH-L1 levels in the surviving group were constantly lower than those in the death group, but there was no significant difference between T0, T1, and T2, whereas at points between T3, T4, and T5, the difference was statistically significant.

Amnesia as an Adverse Event Associated With Fentanyl: An Analysis of the US Food and Drug Administration Adverse Event Reporting System, 2011-2021.

*Department of Medicine, Soldiers’ Home, Chelsea ‡Massachusetts Department of Public Health, Jamaica Plain, MA †Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA W.A.K.: funded by 1R01NS082309-01A1. Serves as a legal consultant for multiple legal and health care entities. Receives royalty payments Oxford University Press and Elsevier, as well as honoraria from National Institutes of Health study sections. Serves on editorial boards for Neurocritical Care and Journal of Neurosurgical Anesthesiology. Coauthored provisional patent number 17-8261/103241.000816 Trustees of the University of Pennsylvania. The remaining authors have no conflicts of interest to declare. Address correspondence to: Jed A. Barash, MD, Department of Medicine, Soldiers' Home, 91 Crest Avenue, Chelsea, MA 02150; telephone: (617) 884-5660; e-mail: [email protected]

Ultrasound-Guided Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Laparoscopic Inguinal Hernia Repair and Appendicectomy Using Ropivacaine With Dexmedetomidine.

Background The present study aims to investigate the efficacy of ultrasound-guided quadratus lumborum (QL)block versus transversus abdominis plane (TAP) block for laparoscopic inguinal hernia repair and appendicectomy using ropivacaine with dexmedetomidine for quality and duration of postoperative analgesia. Settings and design This was a prospective, randomized, single-blind study conducted for one year (September 2020-August 2021) in the Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, after obtaining ethical clearance from the institutional ethics committee. Methods A total of 64 patients of American Society of Anesthesiologists (ASA) grades I-II and ages between 20 and 50 years undergoing laparoscopic inguinal hernia repair and appendicectomy were randomly allocated into two groups of 32 each; group A received ultrasonography (USG)-guided quadratus lumborum block using 0.5% ropivacaine 20 ml with dexmedetomidine 0.5 mcg/kg of body weight, and group B was given USG-guided transversus abdominis plane block using 0.5% ropivacaine 20 ml with dexmedetomidine 0.5 mcg/kg of body weight after the induction of general anesthesia and before surgical incision. Data were analyzed using Student's t-test, Mann-Whitney U test, and chi-square test as applicable. Results The duration of analgesia was statistically higher (P<0.001) in group A (21.00±3.73 hours) as compared to group B (14.44±2.99 hours).Group A had significantly less analgesic (P<0.001) at 12, 18, and 24 hours postoperatively. The visual analog scale (VAS) was significantly decreased in group A at rest and movement. The range of percentage changes in heart rate (HR) was significantly higher in group B as compared to group A at 12, 18, and 24 hours(group A: 7.23%-14.70%; group B: 6.41%-28.01%). The mean blood pressure (MBP) was significantly increased in group B at 12, 18, and 24 hours as compared to group A. The range of changes in baseline MBP in group A was less than in group B(group A: 0.73%-8.34%; group B: 0.73%-18.20%). Conclusion Quadratus lumborum block is effective and better than transversus abdominis plane block for providing postoperative analgesia during laparoscopic inguinal hernia repair and appendicectomy.

Diagnostic Value of Bronchoscopy in Critically Ill Ventilated Patients with the Lower Respiratory Tract Infections: Role in Detecting Bronchial Microbial Patterns

BACKGROUND: Flexible bronchoscopy is an essential tool in critical care medicine. It provides direct access to the lower airways for sampling bronchial and parenchymal tissues directly at the site of lung lesion. AIM: The aim of the study was to study the value of Broncho-Alveolar Lavage (BAL) using bronchoscopy in detecting the bronchial microbial patterns in patients with pneumonia and also, to study the effect of antibiotic upgrading according to BAL results on patients’ outcome. PATIENTS AND METHODS: Sixty patients who were admitted to critical care department and developed pneumonia and put on mechanical ventilator were included in the study consecutively. Clinical and laboratory data were recorded on admission. Clinical and laboratory data, CPIS, PSI, PIRO and IBMP-10 scores were recorded on admission. All patients had bronchoalveolar lavage after diagnosis of pneumonia was established. The BALF was sent for culture and sensitivity. RESULTS: From a total of 60 patients with VAP, 51.7% were males, the age was 59.6 ± 17.5 years, mortality rate was 86.7%. In the non-survival group, the PSI was 133.4 ± 29.4 (p = 0.836). The APACHE II was 18.8 ± 6.6 (p = 0.432), PIRO 1.5 ± 1.1 (p = 0.014), and IBMP – 10 2.3 ± 1.1 (p = 0.021); all were higher in the non-survival group. BAL can detect up to 90% of pathogens responsible for the infection in the lower respiratory tract, while sputum can detect only 55% with accuracy of 65% (p = 0.006). Our results suggest that BAL culture and sensitivity was superior to sputum culture and sensitivity in detecting microorganisms with none of them had statistically significant relation to survival. High PIRO and IBMP-10 scores were good predictors for high mortality unlike PSI or APACHE II. CONCLUSION: Broncho-Alveolar Lavage (BAL) using bronchoscopy can detect the bronchial microbial patterns and superior to sputum culture but has no impact on mortality.

Dexmedetomidine-induced polyuria in a patient with a vestibular schwannoma.

Anaesthesia ReportsVolume 11, Issue 1 e12222 Clinical and Educational Article Dexmedetomidine-induced polyuria in a patient with a vestibular schwannoma S. Kadian, S. Kadian Senior Resident orcid.org/0000-0002-3290-1589 @@kadian_sakshi Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, IndiaSearch for more papers by this authorS. Mallikarjuna, S. Mallikarjuna Senior Resident orcid.org/0000-0002-8260-8276 @@swathim92 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, IndiaSearch for more papers by this authorT. Jamir, T. Jamir Junior Resident orcid.org/0000-0001-9337-296X Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, IndiaSearch for more papers by this authorS. Agrawal, Corresponding Author S. Agrawal Professor and Head of Department sanjay.anaes@aiimsrishikesh.edu.in orcid.org/0000-0002-2806-1943 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, India Correspondence to: S. Agrawal Email: sanjay.anaes@aiimsrishikesh.edu.in Search for more papers by this author S. Kadian, S. Kadian Senior Resident orcid.org/0000-0002-3290-1589 @@kadian_sakshi Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, IndiaSearch for more papers by this authorS. Mallikarjuna, S. Mallikarjuna Senior Resident orcid.org/0000-0002-8260-8276 @@swathim92 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, IndiaSearch for more papers by this authorT. Jamir, T. Jamir Junior Resident orcid.org/0000-0001-9337-296X Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, IndiaSearch for more papers by this authorS. Agrawal, Corresponding Author S. Agrawal Professor and Head of Department sanjay.anaes@aiimsrishikesh.edu.in orcid.org/0000-0002-2806-1943 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, India Correspondence to: S. Agrawal Email: sanjay.anaes@aiimsrishikesh.edu.in Search for more papers by this author First published: 17 March 2023 https://doi.org/10.1002/anr3.12222Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume11, Issue1January‐June 2023e12222 RelatedInformation

Perioperative pearls on epilepsy surgery.

Department of Neuroanaesthesiology and Critical Care, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India Address Correspondence to: Ashish Bindra, DM, Department of Neuroanaesthesiology and Critical Care, First Floor, Room No. 118, JPNA Trauma Centre, AIIMS, New Delhi 110029, Delhi, India. E-mail: [email protected]

Tocilizumab Therapy in Critically Ill Patients with Coronavirus Disease-2019 Pneumonia. A Propensity Score-adjusted Analysis

BACKGROUND: Extubation failure of patients on mechanical ventilation is relatively a frequent finding in the intensive care unit (ICU) and associated with poor prognosis. AIM: We conducted this study in Critical Care Department, Cairo University hospitals in which we aimed to assess if there is advantage to use high flow nasal cannula (HFNC) or non-invasive ventilation (NIV) over conventional oxygen therapy (COT) in success of extubation of patients. METHODS: The study included 60 patients and was randomized into three equal groups. The first group used HFNC, the second group used COT, while the third group used NIV. The reintubation rate, ICU stay, ICU mortality, and 28-day mortality were followed in all groups. RESULTS: The all study population had a mean age of 62 ± 21, 31 patients were male, and 21 patients were smokers. SOFA score on admission, APACHE II, and SOFA pre-extubation was not significantly different in the three groups. Reintubation rate was higher in COT group compared to HFNC or NIV groups (p &lt; 0.05). ICU stay was longer in COT compared to the other two groups, while ICU and 28-day mortality showed no significant difference among the all groups. CONCLUSION: Use of HFNC and NIV was associated with lower reintubation rate, improved oxygenation and shorter ICU stay but no significant effect on mortality in comparison with COT.

Identifying Sources of Moral Distress Amongst Critical Care Staff During the Covid-19 Pandemic Using a Naturalistic Inquiry.

Moral distress can have a significant impact on the mental health and well-being of practitioners. Causes of moral distress in critical care have been identified as futile treatment, conflict between family members and staff, lack of resources, and dysfunctional teams. This study explores the sources of moral distress during the COVID-19 pandemic and the meaning that staff attached to these events. The study aims to examine whether the sources of moral distress are similar, or different, to those that commonly occur in critical care departments. Naturalistic inquiry using semi-structured individual interviews with 17 participants drawn from nursing (n = 12), medicine (n = 3), and the allied health professions (n = 2). The interviews were recorded and transcribed verbatim. The transcripts were analyzed using reflexive thematic analysis. The results suggested that while there were some similar sources of moral distress including caring for dying patients and not being able to provide the usual standard of care, the nature of the disease trajectory and frequency of death had a significant impact. In addition, the researchers found that providing care which was counter-intuitive, concerns about the risks to the staff and their families and the additional burdens associated with leading teams in times of uncertainty were identified as sources of moral distress. This study explored the potential sources of moral distress during the pandemic and the meaning that practitioners attached to their experiences. There were some similarities with the sources of moral distress in critical care which occur outside of a pandemic. However, the frequency and intensity of the experiences are likely to be different during a pandemic, with staff describing high volumes of deaths without family members present. In addition, new sources of moral distress related to uncertainty, counter-intuitive care and concerns about personal and family risk of infection were identified.

Evaluation of Inferior Vena Cava Collapsibility Index as a Predictor of Hypotension Following General Anaesthesia with Thiopentone Induction: An Observational Study

Introduction: Hypotension during surgery can significantly increase morbidity and mortality. Volume depletion poses a major risk for intraoperative hypotension. The role of the Inferior Vena Cava Collapsibility Index (IVCCI) in assessing volume status is crucial, but its utility in predicting hypotension after the induction of general anaesthesia has been less evaluated. Aim: To evaluate the usefulness of IVCCI in predicting postinduction hypotension after general anaesthesia, with the primary objective being to assess the correlation between IVCCI and hypotension. Materials and Methods: An observational study was conducted in the Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma, PGIMS, Rohtak, Haryana,India. Total 100 patients scheduled for elective surgery under general anaesthesia with thiopentone induction. IVCCI was measured preoperatively in spontaneously breathing patients. The patients were grouped into CI+ (Collapsible) and CI- (Non collapsible) groups based on IVCCI values of ≥ 50% and ≤ 50%, respectively. Haemodynamic parameters were recorded for up to one hour after anaesthesia induction. Hypotension was defined as a fall of more than 20% in Systolic Blood Pressure (SBP) or SBP &lt;90 mmHg or a mean blood pressure of &lt;60 mm Hg. Receiver Operating Characteristic (ROC) curve was used to evaluate the performance of IVCCI, and multivariate logistic regression was employed to identify predictors of hypotension. Independent t-test was used for quantitative associations, while Chi-square and Fisher’s-exact test were used for qualitative associations, with a p-value &lt;0.05 considered significant. Results: The mean age of the patients in the study was 42.11±12.6 years. Out of 100, total 44 patients experienced post-induction hypotension, which was significantly higher in females compared to males (p-value=0.02). The mean Basal Metabolic Index (BMI) of the study population was 21.2±3.06 kg/m2 , but hypotension was more common in underweight patients with a BMI &lt;18.5 kg/ m2 (p-value=0.0007). The results showed a significant correlation between IVCCI and hypotension (p-value&lt;0.05). The mean value of IVCCI (%) was 47.34±6.96 in hypotensive patients, which was significantly higher than non hypotensive patients with a mean of 28.45±7.05 (%) (p-value&lt;0.0001). The ROC curve demonstrated an excellent representation of IVCCI (%) (Area Under the ROC Curve (AUC) 0.944; 95% CI: 0.879 to 0.980) in predicting hypotension, with a sensitivity of 95.5% and specificity of 94.6% for hypotension. IVCCI (%) was a significant independent risk predictor of hypotension with a cut-off point of &gt;38, as determined by performing multivariate logistic regression. Conclusion: Preoperative assessment of IVCCI is highly sensitive and specific for prediction hypotension induced by general anaesthesia. It is recommended as a screening tool for high-risk patients.