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Q7. Preoperative Assessment and Anaesthetic Plan for a 65-year-old Male with COPD + T2DM Posted for Cataract Surgery [4+6]

Part A: Preoperative Assessment [4 marks]

History

• Duration, severity, and exercise tolerance for COPD (MRC dyspnoea scale)
• Frequency of exacerbations, hospitalizations, need for home oxygen
• Current medications: metformin, rosiglitazone, inhaled bronchodilators (SABA/LABA), inhaled corticosteroids
• Recent upper respiratory tract infection (URTI) - contraindication if within 4 weeks
• Glycaemic control - last HbA1c, fasting blood glucose, hypoglycaemic episodes
• Allergy history, prior anaesthetic exposure

Physical Examination

• Respiratory: barrel chest, wheeze, air entry, SpO2 on air, peak flow / spirometry
• Cardiovascular: BP, pulse, JVP - COPD with cor pulmonale risk
• Airway: Mallampati, neck mobility, mouth opening (cataract - need for cooperation or immobility)
• Signs of periorbital or systemic infection

Investigations

• ECG: right heart strain pattern (cor pulmonale), arrhythmias
• Chest X-ray: hyperinflation, bullae
• Pulmonary Function Tests (PFT): FEV1/FVC ratio (obstructive pattern), reversibility
• ABG if SpO2 <94% or severe COPD
• Blood glucose, HbA1c, U&E, creatinine (metformin - hold if renal impairment, eGFR <30 ml/min)
• Note: Rosiglitazone (thiazolidinedione) - check for fluid retention, cardiac failure

Optimization

• Continue inhalers on morning of surgery; salbutamol nebulization pre-op if needed
• Hold metformin 48 hours pre-op for procedures with general/regional anaesthesia risk (though cataract is day-case)
• Rosiglitazone - associated with fluid retention and LVF; ECG and cardiac assessment
• Chest physiotherapy if exacerbation features
• Postpone if active URTI or uncontrolled diabetes (glucose >15 mmol/L)

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Part B: Anaesthetic Plan [6 marks]

Choice of Anaesthesia - Local/Regional Preferred

Topical Anaesthesia

• Proxymetacaine 0.5% or lignocaine 4% drops repeated 3-4 times
• Suitable for phacoemulsification
• No akinesia of eye muscles - requires cooperative patient

Peribulbar Block (Preferred)

• Lignocaine 2% + bupivacaine 0.5% (1:1 mix) + hyaluronidase
• Provides globe anaesthesia + akinesia
• Avoid retrobulbar block (retrobulbar haemorrhage, brainstem anaesthesia risk)
• Add sedation with midazolam 1-2 mg IV or low-dose propofol TCI for anxiolysis

If General Anaesthesia Required (uncooperative patient)

• Pre-oxygenation is mandatory (reduced FRC in COPD, obesity risk)
• Avoid intubation if possible - use supraglottic airway (LMA) to minimize airway stimulation
• Induction: propofol IV (avoid ketamine - raises IOP)
• Avoid suxamethonium - raises IOP by 6-8 mmHg (contraindicated)
• Use rocuronium for intubation if needed; reverse with sugammadex
• Volatile agent: sevoflurane preferred (bronchodilatory, less airway irritation)
• Desflurane is relatively contraindicated - airway irritant
• IPPV with low tidal volume, higher RR, I:E ratio 1:3 (COPD)
• Avoid N2O (bowel distension risk, also closed-space expansion)

Intraoperative Precautions

• Avoid rises in IOP: smooth induction, no coughing/straining on LMA/ETT
• Monitor SpO2, EtCO2, blood glucose (2-hourly)
• Keep glucose 6-10 mmol/L intraoperatively
• Avoid extreme head positions - compromised venous return in COPD

Postoperative

• Ensure adequate analgesia (paracetamol)
• Resume inhalers immediately; nebulization if bronchospasm
• Resume metformin when eating and drinking post-op
• Day-case feasible with local anaesthesia; 2-4 hour observation if GA used

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Q8. Inadequate Reversal of Neuromuscular Blockade (NMB) During GA [3+2+5]

Part A: Causes [3 marks]

Drug-Related

1. Excessive depth of blockade - reversal attempted at deep block (0/4 twitches on TOF); neostigmine is ineffective at deep block
2. Wrong reversal agent - neostigmine used without anticholinergic (atropine/glycopyrrolate), causing paradoxical weakness
3. Neostigmine overdose (>0.07 mg/kg) - paradoxical weakness due to depolarization block at NMJ (cholinergic crisis)
4. Insufficient dose of neostigmine given too early when block too deep

Patient/Physiological Factors

1. Hypothermia - reduces metabolism of muscle relaxants, impairs reversal
2. Acid-base disturbance - respiratory acidosis potentiates non-depolarizing NMB
3. Electrolyte imbalance - hypokalaemia, hypermagnesaemia, hypocalcaemia potentiate blockade
4. Renal/hepatic failure - reduced clearance of aminosteroid drugs (vecuronium, rocuronium)
5. Drug interactions - aminoglycosides, clindamycin, calcium channel blockers, furosemide potentiate NMB

Monitoring Related

1. No quantitative TOF monitoring - inadequate assessment of block depth before reversal; subjective fade assessment misses TOF ratio 0.3-0.4

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Part B: Signs and Symptoms of Residual Paralysis [2 marks]

Subjective (Patient)

• Unable to sustain eye opening, diplopia
• Weak phonation, inability to protrude tongue
• Dysphagia, inability to protect airway

Objective (Clinical/Monitor)

• Head lift <5 seconds (insensitive - requires TOF ratio >0.6)
• Weak handgrip, inability to lift leg
• Decreased tidal volume, paradoxical breathing
• SpO2 desaturation, hypercarbia
• Inspiratory stridor post-extubation
• Gold standard: Quantitative TOF monitoring - TOF ratio <0.9 = residual paralysis
• Absent/fade on train-of-four (TOF ratio <0.7), double-burst stimulation fade

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Part C: Management [5 marks]

Immediate

1. Do NOT extubate - maintain ventilatory support until adequate recovery
2. Reassess depth of block using quantitative TOF monitoring
3. Correct reversible causes: warm the patient (hypothermia), correct acidosis and electrolytes

Pharmacological Reversal

• Neostigmine 0.04-0.07 mg/kg IV + glycopyrrolate 0.2 mg (or atropine 0.01 mg/kg)
• Only give at TOF count ≥2 (moderate block)
• Onset 7-10 min; re-test TOF after 10 min

• Fresh Frozen Plasma or fresh blood to provide pseudocholinesterase
• Supportive ventilation until spontaneous recovery

Monitoring After Reversal

• Confirm TOF ratio ≥0.9 before extubation
• Use acceleromyography or electromyography (quantitative)
• Maintain warm, normocapnic environment
• Post-extubation: PACU observation with SpO2, RR monitoring

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Q9. Labour Analgesia Plans for a 22-year-old Primigravida [10 marks]

Introduction

• Stage 1 (T10-L1): Visceral pain from uterine contractions and cervical dilatation
• Stage 2 (S2-S4): Somatic pain from perineal stretching

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A. Non-Pharmacological Methods

1. Psychoprophylaxis / Lamaze technique - antenatal education, breathing exercises, relaxation
2. Continuous labour support (doula) - reduces analgesic requirement
3. TENS (Transcutaneous Electrical Nerve Stimulation) - applied to paraspinal T10-L1; modest benefit in early labour
4. Hydrotherapy - warm bath/pool immersion; reduces pain scores in early labour
5. Acupuncture/hypnosis - limited evidence but acceptable to discuss

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B. Systemic Opioid Analgesia

1. Intramuscular Pethidine (meperidine) - 75-100 mg IM; onset 20 min, duration 3-4 h. Most commonly used in India. Crosses placenta - can cause neonatal respiratory depression (antidote: naloxone 0.01 mg/kg neonatal dose)
2. Fentanyl IV PCA - 10-25 mcg bolus, 10 min lockout. Better maternal satisfaction than pethidine. Less neonatal depression due to shorter half-life
3. Morphine - Used in early labour; not preferred near delivery (neonatal depression, active metabolites)
4. Tramadol - 50-100 mg IM/IV; less neonatal depression but less effective than pethidine
5. Remifentanil PCA (IV) - 20-40 mcg bolus, 2 min lockout. Ultra-short acting (t1/2 4 min), minimal placental transfer. Requires close SpO2 monitoring. Emerging as alternative when epidural contraindicated.

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C. Regional Analgesia (Gold Standard)

1. Epidural Analgesia - Most Effective

• Indications: Any stage of labour, maternal request
• Contraindications: Coagulopathy (platelets <80,000), infection at site, patient refusal, uncorrected hypovolaemia
• Technique: L3-L4 or L2-L3 space, epidural catheter placed
• Drugs: Bupivacaine 0.0625-0.125% + fentanyl 2 mcg/ml
• Initiation: 10-15 ml bolus (test dose 3 ml bupivacaine 0.5% + adrenaline 1:200,000 to exclude intravascular placement)
• Maintenance: PCEA (Patient Controlled Epidural Analgesia) preferred - 5 ml bolus + 5 ml/h background infusion
• Advantages: Excellent analgesia, can be topped up for LSCS if needed, motor block minimal with low concentration
• Complications: Dural puncture (1%), post-dural puncture headache (PDPH), hypotension, pruritus, motor block

2. Combined Spinal-Epidural (CSE)

• Technique: Spinal injection + epidural catheter at same sitting (needle-through-needle technique)
• Spinal component: Bupivacaine 2.5 mg + fentanyl 25 mcg intrathecally - rapid onset (5-10 min)
• Epidural component: For maintenance and top-up as required
• Advantage: Fast onset for spinal, flexibility of epidural; "walking epidural"
• Used when rapid initial analgesia required

3. Intrathecal Opioid Alone (Spinal)

• Fentanyl 25 mcg or sufentanil 10 mcg intrathecally in early labour
• Duration 1.5-2 h, no motor block, allows ambulation
• No further dosing possible (single shot)

4. Continuous Spinal Anaesthesia

• Reserved for those with accidental dural puncture during epidural placement
• Micro-catheter intrathecally; delivers local anaesthetic incrementally

5. Paracervical Block

• Bilateral injection at 4 and 8 o'clock positions at cervicovaginal junction
• Blocks T10-L1 visceral afferents
• High risk of fetal bradycardia (direct injection into uterine vessels); largely abandoned

6. Pudendal Nerve Block

• Bilateral block at ischial spine (S2,3,4)
• Useful for second stage and perineal repair
• Does not help with uterine pain

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D. Inhalational Analgesia

• Entonox (50% N2O + 50% O2) - self-administered via demand valve
• Onset in 30-45 seconds; patient inhales before contraction
• Provides partial but not complete analgesia
• Safe for fetus, no motor block, patient-controlled
• Side effects: nausea, dizziness, light-headedness
• Widely used in the UK and now gaining acceptance in India

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Recommended Plan for This Patient

1. Counsel patient in antenatal period about all options
2. Preferred: Epidural analgesia - gold standard, highest patient satisfaction
3. Discuss Entonox as initial option during early labour
4. Ensure platelets, coagulation tests, IV access before epidural
5. Have neonatal resuscitation ready if systemic opioids used

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Q10. Anaesthetic Considerations for Robot-Assisted Radical Prostatectomy (RARP) [10 marks]

Introduction

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A. Preoperative Assessment

• Elderly male patient (prostate cancer age group 60-75 years)
• Assess cardiac and pulmonary reserve - critical because surgery involves prolonged steep Trendelenburg
• BMI - obesity worsens respiratory compromise in Trendelenburg
• Concurrent medications: anticoagulants (stop as per protocol), antihypertensives
• Previous abdominal surgeries - adhesions may prevent pneumoperitoneum
• Investigations: ECG, echocardiogram if indicated, PFTs, BUN/creatinine, CBC, coagulation

---

B. Airway and Ventilation

Airway

• Endotracheal intubation mandatory (cuffed ETT) - LMA contraindicated with steep Trendelenburg + pneumoperitoneum (risk of aspiration, inadequate seal)
• Assess for potential difficult intubation (steep Trendelenburg causes pharyngeal oedema)
• Airway oedema worsens over time - assess before extubation

Ventilatory Challenges

• Steep Trendelenburg + pneumoperitoneum causes:
  • Cephalad diaphragm displacement - reduced FRC, atelectasis
  • Increased peak airway pressures and plateau pressures
  • CO2 absorption from pneumoperitoneum - hypercarbia
  • Worsened V/Q mismatch

Ventilation Strategy

• Lung-protective ventilation: tidal volume 6-8 ml/kg IBW
• PEEP 5-8 cmH2O to prevent atelectasis
• Increase RR to maintain normocapnia (EtCO2 35-40 mmHg)
• Intraoperative recruitment manoeuvres after positional changes
• Avoid excessive airway pressures

---

C. Cardiovascular Effects

Haemodynamic Effects of Trendelenburg + Pneumoperitoneum

• Initial increase in preload and cardiac output (Trendelenburg-autoloading effect)
• Increased SVR due to pneumoperitoneum (CO2 absorption + mechanical compression of aorta)
• Increased ICP (intracranial pressure) - head-down position raises cerebral venous pressure
• Raised IOP (intraocular pressure) - risk of ischaemic optic neuropathy
• Venous stasis in lower limbs

Management

• Invasive arterial line (IBP) for beat-to-beat monitoring if >3 hours or significant comorbidity
• Central venous access if indicated
• Avoid excessive fluid administration (worsens oedema, especially facial/airway)
• Vasopressors (phenylephrine, noradrenaline) for hypotension
• Restrict fluid to 500-1000 ml crystalloid + replace urine output

---

D. Positioning Complications

Nerve Injuries (most common complication)

• Brachial plexus injury - arm boards incorrectly positioned, shoulder braces
• Common peroneal nerve - pressure at fibular head in lithotomy
• Femoral nerve - extreme hip flexion
• Prevention: Well-padded shoulder braces, arms tucked at sides, check all pressure points

Ocular Complications

• Raised IOP throughout case - risk of ischaemic optic neuropathy (ION)
• Avoid direct pressure on eyes; check every 30 min
• ION rare but devastating; higher risk with >4 h surgery

Compartment Syndrome

• Lower limb compartment syndrome with prolonged lithotomy; release at 4-6 hours if needed

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E. Pneumoperitoneum Management

• IAP (intra-abdominal pressure) 12-15 mmHg
• CO2 insufflation - absorbed systemically causing hypercarbia; increase minute ventilation
• Gas embolism: rare but life-threatening - desaturate, haemodynamic collapse, "mill-wheel" murmur
• Pneumothorax (CO2): desaturation, raised airway pressures; confirm with chest X-ray or ultrasound

---

F. Anaesthetic Technique

General Anaesthesia

• Induction: propofol + fentanyl/remifentanil; rocuronium for intubation
• Maintenance: TIVA (propofol + remifentanil) preferred over volatiles (easier EtCO2 control, less PONV)
• Alternatively: sevoflurane/desflurane in O2/air mixture (no N2O)
• Neuromuscular blockade: moderate block maintained (TOF count 1-2) for optimal surgical conditions; reverse with sugammadex at end
• NMJ monitoring is essential

Analgesia

• Multimodal: paracetamol + NSAIDs + opioids
• Transverse abdominal plane (TAP) block / rectus sheath block at end of surgery
• Avoid morphine (nausea in elderly); use oxycodone or fentanyl PCA

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G. Specific Concerns

---

H. Postoperative

• Urinary catheter in situ (routine)
• DVT prophylaxis: LMWH + TEDS
• Adequate analgesia: paracetamol + NSAIDs + opioid PRN
• Early mobilization
• Monitor for urinary/surgical complications

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Q11a. NDPS Act (Narcotic Drugs and Psychotropic Substances Act, 1985) [5 marks]

Background

Objectives

1. To prohibit and control illicit production, manufacture, cultivation, possession, sale, purchase, transport, storage, and consumption of narcotic drugs and psychotropic substances
2. To implement India's obligations under international conventions (Single Convention on Narcotic Drugs 1961; Convention on Psychotropic Substances 1971)
3. To provide for severe penalties for drug trafficking
4. To allow legitimate medical and scientific use under strict control

Key Provisions

Definitions (Section 2)

• Narcotic drug: Includes coca leaf, cannabis (hemp), opium, poppy straw, and all manufactured drugs including morphine, heroin, codeine, fentanyl, methadone
• Psychotropic substance: Any natural or synthetic substance listed in the schedule - amphetamines, benzodiazepines, barbiturates, LSD, MDMA

Section 8 - Prohibition

Schedules

• Schedule I - Prohibited drugs (no commercial use permitted)
• Schedule II, III - Drugs with controlled medical/scientific use

Penalties

• Offences involving "small quantity" - imprisonment up to 6 months + fine
• Offences involving "commercial quantity" - mandatory 10-20 years' rigorous imprisonment + fine up to Rs. 2 lakh
• Repeat offences - enhanced penalties including death penalty in some cases

2014 Amendment - Critical for Anaesthesiologists

• Relaxed restrictions on Essential Narcotic Drugs (ENDs) - morphine, fentanyl, methadone
• State governments can now license hospitals and practitioners to procure, stock, and prescribe ENDs
• Simplified procurement for palliative care and pain management
• Introduced "medical practitioner" and "hospital" as authorized persons for limited use

Relevance to Anaesthesia Practice

Obligations on Hospitals/Departments

1. Maintain a narcotic register - each vial dispensed and administered must be recorded
2. Double-lock storage for narcotic drugs
3. Only authorized signatories can procure
4. Annual audit and submission to Drug Controller
5. Unused or wasted drugs must be witnessed and countersigned

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Q11b. Point of Care Coagulation Monitoring [5 marks]

Introduction

Why POC Over Conventional Tests?

• Conventional tests (PT, aPTT, INR) measure isolated plasma coagulation pathways, require centrifugation, and have a 30-60 minute turn-around time
• POC tests assess whole blood including platelets and fibrinolysis in real time
• Reduces empirical transfusion of blood products, guides component-specific therapy

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A. Viscoelastic Tests (VETs) - Primary POC Modalities

1. Thromboelastography (TEG) - Haemonetics Corporation

• Principle: A cup of blood oscillates; a pin suspended in the cup measures viscoelasticity as clot forms
• Uses citrated whole blood; recalcified at time of testing
• Generates a characteristic tracing with the following parameters:

2. Rotational Thromboelastometry (ROTEM) - Werfen

• Principle: Pin rotates within cup; resistance measured as clot forms
• Uses separate channels with different activators:
  • EXTEM: Extrinsic pathway (tissue factor activated)
  • INTEM: Intrinsic pathway (contact activated)
  • FIBTEM: Fibrinogen contribution (with platelet inhibitor)
  • APTEM: Fibrinolysis assessment (aprotinin added)

3. Platelet Function Analyser (PFA-100 / Multiplate)

• Assesses primary platelet plug formation
• Used for platelet function disorders, monitoring antiplatelet therapy

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B. Clinical Applications

1. Cardiac Surgery (On-Pump)

• Heparinization and reversal guided by POC ACT (Activated Clotting Time)
• Post-bypass: VETs identify whether bleeding is from heparin rebound, thrombocytopenia, low fibrinogen, or fibrinolysis - direct component therapy accordingly

2. Trauma / Massive Haemorrhage Protocol

• TEG/ROTEM guide ratio of RBC:FFP:platelets
• Detect hyperfibrinolysis early (LY30 >3% = treat with tranexamic acid)
• Evidence: reduces FFP and platelet transfusion without increasing mortality

3. Liver Transplantation

• Complex coagulopathy during hepatic surgery; reperfusion triggers fibrinolysis
• ROTEM FIBTEM guides cryoprecipitate use; APTEM diagnoses fibrinolysis

4. Obstetric Haemorrhage

• Detects consumptive coagulopathy (DIC), hypofibrinogenaemia
• Targets: MCF/MA >50 mm, fibrinogen >2 g/L

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C. Advantages

• Rapid results (15-20 minutes)
• Whole blood, global haemostasis assessment
• Identifies specific deficiency: platelet, fibrinogen, or clotting factor
• Reduces unnecessary FFP and platelet transfusion

D. Limitations

• Not available in peripheral hospitals
• Requires trained operator and quality control
• TEG/ROTEM not standardized across machines
• Does not assess endothelial function or primary haemostasis well (except PFA)
• Reference ranges vary with patient population

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Q12a. Closed-Loop Drug Delivery Systems in Anaesthesia [5 marks]

Concept

Components

1. Sensor/Monitor - measures the controlled variable (e.g., BIS for depth, neuromuscular monitor for relaxation, blood pressure monitor for haemodynamics)
2. Controller - algorithm that compares measured value to the target ("set point") and calculates the required infusion rate change
3. Actuator/Infusion pump - delivers drug at the calculated rate
4. Feedback loop - output of sensor continuously updates the controller

Types of Controllers Used

• PID (Proportional-Integral-Derivative): Most widely used; uses three components:
  • Proportional: responds to current error
  • Integral: responds to accumulated past error
  • Derivative: responds to rate of change
• Model-based (Bayesian/pharmacokinetic): Uses pharmacokinetic-pharmacodynamic models to predict drug levels and guide dosing

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Applications in Anaesthesia

1. Closed-Loop Anaesthetic Depth Control

• Variable monitored: BIS (Bispectral Index) or Entropy
• Drug controlled: Propofol infusion (TIVA) or volatile anaesthetic delivery
• Target: BIS 40-60
• Clinical trials show equivalent or better outcomes vs manual TIVA in maintaining BIS target
• Examples: McSleepy system (University of Montreal); RUGLOOP system

2. Closed-Loop Neuromuscular Blockade

• Variable monitored: TOF ratio (acceleromyography)
• Drug controlled: Atracurium or rocuronium infusion
• Target: TOF count 1-2 (moderate block)
• Prevents over- or under-dosing; avoids residual paralysis

3. Closed-Loop Haemodynamic Management

• Variable monitored: Arterial blood pressure, cardiac output (FloTrac/LiDCO), SvO2
• Drugs controlled: Phenylephrine/noradrenaline vasopressor, colloid fluid
• Used in Goal-Directed Therapy (GDT) protocols
• System: CLMS (Closed-Loop Modulated Sedation); HemoSphere platform
• Reduces intraoperative hypotension time, decreases vasopressor use

4. Closed-Loop Ventilation

• Variable monitored: SpO2, EtCO2, compliance
• System adjusts: FiO2, tidal volume, RR, PEEP
• Used in ICU ventilators (SmartCare/PS); not yet routine in theatre

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Advantages

• More stable drug titration, less variability
• Reduces anaesthetist workload during complex procedures
• Reduces risk of under- or over-dosing
• May improve outcomes (reduced PONV, faster recovery, reduced opioid consumption)

Limitations/Challenges

• Signal artefacts in the sensor can cause incorrect drug dosing
• Safety mechanisms (upper/lower infusion limits) are critical
• High initial cost; not yet widely commercially available
• Regulatory approval challenges
• Cannot replace clinical judgement in emergencies

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Q12b. Advanced Airway Imaging [5 marks]

Introduction

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A. Airway Ultrasound

Uses

1. Confirmation of tracheal intubation - trachea shows "comet tail" artefact; oesophageal intubation shows double-trachea sign
2. Cricothyroid membrane (CTM) identification - most important use
   • CTM identified at bedside before awake intubation or anticipated difficult airway
   • Superficial to skin; identified as hypoechoic space between cricoid and thyroid cartilage
   • Reduces risk of failed cricothyrotomy
3. Prediction of difficult intubation:
   • Pre-tracheal soft tissue thickness at hyoid level >2.8 cm correlates with difficult intubation in obese patients
   • Tongue base thickness, mandible-hyoid distance can be measured
4. Subglottic diameter - important for selecting correct ETT size, especially in paediatric patients
5. Tracheal shift - identifies deviation from central position in mediastinal masses
6. Assessment of vocal cord function - dynamic assessment using high-frequency probe

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B. CT Scan of Airway

Indications

• Mediastinal masses, tracheal tumours, stenosis
• Vascular rings, tracheomalacia
• Tracheal deviation or compression

What It Provides

• 3D reconstruction of entire airway from nasopharynx to carina
• Quantifies degree of tracheal narrowing and its extent
• Identifies subglottic stenosis (grade/level)
• Plans awake intubation level or need for awake tracheostomy

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C. MRI of Airway

• Best soft tissue resolution
• Used for: pharyngeal anatomy, tongue base masses, hypopharyngeal tumours
• Predicts difficult airway in morbid obesity (tongue volume, palatal length)
• Not practical in emergency but useful in planned difficult airway cases

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D. Nasal Endoscopy / Nasendoscopy

• Flexible fibreoptic laryngoscopy in clinic (awake)
• Assesses vocal cord movement, laryngeal masses, subglottic pathology
• Standard pre-assessment for known/anticipated difficult intubation
• Guides decision between awake FOI vs videolaryngoscopy vs surgical airway

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E. Video Laryngoscopy (Indirect Laryngoscopy)

• Not traditional "imaging" but provides real-time video display of larynx
• Glidescope, C-MAC, Airtraq - provide magnified glottis view without line-of-sight
• Reduces intubation failure in anticipated difficult airway from 15% to <5% (ASA DAM Guidelines 2022)

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F. Fluoroscopy / Plain X-Ray

• Lateral neck X-ray: retropharyngeal abscess, epiglottitis (thumb sign), foreign body
• CXR: tracheal deviation, mediastinal widening, double-shadow (aortic aneurysm compressing trachea)
• Fluoroscopy: dynamic assessment of airway collapse, stenosis, vocal cord movement

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Summary Table

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Q13. Diagnostic Criteria for Clinical Diagnosis of Brain Death [10 marks]

Definition

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Prerequisites (Must Be Met Before Testing)

1. Establish a definite cause of coma - structural brain injury (trauma, haemorrhage, hypoxic-ischaemic injury) must be identified; diagnosis must be consistent with brain death
2. Rule out reversible conditions:
   • Drug intoxication / sedative overdose (check drug levels; hold benzodiazepines, opioids for appropriate washout period)
   • Severe metabolic disturbance (Na+, glucose, hepatic/renal failure)
   • Hypothermia - core temperature must be >36°C (97°F)
   • Neuromuscular blocking drug effect (confirm reversal with TOF monitoring)
3. Systemic oxygenation and perfusion must be adequate (systolic BP >100 mmHg, SpO2 >94%)
4. In India, the Transplantation of Human Organs Act (THO Act, 1994) mandates certification by a panel of 4 doctors including a neurologist/neurosurgeon for organ donation purposes

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Clinical Testing: Three Core Components

I. Absence of All Cerebral Functions

• Deep coma - no purposeful movement, no vocalization
• No response to painful stimuli applied to upper and lower body (supraorbital pressure, trapezius pinch, sternal rub)
• Spinal reflexes may persist (deep tendon reflexes, plantar withdrawal) - these do NOT exclude brain death as they are spinally mediated
• Posturing (decerebrate/decorticate) is usually absent; if present, diagnosis should be reconsidered

II. Absence of All Brain Stem Reflexes

III. Apnoea Test

1. Pre-oxygenate with 100% FiO2 for 10 minutes to achieve PaO2 >200 mmHg
2. Obtain baseline ABG (PaCO2 should be 35-45 mmHg; adjust ventilation if needed)
3. Disconnect from ventilator
4. Deliver 100% O2 via T-piece/apnoeic oxygenation at 6-8 L/min (ensures O2 supply but no CO2 washout)
5. Observe for any respiratory effort for 8-10 minutes
6. Repeat ABG at end - PaCO2 must rise to ≥60 mmHg (or 20 mmHg rise above baseline)
7. Test is positive (confirms brain death) if NO respiratory effort is observed

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Number of Examinations and Examiner Qualifications

• In most guidelines (AAN 2010; India THO Act): two separate examinations by two different physicians
• Time interval: at least 6 hours apart in adults
• At least one must be a neurologist or neurosurgeon (for organ donation certification in India)
• Attending anaesthesiologist cannot be the certifying physician if organs are being procured

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Ancillary/Confirmatory Tests (when clinical testing cannot be completed)

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Documentation Required (India - THO Act 1994)

1. Time and date of examination
2. Names and designations of all four certifying physicians
3. Results of each clinical test
4. Apnoea test result with ABG values
5. Ancillary test report if performed
6. Family informed consent for organ donation (separate)

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Q14. CCLS Algorithm (IRC) and Parameters of Good Quality CPR [10 marks]

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Introduction

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CCLS Algorithm - Steps

PATIENT COLLAPSES / FOUND UNRESPONSIVE
              |
    STEP 1: SAFE PLACE
    Ensure safe environment; shift patient to firm surface
              |
    STEP 2: CALL FOR HELP
    Activate Emergency Response System
    Call for crash cart / defibrillator
              |
    STEP 3: CHECK RESPONSE
    Gently shake and shout: "Are you all right?"
              |
    NO RESPONSE
              |
    STEP 4: CHECK BREATHING & PULSE
    Simultaneously (maximum 10 seconds)
    - Look, listen, feel for breathing
    - Check carotid pulse
              |
         /         \
    PULSE           NO PULSE
    Present         Absent
       |               |
  Rescue         STEP 5: START CPR
  Breathing      30 chest compressions : 2 ventilations
                        |
              STEP 6: ATTACH DEFIBRILLATOR / MONITOR
                   Analyse rhythm
                  /              \
         SHOCKABLE             NON-SHOCKABLE
         (VF / pVT)            (PEA / Asystole)
              |                       |
    DEFIBRILLATE 200J          Continue CPR 2 min
    (Biphasic)                 IV/IO access
    Resume CPR immediately     Adrenaline 1 mg IV
              |                every 3-5 min
    Continue CPR 2 min               |
    IV/IO access                Identify & treat
    Adrenaline 1 mg IV           Reversible causes
    every 3-5 min                    (4H & 4T)
    After 3rd shock:
    Amiodarone 300 mg IV
              |
         REASSESS RHYTHM EVERY 2 MINUTES
              |
         ROSC ACHIEVED?
         /           \
        YES           NO
         |             |
   POST-RESUSCITATION  Continue CCLS
   CARE               Consider advanced
                      interventions

Reversible Causes - 4H and 4T

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Drug Doses in CCLS

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Parameters of Good Quality CPR

1. Chest Compression Rate

• 100-120 compressions/minute (not "as fast as possible")
• Above 120/min - incomplete recoil; below 100/min - inadequate perfusion

2. Compression Depth

• 5-6 cm (2-2.4 inches) in adults
• More than 6 cm increases risk of rib fractures and liver laceration
• Less than 5 cm - inadequate perfusion pressure

3. Complete Chest Recoil

• Allow full chest recoil between compressions
• Do NOT lean on the chest between compressions
• Incomplete recoil raises intrathoracic pressure, reduces venous return and coronary perfusion

4. Minimize Interruptions (CCF - Chest Compression Fraction)

• Target CCF >80% (compression fraction of total CPR time)
• Pre-shock pause <10 seconds
• Post-shock pause <10 seconds
• No unnecessary pulse checks

5. Ventilation

• 2 rescue breaths for every 30 compressions (30:2 ratio for unintubated patient)
• Once intubated: 10 breaths/min without interrupting compressions
• Avoid hyperventilation - raises intrathoracic pressure, reduces coronary perfusion pressure
• Each breath: 1 second, enough to cause chest rise (tidal volume ~500-600 ml)

6. Avoid Excessive Ventilation

• Hyperventilation is harmful - raises intrathoracic pressure, reduces ROSC

7. Compressor Fatigue

• Switch compressor every 2 minutes (with rhythm check) to avoid fatigue-related quality decline
• Fatigue sets in within 1-2 minutes; evident by compression depth and rate reduction

8. Monitoring CPR Quality

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"Push hard (5-6 cm), push fast (100-120/min), allow full recoil, minimize interruptions, avoid hyperventilation, rotate compressors every 2 min, and monitor EtCO2."

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Q5. Dynamic and Static Parameters of Fluid Responsiveness + PiCCO Monitor [5+5]

Part A: Parameters of Fluid Responsiveness [5 marks]

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Static Parameters

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Dynamic Parameters

• Stable vasomotor and cardiac function
• Mechanically ventilated, sinus rhythm, no arrhythmias
• Tidal volume ≥8 ml/kg
• PEEP <15 cmH2O (no auto-PEEP)
• No abdominal compartment syndrome or cardiac tamponade

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• Measured from arterial line waveform
• PPV = (PPmax - PPmin) / [(PPmax + PPmin) / 2] × 100
• PPV >13% predicts fluid responsiveness (sensitivity 80%, specificity 83%, AUC 0.86)
• Most widely used dynamic parameter in clinical practice

• Variation in stroke volume with respiratory cycle
• SVV >10-15% = fluid responsive
• Derived from arterial waveform analysis (FloTrac, PiCCO, LiDCO)
• Sensitivity 82%, specificity 77%, AUC 0.87

• Total variation in systolic BP during one respiratory cycle
• SPV = delta-up + delta-down; >10 mmHg suggests hypovolaemia
• Simpler but less specific than PPV

• Patient position: semi-recumbent → legs raised 45° (transferring ~300 ml blood from legs to central circulation = auto-fluid challenge)
• Positive response: CO increase ≥10% within 60-90 seconds
• Advantage: reversible (no actual fluid given), useful in spontaneously breathing patients and atrial fibrillation
• Limitation: contraindicated in raised ICP, severe ARDS, abdominal hypertension

• 100-200 mL crystalloid bolus over 1 minute
• Positive if CO increases ≥10% (detected by pulse contour analysis or echocardiography)
• Less risk than 500 mL challenge

• 15-second end-expiratory pause increases venous return
• Positive if CO/pulse pressure increases ≥5%

• FTc <0.35 sec suggests hypovolaemia (fluid responsive)
• FTc >0.40 sec suggests euvolaemia/fluid non-responsive

• Collapsibility = (IVC max - IVC min) / IVC max × 100
• >18% = fluid responsive in mechanically ventilated patients

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Part B: PiCCO Monitor - Principle and Clinical Utilisation [5 marks]

What is PiCCO?

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Technical Requirements

• Central venous catheter (internal jugular or subclavian) for cold saline injection
• Arterial catheter with a thermistor tip - placed in femoral, brachial, or axillary artery (NOT radial - too far from injection site)
• Dedicated bedside monitor

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Principle: Two Techniques Combined

1. Transpulmonary Thermodilution (Calibration)

• 15-20 mL ice-cold 0.9% NaCl (0-8°C) injected rapidly into CVC
• Cold bolus passes through: SVC → right heart → pulmonary vasculature → left heart → aorta → detected at femoral arterial thermistor
• Temperature-time curve plotted (Stewart-Hamilton equation)
• CO = Volume × (T blood - T injectate) / Area under curve
• Also measures volumetric and extravascular lung water parameters

2. Pulse Contour Analysis (Beat-to-Beat)

• Between thermodilution calibrations, CO is continuously estimated from arterial waveform morphology
• Stroke volume derived from the area under the systolic portion of arterial pulse
• Requires recalibration every 8-12 hours or after major haemodynamic changes

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Parameters Provided by PiCCO

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Unique Advantage: EVLWI

• EVLWI >10 ml/kg indicates significant pulmonary oedema
• PVPI >3 suggests pulmonary permeability oedema (ARDS-like) vs PVPI <3 hydrostatic oedema (cardiogenic)
• Guides decision to restrict fluids vs diuretics vs ventilatory strategies

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Clinical Utilisation

• Goal-directed therapy (GDT): target CI >2.5, SVR >900, EVLWI <10, GEDVI >680
• Guides fluid resuscitation vs vasopressor escalation
• Differentiates distributive (low SVR) from cardiogenic (low CO, high PCWP surrogate) shock

• Monitors EVLWI for post-bypass pulmonary oedema
• Distinguishes between tamponade (low CO, high SVR), LV failure, or hypovolaemia

• When arterial line + CVC already in situ, PiCCO provides comprehensive haemodynamic data

• PVPI guides fluid strategy (restrictive in ARDS with high PVPI)
• EVLWI serves as an endpoint for diuretic therapy

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Limitations

• Requires femoral or brachial arterial catheter (no radial artery)
• Calibration affected by intracardiac shunts, aortic regurgitation, irregular rhythms
• Cannot be used with aortic balloon pump
• Not validated in pregnancy or severe TR/MR
• Cost higher than standard arterial line monitoring

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Q6. Fluid Compartmental Model Updates + Newer Modalities for Perioperative Fluid Management [5+5]

Part A: Fluid Compartmental Model - Recent Updates [5 marks]

Traditional (Starling) Model

• Jv = net fluid flux
• Kf = filtration coefficient
• Pc, Pi = capillary and interstitial hydrostatic pressures
• πc, πi = capillary and interstitial oncotic pressures
• σ = reflection coefficient

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Revised Starling Model (2010-present)

• The vascular endothelium is coated by a 0.2-0.5 µm thick glycocalyx - a mesh of proteoglycans, glycoproteins, and plasma proteins
• The glycocalyx acts as the principal barrier to plasma protein extravasation (not the vascular wall itself)
• The sub-glycocalyx space (between glycocalyx and endothelial cell) has near-zero oncotic pressure - meaning plasma proteins DO NOT extravasate across intact glycocalyx
• This explains why colloids do NOT redistribute to interstitium under normal conditions (explaining their longer intravascular t1/2 than previously thought)

• The oncotic pressure that matters is the difference between intravascular oncotic pressure and sub-glycocalyx oncotic pressure (not interstitial oncotic pressure)
• Sub-glycocalyx oncotic pressure is near zero in healthy endothelium
• Therefore, all colloid infused stays intravascular as long as glycocalyx is intact

• Trauma, sepsis, ischaemia-reperfusion, hyperglycaemia, and excessive crystalloid infusion all damage the glycocalyx
• Degradation products (syndecan-1, heparan sulphate) measurable in plasma as biomarkers of glycocalyx injury
• Once degraded: oncotic pressure gradients are lost, capillary leak increases, colloids behave like crystalloids
• This explains why albumin infusion in critical illness often fails to raise oncotic pressure predictably

• Classical model assumed a free fluid-filled interstitium
• Revised model: interstitium has a gel phase (collagen + hyaluronan) that buffers fluid accumulation
• Under normal conditions, the interstitium has low compliance; once saturated, tissue oedema develops rapidly

• Excessive crystalloid administration in surgery causes glycocalyx disruption → capillary leak → tissue oedema
• Colloids (albumin, starches) maintain intravascular volume better when glycocalyx is intact
• Once glycocalyx is damaged (sepsis, trauma), colloids leak too - so restrict fluids, use vasopressors
• Hyperchloraemic acidosis from large volumes of 0.9% NaCl (strong ion difference effect) → prefer balanced crystalloids (Plasma-Lyte, Hartmann's)

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Part B: Newer Modalities for Perioperative Fluid Management [5 marks]

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1. Oesophageal Doppler Monitoring (ODM) - CardioQ

• Flexible Doppler probe measures blood velocity in descending thoracic aorta
• Parameters: FTc (Corrected Flow Time), descending aortic SV, peak velocity
• FTc <0.35 sec → administer 250 mL colloid bolus; repeat until FTc >0.4
• RCT evidence (Gan et al.): ODM-guided GDT reduced hospital LOS in major surgery
• Limitation: requires intubated patient; cannot use in oesophageal pathology
• Endorsed by NHS NICE (UK) for routine use in major surgery

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2. Arterial Pulse Contour Analysis - FloTrac/Vigileo, LiDCOrapid, PiCCO

• Continuous beat-to-beat CO, SV, SVV, PPV derived from arterial waveform
• Minimally invasive - only requires radial arterial line (FloTrac/LiDCOrapid)
• SVV >13% or PPV >13% = fluid responsive
• Algorithms use patient demographics + waveform morphology (no external calibration for FloTrac)
• PiCCO and LiDCO require calibration (thermodilution or lithium dilution)
• Validated in major abdominal, cardiac, and vascular surgery

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3. Non-Invasive Haemodynamic Monitoring

• Measures phase shift of alternating current across thorax
• Derives CO, SV, SVV non-invasively (no arterial/central line needed)
• Validated in non-intubated spontaneously breathing patients
• Useful in HDU/ward-based GDT

• PPG (photoplethysmography) waveform variation with respiration
• PVI >14% suggests fluid responsiveness
• Completely non-invasive; available on most modern pulse oximeters (Masimo Radical-7)

• Continuous finger cuff method for BP + SV + CO
• Less invasive; validated in low-to-moderate risk surgical patients

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4. Point-of-Care Ultrasound (POCUS) for Fluid Management

• IVC assessment: IVC collapsibility index (spontaneous breathing) or distensibility index (mechanical ventilation)
• Lung ultrasound: B-lines (≥3 per zone = pulmonary oedema) - guides fluid restriction
• LV function: Hyperdynamic (fluid responsive) vs dilated with impaired function
• Provides real-time, repeatable, bedside assessment without additional equipment

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5. ERAS Protocol Fluid Strategy

• Liberal pre-op hydration: No prolonged fasting - clear fluids up to 2 hours pre-op
• Targeted intraoperative: GDT using one of the above monitors
• Near-zero balance: Aim for 0 balance at end of case (+/- 500 mL)
• Avoid >3 L positive balance: Associated with increased anastomotic leak, ileus, wound complications
• Balanced crystalloids (Plasma-Lyte, Hartmann's) over 0.9% NaCl to avoid hyperchloraemic acidosis

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6. Biomarker-Guided Fluid Therapy

• Lactate clearance (target >10%/hr): guides resuscitation adequacy in sepsis
• Central venous oxygen saturation (ScvO2) >70%: endpoint of oxygen delivery
• Serum syndecan-1 and heparan sulphate: glycocalyx damage biomarkers (research stage)

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Q7a. Role of Artificial Intelligence in Anaesthesia [5 marks]

Definition

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Applications

1. Preoperative Risk Stratification

• AI models trained on large perioperative databases (NSQIP, ACS) predict:
  • Risk of postoperative complications (AKI, MACE, respiratory failure)
  • Predicted difficult airway - algorithms analyse facial features/CT data
  • Risk of awareness, PONV, postoperative pain severity
• Example: ML model predicts AKI after cardiac surgery with AUC 0.83 vs 0.72 for conventional scores (Cleveland Clinic)

2. Intraoperative Monitoring and Decision Support

• Early warning systems: AI detects haemodynamic instability 5-15 minutes before clinical detection
  • Hypotension Prediction Index (HPI) by Edwards Lifesciences - FDA-cleared; predicts hypotension (MAP <65 mmHg) up to 15 min in advance with 88% sensitivity
  • Alerts anaesthesiologist to intervene before harm occurs
• Drug dosing optimization: Reinforcement learning algorithms optimize propofol and remifentanil doses based on BIS feedback (closed-loop TIVA)
• Depth of anaesthesia monitoring: AI-enhanced EEG analysis (NeuroSense, Sedline) for more accurate depth assessment

3. Automated Anaesthesia Delivery

• Closed-loop systems for:
  • Anaesthetic depth (BIS-guided propofol)
  • Neuromuscular blockade (TOF-guided rocuronium infusion)
  • Blood pressure (vasopressor closed-loop systems)
• McSleepy (University of Montreal): fully automated TIVA using AI controller; clinical trials demonstrate non-inferior outcomes vs manual TIVA

4. Airway Management

• CNN (Convolutional Neural Networks) for difficult airway prediction from photographs
• AI-assisted videolaryngoscopy: automatically identifies Cormack-Lehane grade, confirms intubation
• Robotic intubation systems guided by AI and image analysis

5. Postoperative and ICU Applications

• Prediction of postoperative delirium from EHR data
• Automated pain assessment from facial expression analysis
• Sepsis early warning: AI models (InSight, EPIC Sepsis Model) detect sepsis 6-12 hours before clinical signs
• Predictive analytics for ICU discharge planning

6. Quality Improvement and Record Analysis

• Automated extraction and analysis of anaesthesia records (NLP)
• Detecting documentation errors, protocol deviations
• Identifying outlier drug doses, near-miss events

7. Simulation and Education

• AI-powered simulation feedback - real-time performance analysis during mannequin scenarios
• Adaptive learning platforms that customize training based on learner gaps

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Limitations and Ethical Concerns

• Explainability ("black box"): Deep learning decisions may not be interpretable
• Bias: Models trained on non-representative populations may perform poorly in diverse settings
• Over-reliance: Deskilling of anaesthesiologists
• Data security and privacy: Large healthcare datasets needed
• Regulatory approval: Most AI tools lack robust RCT validation
• Liability: Unclear when AI contributes to adverse outcomes

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Q7b. Surviving Sepsis Guidelines [5 marks]

Definition (Sepsis-3, 2016)

• Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score increase ≥2)
• Septic shock: Sepsis + vasopressor requirement to maintain MAP ≥65 mmHg + lactate >2 mmol/L despite adequate fluid resuscitation (mortality ~40%)

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SSC Hour-1 Bundle (2018 update, reaffirmed 2021)

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Key 2021 SSC Recommendations

Diagnosis

• Do NOT use qSOFA alone to screen for sepsis (low sensitivity) - use full SOFA or clinical judgement
• NEWS (National Early Warning Score) or MEWS more sensitive than qSOFA for screening

Antimicrobials

• Septic shock: Administer antibiotics immediately (within 1 hour) - strong recommendation
• Sepsis without shock: Antibiotics within 3 hours (if diagnosis uncertain, allow rapid 3-hour workup window)
• Empirical coverage: Broad spectrum covering likely pathogens; tailor once culture results available
• Procalcitonin-guided de-escalation: Recommended to guide antibiotic discontinuation
• Duration: 7-day course for uncomplicated sepsis; longer for specific sources (endocarditis, osteomyelitis)

Fluid Resuscitation

• Initial 30 mL/kg crystalloid: downgraded from strong to weak recommendation (2021 update)
• Balanced crystalloids (Plasma-Lyte, Lactated Ringer's) preferred over 0.9% NaCl (less AKI, less acidosis)
• No albumin as initial resuscitation - may consider albumin to maintain albumin >30 g/L
• After initial 30 mL/kg: use dynamic parameters (PLR, SVV, PPV) to guide further fluids - not CVP

Vasopressors

• Noradrenaline (norepinephrine) = first-line vasopressor; target MAP ≥65 mmHg
• Vasopressin (0.03 units/min) add-on to noradrenaline (spares noradrenaline, reduces tachycardia)
• Adrenaline - add to noradrenaline in refractory shock
• Dopamine - only if low risk of tachyarrhythmia (bradycardic septic shock)
• Avoid dopamine as first-line vasopressor

Corticosteroids

• Hydrocortisone 200 mg/day (50 mg every 6 h or continuous infusion) if vasopressor dose remains high despite adequate fluids
• Do NOT use ACTH stimulation test to guide steroid use

Oxygen and Ventilation

• SpO2 target 92-96% (avoid hyperoxia - excess O2 worsens outcomes)
• High-flow nasal oxygen (HFNO) for hypoxic respiratory failure - reduces need for intubation
• NIV - insufficient evidence in sepsis-induced ARDS
• If intubated: Lung-protective ventilation - TV 6 ml/kg IBW, plateau pressure <30 cmH2O
• Prone positioning if PaO2/FiO2 <150 mmHg

Blood Glucose

• Target blood glucose 7.8-10 mmol/L (140-180 mg/dL)
• Intensive insulin therapy (target <6.1 mmol/L) is harmful - increased hypoglycaemia

Blood Products

• Transfuse RBC if Hb <7 g/dL (unless ACS, severe hypoxia, cardiac disease - target 7-9 g/dL)
• FFP only if active bleeding or invasive procedure with documented coagulopathy
• Platelets if <10,000/mm³ (prophylactic); if <20,000 and high risk of bleeding; if <50,000 for procedures

New in 2021: Post-ICU / Long-term Outcomes

• Screen for physical, cognitive, and psychological rehabilitation needs before ICU discharge
• Shared decision-making for goals of care
• Medication reconciliation at ICU and hospital discharge
• Written/verbal information about sepsis and its sequelae at discharge

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Q8. Ultrasound in Perioperative Care + Haemodynamic Management with USG [4+6]

Part A: Role of Ultrasound in Perioperative Care [4 marks]

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1. Vascular Access

• Central line insertion (IJV, SCV, femoral): Real-time USG guidance reduces:
  • First-pass success rate improves from ~60% to >95%
  • Reduces carotid artery puncture, pneumothorax, haematoma
  • Now recommended as standard of care (NICE guidance IPG321; AHA guidelines)
• Arterial line: USG guided radial artery cannulation improves success in difficult cases

2. Airway Management

• Cricothyroid membrane identification: USG identifies CTM before awake intubation in obesity
• Tracheal intubation confirmation: Tracheal vs oesophageal placement (bilateral lung sliding vs esophageal sign)
• Subglottic diameter: Optimal ETT size selection in paediatrics

3. Regional Anaesthesia

• USG guidance for all peripheral nerve blocks (brachial plexus, femoral, sciatic, popliteal, etc.) and fascial plane blocks
• Reduces LA dose by 30-50% with equivalent analgesia
• Reduces rates of pneumothorax (supraclavicular block), intravascular injection, nerve injury
• Gold standard for neuraxial anaesthesia in difficult cases (obesity, scoliosis)

4. Preoperative Gastric Assessment

• Gastric ultrasound: Visualise gastric antrum in right lateral decubitus position
• Empty stomach: antrum appears flat with no content
• Full stomach (liquid): circular antrum with anechoic content
• Full stomach (solid): hyperechoic heterogeneous antrum ("frosted glass")
• Used for emergency cases with uncertain fasting history

5. Lung Ultrasound

• B-lines (vertical reverberation artefacts): 3 or more per zone = interstitial syndrome (pulmonary oedema or pneumonitis)
• Pleural effusion: Anechoic space at lung base
• Pneumothorax: Absent lung sliding + absent B-lines + lung point sign
• Lung consolidation: Hepatization pattern
• Guides decision to extubate, diurese, or drain effusion

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Part B: Haemodynamic Management Using Ultrasonography [6 marks]

POCUS for Haemodynamic Assessment - "Focus Cardiac Ultrasound" (FoCUS)

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1. Assessment of Volume Status

• Spontaneously breathing patients:
  • IVC collapsibility index (IVC-CI) = (IVCmax - IVCmin) / IVCmax × 100
  • IVC-CI >50% + IVC diameter <1.5 cm = hypovolaemia (fluid responsive)
• Mechanically ventilated patients:
  • IVC distensibility index = (IVCmax - IVCmin) / IVCmin × 100
  • Distensibility >18% = fluid responsive
  • A plethoric, non-collapsible IVC (>2.1 cm) = elevated RA pressure / fluid overload

• Reduced LV end-diastolic diameter with hyperkinetic function = hypovolaemia ("kissing" papillary muscles)
• Dilated, poorly contracting LV = cardiogenic shock

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2. Differentiating Shock Subtypes

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3. Cardiac Function Assessment

• FAC (Fractional Area Change): (EDA - ESA) / EDA × 100; >35% = normal
• EF by eyeballing (semi-quantitative): Adequate for haemodynamic decision-making
• MAPSE (Mitral Annular Plane Systolic Excursion): M-mode at mitral annulus; >8 mm = normal

• RV:LV ratio >1.0 = RV dilation
• D-sign on PSAX: septal flattening = RV pressure/volume overload (PE, pulmonary hypertension, ARDS)
• TAPSE <16 mm = RV systolic dysfunction

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4. Guiding Fluid Administration - Lung Ultrasound Integration

1. Start fluid challenge (250 mL crystalloid)
2. After each bolus, scan 8 lung zones bilaterally for B-lines
3. Stop fluids when B-lines appear/increase (pulmonary oedema developing)
4. This prevents fluid overload while allowing physiological response to each bolus

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5. Monitoring Response to Treatment

• Inotropes: reassess LV function after 15-30 min
• Vasopressors: reassess IVC and SVR (via arterial waveform)
• Volume: reassess IVC diameter and cardiac filling after each challenge

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Advantages of Haemodynamic POCUS

• Non-invasive / minimally invasive
• Immediate bedside availability
• No radiation
• Repeatable, dynamic assessment
• Integrates multiple domains (cardiac, lung, vascular) simultaneously
• Guides specific therapy rather than empirical treatment

Limitations

• Operator-dependent (learning curve: 50-100 supervised scans for competency)
• Image quality poor in obesity, subcutaneous emphysema, bandaged patients
• Cannot replace formal echocardiography for structural pathology
• No continuous monitoring capability (intermittent snapshots)

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Q9. Indian Guidelines for Preoperative Fasting + Role of Carbohydrate Loading [6+4]

Part A: Indian Guidelines for Preoperative Fasting [6 marks]

Rationale for Fasting

• Prevents pulmonary aspiration of gastric contents during anaesthesia
• However, prolonged fasting causes: dehydration, hypoglycaemia, insulin resistance, muscle catabolism, patient discomfort, delayed recovery

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ISA Guidelines for Healthy Adults Undergoing Elective Surgery

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Special Populations (ISA Guidelines)

• Same standard fasting guidelines as general population
• However, morning oral hypoglycaemics should be held; monitor blood glucose
• ISA recommends scheduling diabetics first on the operating list to minimize fasting duration

• Same minimum fasting times; but gastric emptying may be delayed
• Avoid carbohydrate loading in diabetics and markedly obese patients (use with caution)
• Prokinetics (metoclopramide 10 mg) may be considered

• Standard times may not be adequate
• Consider ranitidine 150 mg night before + morning of surgery, or PPI
• Metoclopramide 10 mg pre-op

• Labour: sips of water or isotonic sports drinks acceptable in low-risk labour
• Pre-operative LSCS (elective): 6 hours for solids, 2 hours for clear fluids
• Emergency LSCS: treat as full stomach - rapid sequence induction regardless of fasting duration

• Clear fluids: 1-2 hours
• Breast milk: 4 hours
• Formula/cow's milk/solids: 6 hours
• Encourage clear fluids until 2 hours before surgery (reduce distress, dehydration)

• Postpone if gastric emptying significantly impaired
• 2 hours for clear fluids; 8 hours for solids

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Day-of-Surgery Protocol (ISA recommended)

• Confirm fasting status on day of surgery - document time of last solid and liquid intake
• Avoid early morning cancellation due to missed clear fluid window
• Provide IV fluid (Ringer's Lactate) if patient has been fasting >8 hours

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Part B: Role of Carbohydrate Loading Preoperatively [4 marks]

Concept

Physiological Basis

• Overnight fasting causes glycogen depletion → catabolic state
• The surgical stress response (cortisol, glucagon surge) causes: insulin resistance, protein catabolism, hyperglycaemia, muscle breakdown
• Preoperative CHO loading maximises glycogen stores and reduces postoperative insulin resistance by up to 50%

Preparation Used

• 12.5% maltodextrin solution (e.g., Preop®, Pre-Op®, CarboCal®)
• 400 mL (50g CHO) the night before surgery (8-12 hours prior)
• 200 mL (25g CHO) 2-3 hours before anaesthesia induction
• Gastric emptying: t1/2 of 12.5% maltodextrin ~90 min; gastric emptying complete by 120 min (same as water)

Benefits (Clinical Evidence)

1. Reduces postoperative insulin resistance (by 50% in colorectal surgery)
2. Reduces protein catabolism and nitrogen loss
3. Maintains muscle strength postoperatively (faster rehabilitation)
4. Reduces PONV (full glycogen stores buffer metabolic disturbances)
5. Reduces preoperative thirst, hunger, anxiety - improves patient experience
6. Shorter hospital stay (2-3 days in ERAS colorectal surgery)
7. Reduces postoperative hyperglycaemia - counter-intuitive but correct (by reducing cortisol surge)

Integration with ERAS

• CHO loading is a routine element of ERAS protocols (Enhanced Recovery After Surgery)
• ERAS Society guidelines (2018): CHO loading recommended for all major elective abdominal surgery
• ISA guidelines (2020): Recommend CHO loading for elective surgery in non-diabetic adults

Contraindications

• Diabetes mellitus (especially Type 1 and poorly controlled Type 2) - risk of hyperglycaemia and delayed gastric emptying
• Gastroparesis - any cause
• GORD/hiatus hernia with impaired gastric emptying
• Intestinal obstruction

Safety Profile

• Multiple studies confirm gastric residual volumes equivalent to water at 2 hours
• No increased aspiration risk in non-diabetic patients
• Safe ASA I-III patients in elective surgery

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Q10a. Anaesthetic Technique and Cancer Recurrence [5 marks]

Background

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Mechanisms by Which Anaesthesia Affects Cancer Biology

1. Natural Killer (NK) Cell Function

• NK cells are the primary defence against CTCs
• Volatile anaesthetics (isoflurane, sevoflurane, desflurane): directly impair NK cell cytotoxicity and reduce NK cell numbers
• Opioids (morphine, fentanyl): suppress NK cell activity, reduce T-cell proliferation, increase pro-tumour cytokines (IL-6, IL-10)
• Propofol: preserves NK cell function; animal models show propofol inhibits tumour growth
• Regional anaesthesia: reduces systemic opioid requirement → less NK cell suppression

2. HPA Axis and Surgical Stress Response

• Surgery → cortisol/adrenaline surge → immunosuppression
• Regional anaesthesia blunts the neuroendocrine stress response better than GA alone
• Reduced cortisol → better NK cell and T-cell function in perioperative period

3. Angiogenesis and Tumour Microenvironment

• VEGF (Vascular Endothelial Growth Factor): promotes tumour angiogenesis; levels rise postoperatively
• Opioids upregulate VEGF signalling → promote angiogenesis
• NSAIDs (COX-2 inhibitors): reduce VEGF, reduce prostaglandin E2 (pro-tumour) → may reduce recurrence

4. Direct Effects of Anaesthetic Agents

• Propofol: inhibits tumour cell migration and invasion in vitro; reduces MMP-9 expression
• Ketamine: immunosuppressive; increases pro-tumour IL-6
• Midazolam: may suppress NK cells (GABA-A on immune cells)
• Lidocaine (IV): inhibits tumour cell proliferation and invasion; reduces IL-6; ongoing RCTs

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Clinical Evidence

Retrospective Evidence (Hypothesis-generating)

• Exadaktylos et al. (2006): Paravertebral block for breast cancer surgery reduced recurrence at 3 years (6% vs 24% with GA alone) - landmark observational study
• Biki et al. (2008): Epidural + GA vs GA alone for prostatectomy - 57% lower biochemical recurrence with epidural

Prospective RCT Evidence (The Reality Check)

• MASTER trial (Lancet 2021, n=2132): Paravertebral block + propofol TIVA vs volatile GA + opioids for breast cancer surgery - NO significant difference in cancer recurrence at 3 years
• Similar RCTs for prostatectomy (epidural + GA vs GA alone) showed no benefit
• Conclusion: Despite compelling preclinical and retrospective data, prospective RCTs have NOT confirmed that regional anaesthesia reduces cancer recurrence

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Current Recommendations

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Q10b. Newer Fascial Plane Blocks and Their Implications [5 marks]

Concept

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A. Thoracic Fascial Plane Blocks

1. PECS I Block (Pectoral Nerve Block I)

• Target plane: Between pectoralis major and pectoralis minor muscles
• Nerves blocked: Medial and lateral pectoral nerves
• LA: 10-15 ml at level of 3rd rib
• Indications: Tissue expander/implant breast surgery, port-a-cath insertion
• Limitation: Only blocks pectoral muscles, not breast tissue

2. PECS II Block

• Extension of PECS I: Second injection in plane between pectoralis minor and serratus anterior (at 4th rib)
• Nerves blocked: PECS I + intercostobrachial nerve + long thoracic nerve + upper intercostal nerves (T2-T6)
• Indications: Mastectomy, axillary clearance, sentinel lymph node biopsy
• LA: 20 ml (PECS I) + 20 ml (PECS II)

3. Serratus Anterior Plane Block (SAP Block)

• Target plane: Between serratus anterior and intercostal muscles (deep SAP) OR serratus anterior and latissimus dorsi (superficial SAP)
• Nerves blocked: Long thoracic nerve + intercostal nerve lateral cutaneous branches (T2-T9)
• Indications: Breast surgery, VATS port analgesia, rib fracture analgesia
• LA: 30-40 ml
• Advantage: Large dermatomal coverage T2-T9

4. Erector Spinae Plane Block (ESP Block)

• Target plane: Deep to erector spinae muscle, superficial to transverse process
• Nerves blocked: Dorsal and ventral rami via spread medially
• Indications: Thoracic (VATS, rib fractures, thoracotomy) and abdominal surgery; chronic pain (neuropathic, rib fractures)
• LA: 20-30 ml; spreads 3-4 levels cranially and caudally
• Site: T4-T5 for thoracic; T7-T8 for abdominal; L3-L4 for lumbar
• Advantages: Simple technique, away from neuraxis, no sympathectomy, continuous catheter possible
• Limitation: Less consistent analgesia than epidural; no motor block (good feature for ambulation)

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B. Abdominal Fascial Plane Blocks

5. Transversus Abdominis Plane (TAP) Block

• Target plane: Between internal oblique and transversus abdominis muscles
• Nerves blocked: Thoracolumbar nerves T10-L1 (anterior abdominal wall)
• Indications: Lower abdominal surgery (appendicectomy, hernia, hysterectomy, LSCS), laparoscopic surgery
• LA: 20-25 ml each side (bilateral for midline incisions)
• Limitations: Somatic analgesia only (no visceral analgesia); limited dermatomal coverage

6. Quadratus Lumborum Block (QL Block)

• Three approaches: QL1 (lateral), QL2 (posterior), QL3 (anterior/transmuscular)
• Target plane: Around quadratus lumborum muscle (posterior abdominal wall)
• Nerves blocked: T4/T7-L1 (anterior QL) - wider coverage than TAP + possible visceral component via spread to paravertebral space
• Indications: Major abdominal surgery, colorectal, renal, hip surgery
• Advantage over TAP: More dermatomal coverage, possible visceral analgesia, longer duration
• Risk: Retroperitoneal haematoma, intravascular injection

7. Rectus Sheath Block

• LA injected behind rectus abdominis muscle (posterior rectus sheath)
• Blocks T9-T11 anterior cutaneous branches
• Indications: Periumbilical incisions, laparoscopic port sites, umbilical hernia repair

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C. Lower Limb Fascial Plane Blocks

8. IPACK Block (Infiltration between Popliteal Artery and Capsule of the Knee)

• LA injected between popliteal artery and posterior femur
• Blocks articular branches of sciatic nerve (tibial, common peroneal, obturator) at the knee
• Indication: Total knee arthroplasty (TKA) - reduces posterior knee pain without motor block
• Combined with adductor canal block for complete TKA analgesia

9. Adductor Canal Block (ACB)

• LA in adductor canal (Hunter's canal) between sartorius and vastus medialis
• Blocks saphenous nerve (purely sensory) + nerve to vastus medialis
• Indication: TKA - provides knee analgesia with preserved quadriceps function (allows early mobilization)
• Advantage over femoral nerve block: No motor block → earlier rehabilitation

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Implications of Newer Fascial Plane Blocks

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Surviving Sepsis Campaign (SSC) 2026 Guidelines - Full Update

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Scope and Key Numbers

• 129 total statements (vs 93 in 2021)
• 46 new statements not addressed in 2021 guidelines
• Panel of 69 experts from 23 countries (38% from low- and middle-income countries - reflecting a major inclusivity push)
• Scope expanded: now covers prehospital, in-hospital, and immediate post-hospital settings
• Incorporates explicit antimicrobial stewardship principles
• Includes quick-reference bedside graphics and summary tables of new/revised recommendations

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The 2026 SSC Guidelines - Section by Section

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1. Performance Improvement and Recognition

• Sepsis screening for acutely ill, high-risk patients
• Standard operating procedures for treatment
• Quality improvement strategies

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2. Diagnosis and Infection Source

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3. Antimicrobial Therapy (Major Updates)

Timing

Duration and De-escalation

• 2026 New: Explicit emphasis on antimicrobial stewardship - de-escalate once culture results available
• Short course therapy (7 days) preferred for most uncomplicated sepsis
• Procalcitonin-guided de-escalation: Maintained as a recommendation to shorten antibiotic duration
• 2026 New: Conditional recommendation for selective decontamination of the digestive tract (SDD) in mechanically ventilated adults in units with low prevalence of antimicrobial resistance (moderate evidence)

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4. Haemodynamic Resuscitation (Major Updates)

Fluid Resuscitation

Fluid Removal (New 2026 Recommendation)

• 2026 New: After the acute resuscitation phase, suggest active fluid removal (diuretics; if insufficient, ultrafiltration/CRRT)
• Triggered when: vasopressors are weaning, patient is stabilizing
• Rationale: Fluid overload causes harm - positive fluid balance associated with mortality

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5. Vasopressors (Notable Changes)

First-Line Vasopressor

• Noradrenaline (norepinephrine) remains first-line - unchanged

MAP Target (Updated)

Peripheral Vasopressors (New)

• 2026 New - conditional: Suggest starting vasopressors via peripheral IV access to restore MAP rather than delaying until central venous access is secured
• Rationale: Time lost establishing CVC = worse outcomes; peripheral vasopressors safe for short-term use
• Remarks: Insufficient data on ideal IV size or anatomical location

Vasopressin

• Vasopressin add-on to noradrenaline: maintained as conditional recommendation (systematic review shows reduced mortality vs noradrenaline alone RR 0.91)

Inotropes

• Dobutamine added to noradrenaline OR adrenaline alone for cardiac dysfunction with persistent hypoperfusion: conditional recommendation
• Levosimendan: Suggest against using levosimendan in septic shock with cardiac dysfunction (insufficient benefit, potential harm)
• Midodrine (oral): Insufficient evidence to recommend for ongoing vasopressor requirements

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6. Blood Pressure Monitoring (New)

• Invasive arterial line is advised when: intermediate-to-high dose vasopressors needed, escalating or multiple vasopressors, frequent ABG sampling, or inconsistent non-invasive readings
• Previously, invasive monitoring was implied as standard; this now acknowledges non-invasive as acceptable in stable cases

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7. Oxygen and Ventilation

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8. Glucose Management (Updated)

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9. Blood Transfusion

• Restrict transfusion: Recommend restrictive (Hb <7 g/dL) over liberal strategy - strong recommendation (moderate evidence)
• Unchanged from 2021 in substance but certainty of evidence upgraded

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10. Nutrition

• 2026 New - conditional: Suggest early enteral nutrition within 72 hours of sepsis diagnosis
• Previously, enteral nutrition was mentioned but timing was not specifically addressed in SSC guidelines
• Evidence certainty: Very low (but consistent direction)

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11. Corticosteroids

• Hydrocortisone 200 mg/day for refractory septic shock (vasopressor-dependent despite adequate resuscitation): conditional recommendation maintained
• No change from 2021

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12. Renal Replacement Therapy (RRT)

• No change in fundamental approach
• Initiate RRT for established AKI with life-threatening complications (not prophylactically)
• High-dose RRT not recommended

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13. Post-Sepsis Care and Rehabilitation (Expanded Section - New in 2026)

1. Written and verbal discharge summary for all sepsis survivors and families - must include: hospital stay summary, sepsis diagnosis, treatments given, and common post-sepsis impairments
2. Follow-up with clinicians who can manage new and long-term sequelae for patients who developed new impairments during hospitalization
3. Structured rehabilitation referral - physical, cognitive, and psychological rehabilitation
4. Cognitive therapy - explicitly mentioned as a post-sepsis consideration
5. PICS (Post-Intensive Care Syndrome) screening - physical debility, cognitive impairment, and psychological disorders (depression, PTSD, anxiety) in survivors
6. Shared decision-making in ICU and hospital discharge planning
7. Healthcare systems should implement strategies to ensure continuity of care for sepsis survivors

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Comparison Table: SSC 2021 vs SSC 2026 - Key Differences

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Summary of What's Truly New in 2026

1. Abandonment of the reflexive 30 mL/kg fluid bolus - replaced by dynamic, reassessment-guided resuscitation
2. Elevated lactate ≠ automatic fluid bolus - lactate is multifactorial; other causes must be considered
3. Active fluid removal after stabilization - explicitly recommended for the first time
4. Permissive MAP target (60-65 mmHg) for elderly ≥65 years - reduces vasopressor burden
5. Peripheral vasopressor initiation - do not delay for central line placement
6. Selective digestive tract decontamination (SDD) - conditional, first time in SSC guidelines
7. Levosimendan is now discouraged in cardiac dysfunction in septic shock
8. Post-sepsis structured rehabilitation - formal recommendations for PICS, cognitive therapy, discharge planning
9. Prehospital setting now formally included in scope
10. Single blood culture site may be acceptable (new evidence reviewed)

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SSC 2026 - Surviving Sepsis Campaign Guidelines

Exam-Ready Notes for DNB Anaesthesia (10 Marks)

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DEFINITIONS (Sepsis-3, carried forward)

• Sepsis: Life-threatening acute organ dysfunction due to infection
• Septic shock: Sepsis + vasopressor requirement (MAP ≥65 mmHg) + lactate >2 mmol/L despite adequate resuscitation

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1. SCREENING AND EARLY MANAGEMENT

Performance Improvement (Statement 1)

• RECOMMEND hospitals use a sepsis performance improvement program:
  • Screening of acutely ill high-risk patients
  • Standard operating procedures for treatment
  • Quality improvement strategies
  • (Strong; moderate certainty)

Code Sepsis (Statement 2) - NEW

• SUGGEST using a "code sepsis" or "sepsis huddle" multidisciplinary bedside protocol (Conditional; low certainty)

Prehospital Screening (Statement 3) - NEW

• SUGGEST using a standard sepsis screening tool in adults being transported by ambulance/flight (Conditional; very low certainty)
• NEWS2 had best sensitivity (73.1%) vs qSOFA (sensitivity only 23.1%) prehospitally

In-Hospital Screening (Statement 4) - REVISITED

• RECOMMEND using NEWS, NEWS2, MEWS, or SIRS over qSOFA as a single screening tool (Strong; moderate certainty)
• qSOFA has poor sensitivity for sepsis; EWS are more sensitive

Biomarkers (Statements 5-6) - NEW

• Sepsis is a clinical diagnosis - NOT ruled in/out by a single biomarker (Good practice statement)
• Insufficient evidence for novel rapid host response diagnostics (IntelliSep, SeptiCyte RAPID, TriVerity, MDW)

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2. DIAGNOSIS AND INFECTION

Blood Cultures (Statement 7)

• RECOMMEND collecting blood cultures as soon as possible, ideally before antimicrobials (Strong; low certainty)
• Single-site culture: acceptable in some settings (2025 evidence shows equivalent yield, less contamination)
• Pre-antimicrobial collection reduces yield by 38% at 70 min post-antibiotic

Blood Lactate (Statement 8)

• SUGGEST measuring blood lactate (Conditional; low certainty)
• Lactate ≥2 mmol/L = septic shock (Sepsis-3); intermediate values (>2 to <4) also warrant resuscitation

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3. INITIAL RESUSCITATION

Fluid Resuscitation (Statements 9-11)

• Sepsis is a medical emergency - treat and resuscitate immediately (Good practice statement)
• SUGGEST at least 30 mL/kg IV crystalloid in first 3 hours for sepsis-induced hypoperfusion/shock (Conditional; low certainty)
  • Calculate using actual body weight (adjusted/ideal BW if BMI >30 kg/m²)
  • Frequent reassessment to avoid under- and over-resuscitation
• For sepsis-induced hypotension: SUGGEST initial fluid bolus followed by vasopressor if hypotension persists (Conditional; very low certainty)
  • In unstable shock: consider immediate concurrent vasopressors + fluid

Vasopressor Route (Statement 12) - REVISITED (previously just implied)

• SUGGEST starting vasopressors peripherally to restore MAP rather than delaying for central venous access (Conditional; very low certainty)
  • 86.6% of panelists use peripheral vasopressors
  • Monitor for extravasation; use with caution in resource-limited settings

MAP Targets (Statements 13-14)

• RECOMMEND initial MAP target of 65 mmHg over higher targets (Strong; moderate certainty)
• NEW - For adults ≥65 years: SUGGEST MAP 60-65 mmHg over higher ranges (Conditional; low certainty)
  • Trial showed equivalent mortality at lower target, less vasopressor exposure in elderly

ICU Admission (Statement 15)

• SUGGEST ICU admission within 6 hours (Conditional; low certainty)

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4. INFECTION/ANTIMICROBIALS

Antibiotic Timing - Hospital (Statements 16-20) - REVISITED

• Clinicians should perform rapid assessment of infectious vs. non-infectious etiology (Good practice statement)
• ~10-30% of sepsis-treated patients have final non-infectious diagnosis

Antibiotic Timing - Prehospital (Statement 21) - NEW

• For definite/probable sepsis + hypotension with anticipated >60 min to hospital medical evaluation:
  • SUGGEST administering antibiotics in ambulance or flight (Conditional; very low certainty)
  • Only after structured prehospital sepsis screening in place

Biomarker-Guided Initiation (Statement 22)

• SUGGEST clinical evaluation alone over PCT + clinical evaluation to start antimicrobials (Conditional; very low certainty)

Source Control (Statements 23-24) - REVISITED

• Rapidly evaluate for anatomical source requiring source control (Good practice statement)
• SUGGEST early source control (ideally within 6 hours of diagnosis) over late (Conditional; very low certainty)

Empiric MDR Coverage (Statements 25-26) - NEW

• High risk of MDR: SUGGEST empiric antimicrobial with MDR coverage (Conditional; very low certainty)
• Low risk of MDR: SUGGEST AGAINST empiric MDR coverage (Conditional; very low certainty)
• MDR risk factors: prior MDR colonization/infection, prolonged broad-spectrum antibiotics, prolonged hospitalization in high-MDR unit

Empiric Antifungal (Statement 27) - REVISITED

• SUGGEST AGAINST empirical antifungal therapy (Conditional; low certainty)
• Exception: selected patients with immunosuppression, prolonged antibiotics, intra-abdominal source, prolonged hospitalization

Anaerobic Coverage (Statements 28-29) - NEW

• Without risk factors: SUGGEST empiric regimen without anaerobic coverage (Conditional; very low certainty)
• With risk factors (intra-abdominal, necrotizing infection, head/neck, CNS abscess): SUGGEST include anaerobic coverage (Conditional; very low certainty)

ICU Microbiological Surveillance (Statement 30) - NEW

• Insufficient evidence regarding departmental upper respiratory tract surveillance samples to guide empirical therapy

Pathogen-Specific Rapid Diagnostics (Statement 31) - NEW

• SUGGEST using on case-by-case basis in selected patients based on clinical features, local patterns, availability (Conditional; low certainty)

Candida Biomarkers (Statements 32, 38) - NEW

• SUGGEST AGAINST using Candida biomarkers to initiate empiric antifungal (Conditional; low certainty)
• SUGGEST AGAINST using Candida biomarkers to discontinue empiric antifungal (Conditional; low certainty)

Prolonged Beta-Lactam Infusion (Statement 33) - REVISITED

• RECOMMEND prolonged infusion of beta-lactams (extended or continuous) for maintenance after initial loading dose (Strong; moderate certainty)
• BLING III (2024): Prolonged infusion reduced mortality (RR 0.91; 25 fewer deaths/1000 patients)
• Always give loading dose first; maintain stable IV access

TDM (Statement 34)

• SUGGEST antimicrobial TDM case-by-case based on clinical features, drug class, local pathogen patterns (Conditional; very low certainty)

De-escalation (Statements 35-37) - REVISITED

• Continuously reevaluate; discontinue empiric antibiotics if non-infectious etiology confirmed (Good practice statement)
• RECOMMEND de-escalation when confirmed microbiological diagnosis + susceptibility available (Strong; very low certainty)
• SUGGEST de-escalation when improving and no pathogen identified (Conditional; very low certainty)

Duration (Statements 39-40)

• SUGGEST shorter over longer antibiotic duration (Conditional; very low certainty)
• BALANCE trial: 7 days non-inferior to 14 days for bloodstream infection
• SUGGEST PCT + clinical evaluation to decide when to discontinue (Conditional; low certainty)
• ADAPT-Sepsis trial confirmed procalcitonin-guided de-escalation safety

Selective Digestive Decontamination (Statement 41) - NEW

• SUGGEST SDD in mechanically ventilated adults in units with low AMR prevalence (Conditional; moderate certainty)
• Meta-analysis (32 RCTs, 24,389 patients): reduces mortality (RR 0.91, moderate certainty), reduces AMR (RR 0.64)
• Counter-intuitively, SDD reduces rather than increases antimicrobial resistance in low-AMR settings
• NOT recommended in high-AMR settings

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5. HAEMODYNAMIC MANAGEMENT

Blood Pressure Monitoring (Statement 42) - REVISITED

• SUGGEST either invasive or non-invasive BP monitoring (Conditional; very low certainty)
• Invasive arterial line advised when: intermediate-high vasopressor dose, escalating/multiple vasopressors, frequent ABG, inconsistent non-invasive readings
• EVERDAC trial (published after finalization): non-invasive strategy non-inferior for 28-day mortality

Fluid Type (Statements 43-47) - REVISITED

• RECOMMEND crystalloids as first-line (Strong; moderate certainty)
• SUGGEST balanced crystalloids (Plasma-Lyte, Hartmann's) over 0.9% saline (Conditional; moderate certainty)
  • Exception: traumatic brain injury - use 0.9% saline
  • Evidence: balanced crystalloids probably reduce mortality (OR 0.94) and new RRT (OR 0.86, high certainty)
• SUGGEST crystalloids alone over crystalloids + albumin for resuscitation (Conditional; moderate certainty)
  • Albumin may be appropriate: large crystalloid volumes given already, or cirrhosis
  • Do NOT use albumin in TBI
• RECOMMEND AGAINST starches (Strong; high certainty)
• SUGGEST AGAINST gelatins (Conditional; moderate certainty)

Liberal vs. Restrictive Fluids (Statement 48) - REVISITED

• After initial 30 mL/kg with persistent hypoperfusion: SUGGEST either liberal or restrictive strategy based on patient/health system factors (Conditional; low certainty)
• 4 RCTs (3,320 patients): no difference in mortality between approaches

Dynamic Measures (Statement 49) - REVISITED

• SUGGEST dynamic measures over physical exam or static measures to guide further fluid resuscitation (Conditional; low certainty)
• Dynamic measures: PPV, SVV, PP, SV response to PLR or fluid bolus (>10-15% increase = fluid responsive)
• POCUS-guided resuscitation: reduces 28-day mortality (RR 0.88)

Cardiac Output Monitoring (Statement 50) - NEW

• Insufficient evidence for minimally-invasive or non-invasive (bioreactance) CO monitoring in addition to usual care

Serial Lactate (Statement 51) - REVISITED

• SUGGEST serial lactate to guide resuscitation (Conditional; low certainty)
• Target ≥10% clearance per 2 hours
• Fluid administration should be individualized - do NOT continue fluids until lactate normalizes

Capillary Refill Time (Statement 52) - REVISITED

• SUGGEST CRT to guide resuscitation as adjunct to other perfusion measures (Conditional; low certainty)
• ANDROMEDA-SHOCK-2 (2025): CRT-targeted protocol improved win ratio composite outcome (1.16; p=0.04)

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6. VASOPRESSORS

First-Line (Statements 53-55)

• RECOMMEND norepinephrine over dopamine, epinephrine, selepressin (Strong)
• SUGGEST AGAINST terlipressin (Conditional)
• SUGGEST norepinephrine over vasopressin or angiotensin II (Conditional)

Escalation Sequence (Statements 56-58)

• SUGGEST ADD vasopressin when escalating norepinephrine doses (Conditional; moderate certainty)
  • Meta-analysis (9 RCTs): probably reduces mortality (RR 0.89), reduces atrial fibrillation
  • Most panelists initiate vasopressin at 0.3 µg/kg/min norepinephrine
• SUGGEST ADD epinephrine when MAP inadequate despite norepinephrine + vasopressin (Conditional; very low certainty)
• NEW - Septic shock + cardiac dysfunction: SUGGEST either norepinephrine or epinephrine (Conditional; very low certainty)
  • Norepinephrine preferred in tachyarrhythmia
  • Epinephrine preferred in bradyarrhythmia

Methylene Blue (Statement 59) - NEW

• Insufficient evidence for IV methylene blue in refractory septic shock
• May improve BP (reduces vasopressor duration); insufficient evidence for survival benefit
• 69% of panelists "never/almost never" use it; reasonable in potentially survivable illness

Inotropes (Statements 60-62)

• SUGGEST inotropes (dobutamine or epinephrine) over no inotropes in cardiac dysfunction with persistent hypoperfusion despite adequate fluid + MAP (Conditional; very low certainty)
• SUGGEST AGAINST levosimendan in septic shock with cardiac dysfunction (Conditional; low certainty)
• Insufficient data to recommend dobutamine vs. milrinone

Midodrine (Statement 63) - NEW

• Insufficient evidence for oral midodrine in ongoing vasopressor requirement

Beta-Blockers (Statement 64) - NEW

• SUGGEST AGAINST beta-blockers as treatment for septic shock (Conditional; very low certainty)
• Probably reduces new-onset tachyarrhythmias (moderate certainty) but probably increases vasopressor duration (moderate certainty)

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7. RESPIRATORY SUPPORT

Oxygenation Monitoring (Statement 65) - NEW

• SUGGEST measuring oxygenation by either SpO2 or SaO2 (ABG) in conjunction with clinical exam (Conditional; very low certainty)
• ABG is gold standard; SpO2 less accurate in shock, dark skin tones, SpO2 <90% or >97%

Oxygen Targets (Statement 66) - NEW

• SUGGEST titrating FiO2 for either higher (liberal) or lower (conservative) oxygen targets based on patient factors (Conditional; low certainty)
• No difference in mortality between conservative (SpO2 ~90-93%) and liberal (SpO2 ≥96%) targets
• Panel targets SpO2 90-96% for sepsis with acute hypoxemic respiratory failure

HFNC (Statements 67-69) - NEW

• SUGGEST HFNC over conventional oxygen for PaO2/FiO2 <200 (Conditional; very low certainty)
• SUGGEST HFNC as initial therapy over NIPPV (Conditional; low certainty)
• SUGGEST HFNC over alternating HFNC + NIPPV (Conditional; very low certainty)

Awake Proning (Statement 70) - NEW

• SUGGEST a trial of awake prone positioning in non-intubated patients with acute hypoxemic respiratory failure (Conditional; very low certainty)
• Reduces intubation (RR 0.82, low certainty)
• Do NOT sedate to achieve proning; duration depends on tolerance

Invasive Ventilation (Statements 71-78)

• RECOMMEND low tidal volume 6 mL/kg IBW in ARDS (Strong; high certainty)
• NEW - Without ARDS: SUGGEST 6-8 mL/kg IBW over lower (4-6 mL/kg) tidal volumes (Conditional; low certainty)
  • Screen regularly for development of ARDS
• RECOMMEND plateau pressure ≤30 cmH2O (Strong; high certainty)
• SUGGEST higher PEEP for moderate-severe ARDS (Conditional; moderate certainty)
• RECOMMEND AGAINST incremental PEEP titration strategy (Strong; moderate certainty)
• SUGGEST prone ventilation >12 hr/day for moderate-severe ARDS (Conditional; moderate certainty)
• SUGGEST intermittent NMBA boluses over continuous infusion (Conditional; moderate certainty)
• SUGGEST venovenous ECMO when conventional MV fails in severe ARDS (Conditional; low certainty)

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8. ADJUNCTIVE THERAPIES

Corticosteroids (Statement 79) - REVISITED

• SUGGEST IV corticosteroids in septic shock (Conditional; low certainty)
• Meta-analysis (45 RCTs, 9,543 patients): small reduction in mortality (RR 0.92), high certainty increase in shock reversal at 7 days (RR 1.29)
• Dose: Hydrocortisone 200 mg/day (equivalent); most give as intermittent doses
• No dose-response benefit above 260 mg/day hydrocortisone equivalent

Antipyretics (Statement 80) - NEW

• SUGGEST AGAINST antipyretic therapy (pharmacologic or surface cooling) to improve clinical outcomes (Conditional; very low certainty)
• May use for symptom control (patient comfort) - separate decision
• Does not preclude use for pain control or in neurological patients/post-cardiac arrest

Vitamin C (Statement 81) - REVISITED

• SUGGEST AGAINST IV vitamin C (Conditional; low certainty)
• LOVIT trial: no mortality benefit in low-risk-of-bias trials (RR 1.06 at 90 days)

IVIG (Statement 82)

• SUGGEST AGAINST IV immunoglobulins (Conditional; low certainty)

Blood Purification (Statements 83-84) - REVISITED

• SUGGEST AGAINST hemoperfusion, high-dose hemofiltration, plasma exchange (Conditional; very low certainty)
• SUGGEST AGAINST polymyxin B hemoperfusion (Conditional; low certainty)

Vitamin D (Statement 85) - NEW

• SUGGEST AGAINST Vitamin D therapy for sepsis treatment (Conditional; very low certainty)
• VIOLET trial subgroup: possible harm with high-dose Vitamin D in sepsis patients

XueBiJing (Statement 86) - NEW

• SUGGEST AGAINST XueBiJing injection outside jurisdictions with regulatory approval (Conditional; very low certainty)

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9. ADDITIONAL SUPPORTIVE THERAPIES

Stress Ulcer Prophylaxis (Statement 87) - REVISITED

• For patients with risk factors for GI bleeding: SUGGEST stress ulcer prophylaxis with PPIs over no prophylaxis (Conditional; moderate certainty)
• Risk factors: AKI, male sex, coagulopathy, shock, chronic liver failure
• REVISE trial (2024): PPIs reduced clinically-important GI bleeding (RR 0.48)

Probiotics (Statement 88) - NEW

• SUGGEST AGAINST probiotics (Conditional; very low certainty)
• PROSPECT trial (large RCT): no benefit on VAP or mortality in low-risk-of-bias analysis

Active Fluid Removal (Statement 89) - NEW

• SUGGEST active fluid removal after acute resuscitation phase in septic shock (Conditional; very low certainty)
• Diuretics first; if insufficient: ultrafiltration/extracorporeal fluid removal
• "Acute resuscitation" = escalating/ongoing high-dose vasopressors, or needing ongoing volume expansion
• Patient panel: high value placed on avoiding oedema

Blood Transfusion (Statement 90)

• RECOMMEND restrictive transfusion (Hb threshold <7 g/dL) over liberal (Strong; moderate certainty)

Enteral Nutrition (Statement 91)

• SUGGEST early (within 72 hours) initiation of enteral nutrition (Conditional; very low certainty)

Insulin Therapy (Statement 92)

• RECOMMEND initiating insulin at glucose ≥180 mg/dL (10 mmol/L) (Strong; moderate certainty)

RRT (Statements 93-94)

• SUGGEST AGAINST RRT in AKI without definitive indication (Conditional; moderate certainty)
• SUGGEST either continuous or intermittent RRT when warranted (Conditional; low certainty)

Sodium Bicarbonate (Statements 95-96)

• SUGGEST AGAINST sodium bicarbonate for hemodynamic improvement or vasopressor reduction (Conditional; low certainty)
• SUGGEST sodium bicarbonate for septic shock + pH ≤7.2 + AKI (AKIN 2 or 3) (Conditional; very low certainty)

VTE Prophylaxis (Statements 97-99)

• RECOMMEND pharmacological VTE prophylaxis unless contraindicated (Strong; moderate certainty)
• RECOMMEND LMWH over unfractionated heparin (Strong; moderate certainty)
• SUGGEST pharmacological alone over pharmacological + mechanical prophylaxis (Conditional; moderate certainty)

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10. GOALS OF CARE

• Discuss GoC and prognosis with patients/families (Good practice statement)
• Address GoC within 72 hours (Conditional; low certainty)
• Insufficient evidence for standardized criteria to trigger GoC discussions
• NEW: Health systems should implement strategies for patients to execute advanced directives before discharge (Good practice statement)
• Insufficient evidence for formal time-limited trials (TLTs) of critical care

Palliative Care

• Integrate palliative care principles when appropriate (Good practice statement)
• SUGGEST AGAINST routine formal palliative care consultation (Conditional; low certainty)

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11. TRANSITIONS OF CARE AND POST-SEPSIS

• SUGGEST critical care transition program at ICU to floor transfer (Conditional)
• SUGGEST structured handoff at all transitions (Conditional)
• Medication reconciliation at all care transitions (Good practice statement)
• SUGGEST pharmacist-based medication reconciliation (Conditional; very low certainty)
• NEW: Health systems must ensure patient and family education about sepsis, treatment, and post-sepsis impairments before discharge (Good practice statement)
• Insufficient evidence for specific structured multi-component discharge planning process

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12. LONG-TERM OUTCOMES AND RECOVERY

Post-Hospital Follow-Up (Statements 124-126) - REVISITED

• Health systems should facilitate assessment for physical, cognitive, and emotional problems post-discharge (Good practice statement)
• SUGGEST offering post-critical illness follow-up services (Conditional; low certainty)
• For mechanical ventilation >48 hours: SUGGEST physical rehabilitation post-discharge (Conditional; low certainty)

Mental Health (Statements 127-128) - REVISITED

• SUGGEST mental health support services post-discharge (Conditional; low certainty)
• Patients with clinical symptoms should be referred to appropriate professionals (Good practice statement)
• Addresses: anxiety, depression, PTSD (Post-Intensive Care Syndrome - PICS)

Cognition (Statement 129) - NEW

• Insufficient evidence for cognition-targeted therapies; if being used, reasonable to continue

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KEY NEW STATEMENTS SUMMARY (46 New in 2026)

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