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Background The world is presently struggling with the pandemic of COVID-19 (coronavirus disease). Owing to the poor outcome and high contagiousness of COVID-19, cardiopulmonary resuscitation (CPR) of COVID-19-positive patients is still questionable. Main body It is imperative for the healthcare workers to follow the precautions during CPR of suspected or confirmed COVID-19 patients. In the present article, we have compiled the resuscitation guidelines subjected to the availability of resources in India/developing nations. Conclusion Compression-only CPR should be initiated whether cardiac arrest is of presumed hypoxic or cardiac etiology. If a patient with an unknown status/suspected/confirmed COVID-19 has out of the hospital cardiac arrest, hands-only CPR could be performed only after covering the mouth and nose of the patient and healthcare worker with the face mask or cloth. During in-hospital cardiac arrest, patients should be shifted to a negative pressure ventilation room, and healthcare worker should wear personal protective equipments.

Background: Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes. We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOT-VTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysm clipping in aneurysmal subarachnoid hemorrhage patients.Methods: Fifty adults scheduled for urgent craniotomy for aneurysm clipping were randomly allocated to 2 groups: group G (n = 25) received GDFT guided by LVOT-VTI and group C (n = 25) received CVP-guided fluid management. The primary outcome was intraoperative mean arterial pressure (MAP). Secondary outcomes included volume of fluid administered and several other intraoperative and postoperative variables, including neurological outcome at hospital discharge and at 30 and 90 days.Results: There was no difference in MAP between the 2 groups despite patients in group G receiving lower volumes of fluid compared with patients in group C (2503.6 ± 534.3 vs. 3732.8 ± 676.5 mL, respectively; P < 0.0001). Heart rate and diastolic blood pressure were also comparable between groups, whereas systolic blood pressure was higher in group G than in group C at several intraoperative time points. Other intraoperative variables, including blood loss, urine output, and lac-tate levels were not different between the 2 groups. Postoperative variables, including creatinine, duration of postoperative mechanical ventilation, length of intensive care unit and hospital stay, and incidence of acute kidney injury, pneumonitis, and vasospasm were also comparable between groups. There was no difference in neurological outcome at hospital discharge (modified Rankin scale) and at 30 and 90 days (Extended Glasgow Outcome Scale) between the 2 groups. Conclusion:Compared with CVP-guided fluid therapy, transesophageal echocardiography-guided GDFT maintains MAP with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications.

The patient profile undergoing neurosurgery varies from neonates to elderly, and from patients undergoing elective surgery to patients undergoing emergency surgeries. The goals of postoperative management include prevention of secondary brain injury and taking care of the major organ systems till the time patient recovers from the primary insult. Postsurgery, patients may be shifted to a neurosurgical intensive care unit or managed in a neurosurgical ward. As a general rule, all patients should be nursed 30-degree head up. We will be discussing the basic principles of postoperative management of neurosurgical patients.

Background: Manipulation during endotracheal intubation in patients with craniovertebral junction (CVJ) anomalies may cause neurological deterioration due to underlying instability. Fiberoptic-bronchoscopy (FOB) is better than video laryngoscope (VL) for minimizing cervical spine movement during intubation. However, evidence suggesting superiority of FOB in patients with CVJ instability is lacking. We prospectively compared dynamic movements of the upper cervical spine during intubation using FOB with VL in patients with CVJ anomalies. Methods: A prospective, randomized, and clinical trial was conducted in 62 patients of American Society of Anaesthesiologist Grade I-II aged between 12 and 65 years with CVJ anomalies. Patients were randomized for intubation under general anesthesia with either VL or FOB. The intubation process was done with application of skeletal traction and recorded cinefluroscopically. The dynamic interrelationship of bony landmarks (horizontal, vertical, and diagonal distances between fixed points on posterior C1 and C2) was analyzed to indirectly calculate alteration of the upper cervical spinal canal diameter (at CVJ). Atlanto-dental interval (ADI) was calculated wherever possible. Results: The alteration in canal diameter (using bony landmarks) at CVJ during intubation was not significant with the use of either VL or FOB (P > 0.05). In 41 patients, where ADI could be measured, ADI was reduced (increased spinal canal diameter) in a greater number of patients in VL group when compared to FOB group (P < 0.05). Conclusion: Using rigid skull traction, intubation under general anesthesia with VL offers similar advantage as FOB in terms of the spinal kinematics in patients with CVJ anomalies/instability. Nevertheless, greater number of patients intubated with VL may have an advantage of increased cervical spinal canal diameter when compared to FOB.

Background: The maintenance of hemodynamic stability is of pivotal importance in aneurysm surgeries. While administering anesthesia in these patients, the fluctuations in blood pressure may directly affect transmural pressure, thereby precipitating rupture of aneurysm and various other associated complications. We aimed to compare the effects of ketofol with propofol alone when used as an induction and maintenance anesthetic agent during surgical clipping of intracranial aneurysms. Materials and Methods: Forty adult, good-grade aneurysmal subarachnoid hemorrhage patients posted for aneurysm neck clipping were included in the study. The patients were randomized into two groups. One group received a combination of ketamine and propofol (1:5 ratio) and the other group received propofol for induction and maintenance of anesthesia. Intraoperative hemodynamic stability, intraventricular pressure, and quality of brain relaxation were studied in both the groups. Results: The patients were comparable with respect to demographic profile, Hunt and Hess grade, world federation of neurological surgeons (WFNS) grade, Fisher grade, duration of anesthesia, duration of surgery, optic nerve sheath diameter, and baseline hemoglobin. Intraoperative hemodynamics were better maintained in the ketofol group during induction, with only 15% of patients having >20% fall in mean arterial pressure (from baseline) intraoperatively, compared to 45% of patients receiving propofol alone ( P = 0.038). The mean intraventricular pressure values in both the groups were in the normal range and the quality of brain relaxation was similar, with no significant difference ( P > 0.05). Conclusion: Ketofol combination (1:5) as compared to propofol alone provides better hemodynamic stability on induction as well as maintenance anesthesia without causing an increase in intracranial pressure. Effect of ketofol on cerebral oxygenation and quality of emergence need to be evaluated further by larger multicentric, randomized control trials.

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