Darshana Rathod

Background: Cannulation of the internal jugular vein (IJV) is traditionally performed in the supine position; however, during surgeries in the prone position, it may become necessary to obtain central venous access because of unexpected blood loss. Methods: This prospective, randomized, open-label, non-inferiority trial was conducted at an academic medical center between May 2024 and June 2025. A total of 192 adult patients requiring IJV cannulation were enrolled and randomly assigned to two groups: the supine (S) group and the prone (P) group. All procedures were performed using an ultrasound (USG)-guided short-axis, out-of-plane approach. The primary outcome was to compare first-attempt success between the supine and prone positions. Secondary outcomes included comparisons of access time, guidewire insertion time, catheterization time, number of attempts, and associated complications. Results: The first-attempt success rate was 90.62% in the supine position compared with 77.08% in the prone position (absolute risk difference, 13.54%; two-sided 90% CI, 4.95–22.13%), indicating that the non-inferiority of prone vs supine was not demonstrated. The prone group had considerably longer access, guidewire insertion, and catheterization times than the supine group ( P < 0.0001). However, despite these statistically significant differences, successful cannulation was achieved in both groups. The complication rates were similar across the two groups ( P = 0.688). Conclusion: In this study, USG-guided IJV cannulation in the prone position did not meet the pre-specified criterion for non-inferiority compared with the supine approach. It was nonetheless achievable in all patients in the hands of skilled practitioners, suggesting its use as a rescue option rather than as a comparable alternative.

Shalini Bala, Tanvi M Meshram, Pradeep Bhatia, Darshana Rathod, Manbir Kaur, Kamlesh Kumari. Journal of Minimally Invasive Surgery 2025;28:176-83. https://doi.org/10.7602/jmis.2025.28.4.176

Background: Postoperative pain after laparoscopic surgery can include referred shoulder pain, visceral pain, and incisional pain, often due to CO₂ insufflation and peritoneal irritation. Although opioids are widely used for pain management, their side effects, such as sedation, nausea, and constipation, can delay recovery and increase costs. Opioid-free anesthesia (OFA) is an emerging alternative that aims to relieve pain using non-opioid medications, reducing these risks and potentially enhancing recovery. Methods: This single-center, prospective, randomized controlled trial included neonates and infants (ASA 1 and 2) undergoing laparoscopic or endoscopic surgeries. Participants randomly received either opioid-based anesthesia (OA) with intravenous fentanyl at induction, followed by continuous infusion or OFA with ketamine at induction, followed by infusion. The primary outcome was postoperative pain, assessed using the Neonatal Infant Pain Scale (NIPS) on admission to the post-anesthesia care unit (PACU). Secondary outcomes included pain scores at intervals up to 12 h postoperatively. Results: NIPS scores were significantly higher in the OFA group in the PACU, with more patients experiencing moderate pain (NIPS >4) in the first hour (41.7%, n = 20 vs. 16.6%, n = 8, respectively; P < 0.001). Both approaches demonstrated similar intraoperative stability, recovery, and safety, suggesting that either method can be chosen based on clinical requirements. Conclusions: OA with fentanyl offered superior immediate postoperative analgesia compared to OFA with ketamine, while both approaches demonstrated comparable intraoperative stability, recovery profiles, and safety, supporting their use based on clinical needs and patient-specific factors.

Background and Aims: Analgesic efficacy and safety of continuous catheter technique in transmuscular quadratus lumborum block (QLB3) for laparoscopic nephrectomy has not been studied. This study was planned to evaluate the efficacy and safety of ultrasound (US)-guided continuous QLB3 for postoperative analgesia after laparoscopic nephrectomy. Material and Methods: In this randomized, open-label, single-centered trial, 64 patients belonging to the American Society of Anesthesiologists, physical status grade I and II, 18–65 years of age, scheduled for laparoscopic nephrectomy were included. Patients were randomized into the QLB group and the control group. After surgery, the QLB group received transmuscular QLB with a 0.4 mL/kg bolus of 0.25% ropivacaine and catheter insertion for continuous infusion of 0.25% ropivacaine at 0.1 mL/kg/h. Patients in both groups received fentanyl (0.5 μg/kg) as rescue analgesia by IV PCA pump. Results: The data of 30 patients in each group were analyzed. Total fentanyl consumption during the first 48 h postoperatively was significantly lower in the QLB group compared to the control group (mean ± SD; QLB group = 74.33 ± 32.75 μg; control group = 209.10 ± 52.04 μg) (P < 0.001). Postoperative NRS pain scores at rest and on movement were significantly lower in the QLB group compared to the control group at various time intervals up to 48 h postoperative (P < 0.05). No severe complications were seen in any of the patients. Conclusions: US-guided continuous catheter transmuscular QLB reduced postoperative opioid consumption by 64.45% and decreased NRS pain scores after laparoscopic nephrectomy without complications.

Background: No research has been conducted to compare long-axis in-plane and short-axis out-of-plane techniques for ultrasound-guided posterior tibial artery cannulation in adults. This study compared these two procedures for cannulating the posterior tibial artery. Methods: This prospective randomized trial included 236 adult patients undergoing general anesthesia who required arterial cannulation. The posterior tibial artery was cannulated using either the long-axis in-plane technique (group LAIP) or the short-axis out-of-plane method (group SAOP) with an ultrasound machine. First-attempt cannulation success, the number of cannulation attempts required to achieve successful cannulation, ultrasound localization time, cannulation time, and perioperative complications in these two groups were analyzed. Results: The LAIP group demonstrated a significantly higher first-attempt success rate (40.7% vs 18.6%, p < 0.001), shorter ultrasound localization time (36.5 [30, 60] s vs 50 [35, 80] s, p < 0.001), and faster cannulation time (80 [55, 100] s vs 110 [70, 180] s, p < 0.001). LAIP group showed a significantly higher overall success rate (92.4% vs 81.4%, p = 0.012). The median number of cannulation attempts in the LAIP and SAOP groups were 2 [1, 2] and 2 [2, 3], respectively ( p < 0.001). Complications were comparable between groups ( p = 0.248). Conclusions: The LAIP group demonstrated higher first-attempt and overall success rates compared to the SAOP group for ultrasound-guided posterior tibial artery (PTA) cannulation in adult patients.

Background and Aims: Preoperative parental anxiety can have a profound impact on their children undergoing surgery. The present study was done to analyse the correlation between preoperative parental anxiety and their child’s anxiety in paediatric patients undergoing elective surgery. Methods: Paediatric patients aged 2–12 years, scheduled for elective surgeries under general anaesthesia, were included in the study. The child’s behaviour and anxiety were assessed in the preoperative area using the modified Yale Preoperative Anxiety Scale (m-YPAS). The parent filled out the demographic questionnaire and the Spielberger State–Trait Anxiety Inventory (STAI) form in the preoperative area on the day of surgery. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) statistics software version 23.0 (IBM Corp, Armonk, NY, USA). Results: A total of 150 children undergoing elective surgery were analysed. Our results showed a strong positive correlation between a child’s m-YPAS and his/her parents’ anxiety on the day of the surgery (STAI-state) ( r = 0.545, P < 0.001). However, the correlation between a child’s m-YPAS and his/her parents’ anxiety levels (STAI-trait) was not found to be significant ( r = 0.109, P = 0.188). A positive correlation was observed between a parent’s STAI-state and STAI-trait ( r = 0.366, P < 0.001). Factors like area of residence, type of surgery and previous hospitalisation had an influence on the anxiety levels of the child. The birth order of the child, previous hospitalisation and gender of the parent also influenced parental anxiety. Conclusion: Parental anxiety has a significant impact on the child’s anxiety during the preoperative period.

How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod DK, Meshram T, et al. Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia. Indian J Crit Care Med 2024;28(6):626–627.

Background:Acute hypoxemic respiratory failure is among the more commonly occurring complications in postoperative patients. Supplemental oxygen and addressing the primary etiology form the basis of its treatment. Materials and methods: We conducted an open -labeled randomized control trial with 90 adult patients and compared three oxygen delivery vehicles (ODV), i.e., noninvasive ventilation (NIV), high -flow nasal cannula (HFNC), and venturi mask (VM) in postoperative hypoxemic patients. The primary outcome variable was a change in the P/F ratio after 2 hours of use of ODV. Results: It was observed that the change in P/F ratio after 2 hours was similar in all three ODV groups (p = 0.274). The mean values of the postODV P/F ratio were comparable with the pre-ODV P/F ratio in all three modalities. The P/F ratio after HFNC was 358.08 +/- 117.95; after NIV was 357.60 +/- 220.67; and after VM was 355.47 +/- 101.90 (p = 0.997). Conclusion: Among HFNC, NIV, and VM, none of the devices proved superior to the other for use in postoperative hypoxemia.