Ultrasonography Imaging versus Waveform Capnography in Detecting Endotracheal Tube Placement during Intubation at a Tertiary Hospital.

Background: There is continued research to find new faster, highly accurate, easily accessible, and portable methods of confirming endotracheal tube position during intubation. A newer modality for visualizing endotracheal tube location is transtracheal or transcricothyroid ultrasonography. The aim of this study was to see if ultrasound machine can also be routinely used for the confirmation of endotracheal tube position in operating theaters along with capnograph. Methods: The study was observational and prospective, conducted from January 2017 to July 2017. Study locations were at the Tribhuvan University Teaching Hospital and Manmohan Cardiothoracic Vascular and Transplant Center operating rooms. Sample size taken was 95. Results: In the study, 11 patients had esophageal intubation out of the 95. The accuracy of both ultrasonography and capnography was found to be 96.84%. For ultrasonography, the sensitivity, specificity, along with positive predictive value and negative predictive value were 97.62%, 90.91%, 98.80%, and 83.33%, respectively, while that for capnography were found to be 96.43%, 100%, 100%, and 78.57%, respectively. The kappa value was calculated to be 0.749, which suggested the degree of agreement of result between the methods to be good. Compared to capnography, ultrasonography was found to be significantly faster for the confirmation of endotracheal tube location by 16.36 s (15.70-17.02) (P = 0.011). Conclusion: Both waveform capnography and ultrasonography were found to be accurate and reliable in confirming endotracheal tube location. The use of ultrasound during intubation can help confirm endotracheal tube location faster and also aid in precision when used along with capnography. Manual bag ventilations are not necessary when confirming endotracheal tube position by ultrasonography and thus may help in preventing aspiration of gastric contents into the lungs of the patient.

Del Nido Cardioplegia in Coronary Artery Bypass Grafting Surgery: A safe, efficacious and economic alternative to St. Thomas solution; an experience from a developing nation.

INTRODUCTION: del Nido cardioplegia is a newer solution getting popular worldwide, whereas in Nepal, St. Thomas cardioplegia solution is conventionally used. There is no national recommendation on cardioplegia solutions supported by evidences from Nepalese studies. This study aimed to evaluate and compare the efficacy of these solutions in Nepalese patients undergoing coronary artery bypass grafting. METHODS: Patients undergoing coronary revascularization, from May 2018 to December 2019, were randomized into St. Thomas and del Nido groups based on the cardioplegia administered, with 45 patients in each group. Preoperative, intraoperative, and postoperative parameters and cost of cardioplegia preparation in the two groups were compared. RESULTS: The cardiopulmonary bypass time (106.13 ± 24.65 minutes vs 107.62 ± 18.69 minutes, p = 0.02), aortic cross clamp time (66.22 ± 15.40 minutes vs 72.07 ± 12.23 minutes, p = 0.04), volume (1059.22 ± 100.30 ml vs 1526.67 ± 271.81 ml, p < 0.001) and number of cardioplegia doses (1.00 ± 0.00 vs 2.51 ± 0.66, p < 0.001) were significantly lower with del Nido cardioplegia. A lower CPK-MB at second post-operative (59.91 ± 31.62 vs 73.82 ± 37.25, p = 0.03) and a higher left ventricle ejection fraction at discharge (56.33 ± 8.94% vs 50.45 ± 8.55%, p < 0.001) was observed in del Nido group. There was one death in St. Thomas group. ICU and hospital stay were similar in both groups. St. Thomas solution was found to be costlier than del Nido solution (USD 5.40 ± 0.96 vs USD 3.50 ± 0.34, p < 0.001). CONCLUSION: The del Nido cardioplegia was found to be efficacious, safe and more economical alternative to St. Thomas solution.

Medical Education in Nepal: Impact and Challenges of the COVID-19 Pandemic.

During the COVID-19 pandemic, there has been a global shift toward online distance learning due to travel limitations and physical distancing requirements as well as medical school and university closures. In low- and middle-income countries like Nepal, where medical education faces a range of challenges-such as lack of infrastructure, well-trained educators, and advanced technologies-the abrupt changes in methodologies without adequate preparation are more challenging than in higher-income countries. In this article, the authors discuss the COVID-19-related changes and challenges in Nepal that may have a drastic impact on the career progression of current medical students. Outside the major cities, Nepal lacks dependable Internet services to support medical education, which frequently requires access to and transmission of large files and audiovisual material. Thus, students who are poor, who are physically disadvantaged, and who do not have a home situation conducive to online study may be affected disproportionately. Further, the majority of teachers and students do not have sufficient logistical experience and knowledge to conduct or participate in online classes. Moreover, students and teachers are unsatisfied with the digital methodologies, which will ultimately hamper the quality of education. Students' clinical skills development, research activities, and live and intimate interactions with other individuals are being affected. Even though Nepal's medical education system is struggling to adapt to the transformation of teaching methodologies in the wake of the pandemic, it is important not to postpone the education of current medical students and future physicians during this crisis. Looking ahead, medical schools in Nepal should ensure that mechanisms are proactively put into place to embrace new educational opportunities and technologies to guarantee a regular supply of high-quality physicians capable of both responding effectively to any future pandemic and satisfying the nation's future health care needs.

Anxiety evaluation in Nepalese adult patients awaiting cardiac surgery: A prospective observational study.

Perioperative anxiety could negatively affect surgery outcomes, and cardiac diseases have long been known to be an independent risk factor for anxiety development. However, little is known about preoperative anxiety in Nepalese adult cardiac patients waiting for surgery. The primary objectives of this study were to: (1) clarify the levels of preoperative anxiety in Nepalese adult cardiac patients waiting for open heart surgery; (2) identify factors associated with preoperative anxiety; and (3) evaluate any possible factors associated with patients' desire to obtain information related to their heart surgery.This is a prospective observational study for patients already scheduled for cardiac surgery at a core medical institution in Kathmandu, Nepal. We collected sociodemographic and clinical characteristics of the patients from their medical charts, and assessed their preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale. We performed descriptive analyses of the collected data. Further, we employed regression models to assess to the objectives of the study.In total, 140 patients participated, and data of 123 (87.9%) were used for analysis. 58.5% of the participants had preoperative anxiety. Female gender (OR 0.31, 95% CI 0.15-0.65, P < .001) and past anesthesia exposure (OR 2.38, 95% CI 1.01-5.62, P < .05) were identified as risk factors for developing anxiety before cardiac surgery. Further, female gender (IRR 0.80, 95% CI 0.67-0.94, P < .001), higher education levels (IRR 1.18, 95% CI 1.01-1.40, P < .05), and higher preoperative anxiety (IRR 1.44, 95% CI 1.21-1.73, P < .001) could lead to higher levels of desire to acquire information related to the procedure.The study concluded that more than a half of the cardiac surgery patients experiences preoperative anxiety; female gender and having past anesthesia exposure are the risk factors. Anxious patients have more desire to acquire knowledge about the procedure. Thus, the evaluation and adequate management of preoperative anxiety should be proposed in high-risk groups.

Comparison of acute physiology and chronic health evaluation II and acute physiology and chronic health evaluation IV to predict intensive care unit mortality.

CONTEXT: Clinical assessment of severity of illness is an essential component of medical practice to predict the outcome of critically ill-patient. Acute Physiology and Chronic Health Evaluation (APACHE) model is one of the widely used scoring systems. AIMS: This study was designed to evaluate the Performance of APACHE II and IV scoring systems in our Intensive Care Unit (ICU). SETTINGS AND DESIGN: A prospective study in 6 bedded ICU, including 76 patients all above 15 years. SUBJECTS AND METHODS: APACHE II and APACHE IV scores were calculated based on the worst values in the first 24 h of admission. All enrolled patients were followed, and outcome was recorded as survivors or nonsurvivors. STATISTICAL ANALYSIS USED: SPSS version 17. RESULTS: The mean APACHE score was significantly higher among nonsurvivors than survivors (P < 0.005). Discrimination for APACHE II and APACHE IV was fair with area under receiver operating characteristic curve of 0.73 and 0.79 respectively. The cut-off point with best Youden index for APACHE II was 17 and for APACHE IV was 85. Above cut-off point, mortality was higher for both models (P < 0.005). Hosmer-Lemeshow Chi-square coefficient test showed better calibration for APACHE II than APACHE IV. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.748 (P < 0.01). CONCLUSIONS: Discrimination was better for APACHE IV than APACHE II model however Calibration was better for APACHE II than APACHE IV model in our study. There was good correlation between the two models observed in our study.