Comparison of Dexmedetomidine with Midazolam as an adjuvant with Propofol for insertion of ProSeal laryngeal mask airway in Children.

OBJECTIVE: Propofol is required in higher doses for smooth insertion of the ProSeal laryngeal mask airway. The ideal adjuvant drug so as to minimise induction doses of propofol is still not known. Dexmedetomidine and midazolam are equally effective for premedication in children. We have designed this study to compare dexmedetomidine and midazolam as adjuvants with propofol for insertion characteristics of ProSeal laryngeal mask airway. METHODS: A total of 130 paediatric patients undergoing elective surgery were randomly allocated into 2 groups of 65 each. One group was induced using propofol, fentanyl and midazolam, whereas the other group received propofol, fentanyl and dexmedetomidine. Subsequently, insertion characteristics of ProSeal laryngeal mask airway were documented in terms of number of attempts and by using modified Muzi score. Post-operative sedation was recorded by Ramsay Sedation Scale and pain was assessed by using Wong-Baker Faces pain scale. RESULTS: Out of 130 patients, ProSeal laryngeal mask airway was inserted in a second attempt in only 5 patients of midazolam group. Time taken for insertion was significantly higher among the midazolam group (21 seconds) than the dexmedetomidine group (19 seconds). A total of 93.8% of patients administered dexmedetomidine had excellent Muzi scores in comparison to midazolam group where only 13.8% patients had excellent Muzi scores (P < .001). CONCLUSION: Dexmedetomidine in a dose of 1 µg kg-1 as compared to midazolam (20 µg kg-1) produces better insertion characteristics for ProSeal laryngeal mask airway when used as adjuvant with propofol in terms of jaw opening, ease of insertion, coughing, gagging, patient movement, and laryngospasm.

Recent advances in paediatric anaesthesia.

Recent development in science has led to a significant improvement in safety for the anaesthetic management of children. Enhanced recovery after surgery is one of the novel approaches aiming to enhance paediatric surgical outcomes and their quick recovery. Preoperative counselling, minimal fasting, and no routine pharmacological premedication are critical components of enhanced recovery after surgery. As anaesthetists, management of airway is our priority and introduction of paraoxygenation in addition to preoxygenation has resulted in reduction in desaturation episodes during periods of apnoea. Safe care has been made possible by improvements in monitoring, equipment, medications, techniques, and resuscitation protocols. We are motivated to collect more evidence regarding ongoing disputes and issues, such as the effect of anaesthesia on neurodevelopment.

Comparative Evaluation of C-MAC Videolaryngoscope with Macintosh Direct Laryngoscope in Patients with Normal Airway Predictors.

Background: Video laryngoscopes (VL) assist in securing the airway faster and more accurately in difficult airways. However, data regarding its usefulness in patients with normal airways are sparse. Aim: We designed this study to compare the ease and success of endotracheal intubation between C-MAC and Macintosh direct laryngoscope (DL) in adult patients with no anticipated airway difficulty. Settings and Design: The design involves prospective randomized case - control study. Subjects and Methods: One hundred and twenty adult patients with predicted normal airway were randomized into two groups and were intubated using VL (C-MAC VL) and DL (Macintosh DL), respectively. The Cormack-Lehane (CL) grade, time taken for intubation, attempts taken (number), and need for laryngeal maneuvers or stylets were recorded and analyzed for statistical significance. Results: Thirty-eight patients in the DL group and 48 patients in the VL group had CL I view, 20 patients in the DL group and 16 patients in the VL group had CL II, and two patients in the DL group had CL III view. None of the patients in Group VL had CL III view. In seven out of 60 cases in the DL group, difficulty was experienced during insertion of the laryngoscope blade as compared to two cases out of 60 in the VL group. The mean time taken for intubation was lesser in Group DL (28.48 s) as compared to 39.3 s in Group VL. Nine patients in Group DL and 16 patients in Group VL required external laryngeal manipulation. Stylets were used, in seven patients in group DL and in 11 patients in group VL. Conclusions: In patients with a predicted normal airway, C-MAC provides a better glottic view compared to Macintosh DL. Time taken for intubation using the C-MAC video laryngoscope was more. However, success rates on the first attempt at endotracheal intubation and the number of intubation attempts with either laryngoscope were similar.

Fraser Syndrome: A Stumbling Block for the Anaesthesiologist.

Fraser syndrome is a rare autosomal recessive disorder with spectrum of malformations. Gamut of abnormal airway includes high arched palate, laryngeal atresia, hypoplasia, laryngeal stenosis etc. Laryngeal intubation difficulties have often been reported in literature. Airway management and decision process leading to emergency tracheostomy in these children has been discussed.

Comparison of Ultrasoundguided Ilioinguinal Iliohypogastric Nerve Block with Wound Infiltration during Pediatric Herniotomy Surgeries.

BACKGROUND AND AIMS: The purpose of this study was to compare the analgesic efficacy of the ilioinguinal-iliohypogastric nerve block (II/IH) with local wound infiltration in children undergoing herniotomy surgeries. METHODS: After ethics committee approval and informed consent, 100 children aged 6 months-7 years posted for herniotomy surgeries were randomly divided into Group B and Group W. Local wound infiltration was performed in Group W by the surgeon at the time of port placement and the end of the surgery with 0.2 mL.kg-1 of 0.25% bupivacaine. Ipsilateral II/IH was performed in Group B at the end of the surgery, under ultrasonographic guidance with a Sonosite portable ultrasound unit and a linear 5-10 MHz probe with a 22G hypodermic needle, and 0.2 mL.kg-1 of 0.25% bupivacaine was used on each side. The parameters recorded were postoperative hemodynamics, paracetamol and opioid requirements, postoperative pain scores, postoperative nausea vomiting, and the need for rescue analgesia in the first 6 h postoperatively. RESULTS: The median pain scores were significantly lower in the II/IH group than the local wound infiltration group at 10 min (2 [0-2.5] compared to 2 [3-4]; P = 0.011), 30 min (1.5 [0-3] compared to 3 [2-5]; P < 0.001), 1 h (1.5 [0-2] compared to 2 [2-3]; P < 0.001) and 2 h (2 [0-2] compared to 2 [1.5-2.5]; P = 0.010) postoperatively. The need for postoperative opioids and rescue analgesia was also significantly lower in the II/IH group (P < 0.001). CONCLUSION: II/IH is superior to local wound infiltration for postoperative analgesia in pediatric herniotomy surgeries.

Inadvertent Massive Overdose of Lidocaine in an Infant With Arthrogryposis Multiplex Congenita Treated Successfully With Lipid Emulsion.

Severe local anesthetic toxicity is potentially life threatening and is often refractory to standard resuscitative measures. Infants are a particularly susceptible population in this regard because of their unique physiologic features. Recently, 20% intravenous (IV) lipid emulsion (Intralipid) has been proposed as a "one-stop solution" to toxicity related to all commonly used amide local anesthetics. There is an abundance of literature describing its uses in association with regional blocks in adults. However, there is a scarcity of reports describing its application in children, and use of 10% IV lipid emulsion (Intralipid) has not been described in children for rescue therapy, to our knowledge. We report a case of accidental life-threatening overdose of IV lidocaine (lignocaine) in an infant, which was successfully managed with 10% lipid emulsion.

Cancellation of elective cases in pediatric surgery: An audit.

AIM: To determine the main reasons for cancellation of elective cases on scheduled date of surgery in pediatric patients. MATERIALS AND METHODS: The audit was conducted in a 216 beds tertiary care pediatric super-specialty hospital. Two operation theatres (OT) provide elective surgical services to pediatric surgery, orthopedics, ophthalmology and otorhinolaryngology. The audit included all those patients who were posted for elective surgery over a period of one year. Cancelled cases were identified from predesigned OT utilization formats and the reasons for cancellation were evaluated. RESULTS: A total of 2473 cases were posted for the elective surgery in the year 2009 and 189 (7.64%) patients had their surgery cancelled. The main reasons for cancellation were upper respiratory infections (30.68%) and shortage of time (29%). Other reasons were medically unfit patients (15.34%), precedence of emergency cases (3.7%); non-availability of ventilator and intensive care bed (4.7%); no-show by patient (4.76%); non-availability of blood (4.2%); incomplete work up (2.64%); administrative reasons (1.58%); patient not fasting (1.58%) and unspecified reasons (2.1%). Overall, 38.6% causes were preventable. CONCLUSIONS: Elective surgery cancellation is a significant problem with multifactorial etiology. Most common reasons for cancellation of planned surgery were sudden onset of respiratory tract infection in the admitted patient and shortage of time. It suggests that on many occasions, surgeons take more time than anticipated for performing the procedure.

Cystic adenomatoid malformation of the lung: a diagnostic dilemma.

Congenital cystic adenomatoid malformation (CCAM) of the lung is an uncommon anomaly that arises from excessive disorganised proliferation of tubular bronchial structures excluding the alveoli. These are believed to represent focal pulmonary dysplasia because skeletal muscle may be identified from within the cyst wall. This report describes a case of an infant operated for presumed diagnosis of congenital diaphragmatic hernia. Diaphragm was found to be normal and further investigations revealed cystic mass in the lower lobe of the left lung. Thoracotomy was done to resect the lesion that revealed a type II CCAM on histopathological examination. The case stresses the need for better clinical examination and advanced radiological investigations in doubtful cases.