Anesthetic Management of a Massive Cystic Hygroma of the Neck in a Neonate.

Cystic hygroma of the neck, a congenital benign tumor of the lymphatic system, is a potential cause of neonatal airway obstruction leading to stridor. Meticulous airway evaluation, case appropriate preparation, and use of advanced technology, including videolaryngoscope and ultrasonography, can facilitate the safe management of the difficult airway.

Recent advances in research, training and teaching in anaesthesia and critical care.

Teaching and learning in anaesthesia and critical care has traditionally included seminars, journal clubs and clinical teaching in the operation theatre. The aim has always been to ignite the spark of thinking and self-directed learning in the students. The process of 'dissertation preparation' introduces basic knowledge and interest in research in the postgraduate student. All this is followed by an examination at the end of the course including the theory and practical assessment in the form of long and short case discussions and table viva-voce. The National Medical Commission in 2019 introduced the competency-based medical education curriculum for anaesthesia postgraduates. This curriculum focuses on structured teaching and learning. It has specific learning objectives in theoretical knowledge, skills and attitude development. The building up of communication skills has been given due importance. Though research in anaesthesia and critical care is steadily progressing, much work needs to be done on its improvement.

Recent advances in cardiac anaesthesia.

The speciality of cardiac anaesthesia has rapidly evolved over the past few decades with advances in technology, including artificial intelligence (AI), newer devices, techniques, imaging, pain relief and a better understanding of the pathophysiology of disease states. Incorporation of the same has led to improved patient outcomes in terms of morbidity and mortality benefits. With the advent of minimally invasive surgical methods, minimising the dose of opioids and ultrasound-guided regional anaesthesia for pain relief, enhanced recovery after cardiac surgery has been made possible. Perioperative imaging including 3D transoesophageal echocardiography, newer devices and drugs and AI algorithms will play a significant role in cardiac anaesthesia. This review briefly addresses some of the recent advances that the authors believe can impact the practice of cardiac anaesthesia.

Challenges and outcomes of pregnancy in an uncorrected Tetralogy of Fallot with pulmonary atresia and major aorta-pulmonary collateral arteries (MAPCA): a case report.

BACKGROUND: Tetralogy of Fallot is a severe type of congenital heart disease (CHD) and one of the leading indirect causes of mortality & morbidity among women with CHD. We came across a rare case of an uncorrected Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries in pregnancy. CASE PRESENTATION: We are reporting the challenges in managing a pregnancy of 25-years-old G3 P0110, previous one stillbirth and who was diagnosed to have congenital heart disease during pregnancy following spontaneous abortion. CONCLUSIONS: This case report highlights the role of multidisciplinary care in managing such a high risk case. It also emphasizes the role of cardiac examination of every woman before pregnancy so that definitive treatment or optimization can be done in time for a better outcome.

Quantitative Assessment of Nitrous Oxide Levels in Room Air of Operation Theaters and Recovery Area: An Observational Study.

BACKGROUND: Nitrous oxide has been used during surgical anesthesia for many years. However, information about occupational exposure and related risks due to N2O exposure to the health care personnel in India are still poorly understood. Here, we measured the residual N2O levels during the working time of operation theatre room air in our tertiary care hospital. MATERIAL AND METHODS: The air samples were collected from different anesthesia exposure zones on different days for quantitative analysis of available N2O in the room air in respective areas. Nitrous oxide concentrations in the ambient air were also measured to compare outdoor and indoor levels. OBSERVATIONS AND RESULTS: Nitrous oxide mixing ratios were found to be 65.61 ± 0.05 ppm, 281.63 ± 0.43 ppm, and 165.42 ± 0.42 ppm in elective surgical theatres of the hospital on three different days whereas in emergency operation theatres of the same hospital levels of N2O were 166.75 ± 0.07 ppm, 510.19 ± 0.30 ppm and 2443.92 ± 0.64 ppm during same period. In elective pediatric surgical theatres levels of N2O were found to be 1132.55 ± 0.70 ppm and 362.21 ± 0.13 ppm on two days of reading respectively. Outdoor levels of N2O in contrast found 0.32 ± 0.01 ppm and was lower by a factor of 1000. CONCLUSION: We observed the very high ambient concentration of N2O in the surgical theatre's environment (up to 2443 ppm) and recovery areas (up to 50 ppm). It was 5 to 50 times higher ambient concentration of N2O than REL in OT area and 200-7000 times higher ambient concentration of N2O than outdoor ambient air in all surgical theaters other than CTVS OTs.

Limited condylar mobility by ultrasonography predicts difficult direct laryngoscopy in morbidly obese patients: An observational study.

BACKGROUND AND AIMS: Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially in morbidly obese patients. The present study aimed to determine the efficacy of different sonographic measures as predictors of difficult laryngoscopy in morbidly obese patients undergoing elective surgery. METHODS: This observational study evaluated 70 morbidly obese adult patients (body mass index >35 kg/m2) undergoing elective surgery under general anaesthesia with tracheal intubation. Pre-operative clinical and ultrasonographic variables (anterior condylar translation, tongue thickness, hyomental distance and oral cavity height) associated with difficult direct laryngoscopy ([Cormack Lehane (CL) grade>2]) were analysed. The primary outcome was to determine the efficacy of the above-mentioned sonographic measures as predictors of difficult laryngoscopy (CL grade >2). The secondary outcome compared ultrasonographic predictors with clinical predictors in morbidly obese patients for determining difficult direct laryngoscopy. RESULTS: Amongst the primary outcome measures, limited condylar mobility (anterior condylar translation <9.25 mm) [odds ratio (OR) 0.3, confidence interval (CI):1.04-1.22;P<0.001;area under curve (AUC):0.8] and increased tongue thickness >5.85 cm [OR: 3.2, CI: 1.05-10; P < 0.04; AUC: 0.73] were two independent sonographic predictors for difficult direct laryngoscopy by multivariate logistic regression and receiver operating characteristic curve analyses in morbidly obese patients. The secondary outcome suggested that as compared to clinical predictors such as Mallampati grade and thyromental distance, ultrasonographic variables such as tongue thickness and limited condylar mobility (sensitivity: 56.4%, 70.9%, 66.7% and 93.3%, respectively) better predicted difficult direct laryngoscopy in morbidly obese patients. CONCLUSION: Limited condylar mobility and increased tongue thickness are independent sonographic predictors of difficult direct laryngoscopy in morbidly obese patients.

Unusual "cardiac" cause of hemoptysis: Accessory cardiac bronchus.

Hemoptysis is a common presenting feature of tuberculosis, pulmonary parenchymal malignancy, bronchiectasis, or a cardiac pathology as mitral stenosis. Relevant clinical history, physical examination, laboratory investigations, and radiology usually identify the cause of hemoptysis in the majority of the cases. We report a case of a 50-year-old male with intermittent hemoptysis which was the presenting feature of accessory cardiac bronchus.

Recurrent unilateral hemorrhagic pleural effusion: A rare manifestation of thoracic endometriosis syndrome.

Unilateral recurrent pleural effusions are commonly encountered in critical care practice. Relevant clinical history, physical examination, radiology, and diagnostic thoracentesis usually identify the cause of pleural effusion in most cases. Thoracoscopy or video-assisted thoracic surgery may be required in selective cases. We report a case of 32-year-old female with recurrent unilateral hemorrhagic pleural effusion that was the presenting feature of thoracic endometriosis syndrome.

Two-Stage Fiberoptic Intubation in an Infant With a Rare Congenital Laryngopharyngo-Cutaneous Fistula: A Case Report.

Branchial arches represent embryological precursors of the face, neck, and pharynx, and developmental abnormalities of these branchial arch derivatives can lead to airway anomalies. We report definitive repair of the fistula in an infant with a rare congenital laryngopharyngo-cutaneous fistula. This is the first report that describes a 2-stage fiberoptic intubation, a challenging technique performed for airway management of the aforementioned fistula in a patient with a difficult airway.

Early thrombolysis is associated with decreased operative mortality in postinfarction ventricular septal rupture.

BACKGROUND: Post myocardial infarction ventricular septal rupture (PMI-VSR) is a dreaded mechanical complication of acute coronary syndromes. Given that surgical mortality approaches 50%, it is pragmatic that the risk factors for mortality and outcomes after surgical correction of PMI- VSR are carefully scrutinized. METHODS: We performed a single-center, retrospective cohort study of 35 patients presenting for surgical closure of post myocardial infarction ventricular septal rupture over six years. We reviewed patient characteristics, clinical, echocardiographic, angiographic and perioperative risk factors which may affect mortality after surgical repair of PMIVSR and 30 day and one year mortality rates of these patients. Univariate and multivariate logistic and cox proportional hazard regression analysis was used to identify predictors of operative and overall mortality. Long term survival was presented with Kaplan-Meier Survival Curve. RESULTS: Sixteen patients (46%) were in cardiogenic shock. Concomitant coronary artery bypass grafting (CABG) was done in 22 patients (63%) but did not influence survival. Preoperative thrombolysis was done in 12 patients (34%) out of which 10 (53%) survived Operative mortality was 46% and one-year mortality was 49%. Multivariate analysis identified preoperative thrombolysis: Hazards ratio, 0.12; 95% CI, 0.02-0.61; p value of 0.01, as significant independent predictor of survival in PMIVSR cohort. CONCLUSIONS: Preoperative thrombolysis is associated with decreased odds of operative and overall mortality after surgical repair in PMIVSR patients.

Successful surgical management of an aorto-oesophageal fistula caused by button battery ingestion.

Aorto-oesophageal fistula is a rare complication of foreign body ingestion from which few patients survive. Aggressive surgical treatment is the only form of effective therapy for this fatal complication. We present the successful surgical treatment of an aorto-oesophageal fistula in a child without using cardiopulmonary bypass.