Ultrasound guided costoclavicular block in pediatric population: A prospective observational study.

BACKGROUND: The costoclavicular space serves as an alternative approach to the infraclavicular brachial plexus block, and numerous studies in adults have demonstrated promising outcomes for distal upper limb surgery. Blocking the brachial plexus at this level is potentially advantageous because the cords are relatively superficial, located in close proximity to each other and easily identified using ultrasound. AIMS: This study aimed to assess the success rate and feasibility of costoclavicular block in children undergoing unilateral below elbow upper limb surgery. METHODS: Thirty children aged 2-12 years scheduled for unilateral below elbow surgery under general anesthesia were included. Costoclavicular block was performed under ultrasound and nerve stimulator guidance with 0.5% ropivacaine, 0.5 mL/kg. Success was evaluated based on the absence of significant hemodynamic response to skin incision made 20 min after the block. The sono-anatomy of costoclavicular space, ease of needling, complications, and the post-operative pain scores were assessed. RESULTS: The mean age and weight of the children were 6.5 ± 3.8 years and 19.7 ± 9.1 kg, respectively. The success rate of costoclavicular block in our cohort is 100%. Sonographic visualization was graded as excellent (Likert Scale 2) in 90% of cases. The plexus was located at a depth of 1.4 ± 0.3 cm from the skin, the lateral extent of cords from the artery was 0.8 ± 0.4 cm and they were observed inferior and lateral to the artery. The mean needling time was 3.6 ± 1.1 min. None of the children experienced complications such as vascular or pleural puncture, hematoma, Horner's syndrome or diaphragmatic palsy. Postoperative pain scores were low, and no rescue analgesia was required. CONCLUSIONS: In conclusion, the costoclavicular block exhibited a notably high success rate in pediatric population. This study substantiates that the three cords of the brachial plexus are consistently visible and superficial during ultrasound examination using this approach, confirming their separation from vascular structures and the reliable achievement of blockade without observed complications.

Comparison of BlockBuster laryngeal mask with Air-Q intubating laryngeal airway as a conduit for fiber-optic guided intubation in children: A prospective randomized controlled study.

BACKGROUND: The pediatric sizes of BlockBuster supraglottic airway (SGA) have been introduced recently. Its efficacy as a conduit for endotracheal intubation in children has not been assessed. Newer devices are often compared with Air-Q SGA to assess their intubating capability. AIMS: The primary objective was to compare the time taken for fiber-optic-guided intubation through the BlockBuster and the Air-Q SGAs. METHODS: Sixty children aged 6 months to 12 years with normal airways were randomized into two groups: Air-Q SGA (Group A) and Blockbuster SGA (Group B). After administration of general anesthesia, an appropriately sized SGA was inserted. The time taken for fiber-optic-guided intubation through the SGA, success, ease, and time for SGA insertion and removal were noted. The glottic view was graded by fiber-optic bronchoscopy. RESULTS: Demographic parameters were comparable. The time to intubate with the BlockBuster 62.40 ± 17.2 s was comparable to the Air-Q 60.8 ± 18.5 s (mean difference 1.6 s, 95% CI -7.65 to10.85; p = .73). The average time for SGA insertion in BlockBuster and Air-Q was 14.57 ± 3.2 s and 16.67 ± 5.39 s, respectively (mean difference -2.1, 95% CI -4.39 to 0.19 s; p = .07). The first-attempt intubation success and overall intubation success rates were comparable in both groups, 96.7% and 100%, respectively. In Group B, 25/3/1/1/0 cases had a glottic view grade of 1/2/3/4/5, respectively. In Group A, 23/3/2/2/0 cases had grade of 1/2/3/4/5 glottic views respectively. The average time to SGA removal was comparable between the BlockBuster (20.17 ± 5.8 s) and the Air-Q (22.5 ± 12.8 s) groups (mean difference -2.3 s, 95% CI -7.5 to 2.82 s; p = .37). None of the children had any perioperative complications. CONCLUSION: BlockBuster SGA may be a useful alternative to Air-Q for SGA-assisted, fiber-optic-guided tracheal intubation in children.

Comparison of Ambu AuraGain and BlockBuster laryngeal mask for controlled ventilation in children undergoing minor surgical procedures under general anesthesia: A prospective randomized controlled study.

BACKGROUND: Ambu AuraGain has proven to be better compared with other supraglottic airway devices in terms of higher first-attempt insertion success rate, time and ease of insertion, high oropharyngeal leak pressure, and fewer complications in children. The performance of the BlockBuster laryngeal mask has not been evaluated in children. AIMS: The primary objective of this study was to compare the oropharyngeal leak pressure of the BlockBuster laryngeal mask with those of the Ambu AuraGain during controlled ventilation in children. METHODS: Fifty children aged 6 months to 12 years with normal airways were randomized into group A (Ambu AuraGain) and group B (BlockBuster laryngeal mask). After administration of general anesthesia, an appropriate size supraglottic airway (size 1.5/2.0/2.5) was inserted according to the groups. Oropharyngeal leak pressure, success and ease of supraglottic airway insertion, gastric tube insertion, and ventilatory parameters were noted. The glottic view was graded by fiberoptic bronchoscopy. RESULTS: Demographic parameters were comparable. The mean oropharyngeal leak pressure in the BlockBuster group (24.72 ± 6.81 cm H2 O) was significantly higher than Ambu AuraGain group (17.20 ± 4.28 cm H2 O) by 7.52 cm H2 O (95% CI 4.27 to 10.76; p = 0.001). The mean time for supraglottic airway insertion in the BlockBuster and Ambu AuraGain group was 12.04 ± 2.55 s and 13.64 ± 2.76 s, respectively (mean difference- 1.6 s, 95% CI 0.09-3.12; p = 0.04). Ventilatory parameters, first-attempt supraglottic airway insertion success rate, and ease of gastric tube insertion were comparable between the groups. The BlockBuster group showed easy supraglottic airway insertion compared with the Ambu AuraGain group. The BlockBuster group had better glottic views with only the larynx seen in 23 out of 25 children compared to the Ambu AuraGain with only the larynx seen in 19 out of 25 children. No complication was noted in either group. CONCLUSIONS: We found that the BlockBuster laryngeal mask has higher oropharyngeal leak pressure compared with Ambu AuraGain in a pediatric population.

A novel low-cost indigenous goggle design for oxygen delivery in oxygen supplemented accelerated corneal collagen cross-linking.

PURPOSE: Our study aims to describe a novel low-cost indigenous design of goggles for delivery of oxygen during oxygen supplemented accelerated corneal collagen cross-linking (CXL). METHODS: The goggles were prepared by modifying the safety goggles available in personal protective equipment (PPE) kit. The goggle has two side openings covered with plugs. One plug was removed to insert a tubing for oxygen delivery at a rate of 5 litres/minute. A 20-gauge intravenous cannula was introduced from superior aspect of the goggle for measuring oxygen saturation in periocular environment. RESULTS: The procedure could be successfully performed without any intraoperative difficulty with an oxygen concentration between 80-90% throughout procedure. The time to achieve maximum concentration after switching on oxygen supply was between 30-60 s. None of our patients complained of any discomfort due to goggles. There was no mechanical interference of the goggles with the UV delivery system and a focused UV light could be delivered. The opening in goggles allowed for uninterrupted alignment and centration of UV light at the corneal level. The effective cost of the goggles, canula and tubing amounted to 400INR (5.50USD). There was no distortion, kinking or slippage of the tubing allowing for uninterrupted oxygen flow. These goggles could be sterilized multiple times using plasma sterilization. CONCLUSION: The current modified cost-effective goggle design could be an effective alternative to the currently available oxygen delivery goggles, especially in a low resource setting.

Evaluation of performance of C-MAC® video laryngoscope Miller blade size zero for endotracheal intubation in preterm and ex-preterm infants: A retrospective analysis.

BACKGROUND AND AIMS: The preterm and ex-preterm babies form a separate group among the paediatric population with unique airway anatomy. The utility of C-MAC® Video laryngoscope (VL) for routine intubation of preterm babies has not been evaluated. The purpose of this study is to report the performance of C-MAC® VL Miller blade size-0 for endotracheal intubation in preterm babies at our institute. METHODS: After Institute Ethics Committee approval, a retrospective study was designed to evaluate the performance of C-MAC® VL for intubation in preterm and ex-preterm babies. The medical files, and video recordings of preterm babies up to 60 weeks of post-gestational age who had undergone surgery for retinopathy of prematurity from January 2014 to April 2016 were reviewed. All babies were intubated with C-MAC® Miller blade size-0. Demographic parameters, time to best glottic view (TTGV), time to intubate (TTI), ease and number of intubation attempts were assessed. Episodes of desaturation and complications related to intubation were recorded. RESULTS: Data of 37 preterm and ex-preterm babies were analysed. The mean age and weight at the time of surgery were 40.5 (±4.9) weeks and 2532 (±879) grams respectively. The median TTGV and TTI were 11.0 and 22.0 seconds. A total of 32 babies (86.5%) were intubated on initial attempt and five were intubated on second attempt. Stylet was used to facilitate intubation in all infants. There was no incidence of desaturation, mucosal injury or bleeding. CONCLUSION: C-MAC video laryngoscope Miller blade size 0 is suitable for endotracheal intubation in preterm and ex-preterm infants.

Comparison of low-fresh gas flow technique to standard technique of sevoflurane induction in children-A randomized controlled trial.

BACKGROUND: Although sevoflurane is preferred for inhalational induction in children, financial and environmental costs remain major limitations. The aim of this study was to determine if the use of low-fresh gas flow during inhalational induction with sevoflurane could significantly reduce agent consumption, without adversely affecting induction conditions. METHODS: After institutional ethical committee approval, 50 children, aged 1-5 years, undergoing ophthalmic procedures under general anesthesia, were randomized into two groups-standard induction (Group S) and low-flow induction (Group L). A pediatric circle system with 1 L reservoir bag was primed with 8% sevoflurane in oxygen at 6 L min-1 for 30 seconds before beginning induction. In Group S, fresh gas flow was maintained at 6 L min-1 until the end of induction. In Group L, fresh gas flow was reduced to 1 L min-1 after applying facemask (time = T0). In both groups, sevoflurane was reduced to 5% after loss of eyelash reflex (T1). Once adequate depth of anesthesia was achieved (regular respiration, loss of muscle tone, and absence of movement to trapezius squeeze), intravenous access was secured (T2), followed by insertion of an appropriately sized LMA-Classic™ (T3). Heart rate and endtidal sevoflurane concentration were measured at each of the above time points, and at 15 seconds following laryngeal mask airway insertion (T4). The total amount of sevoflurane consumed during induction was recorded. RESULTS: Sevoflurane consumption was significantly lower in Group L (4.17 ± 0.70 mL) compared to Group S (8.96 ± 1.11 mL) (mean difference 4.79 [95% CI = 4.25-5.33] mL; P < 0.001). Time to successful laryngeal mask airway insertion was similar in both groups. There were no significant differences in heart rate, incidence of reflex tachycardia, or need for rescue propofol. CONCLUSION: Induction of anesthesia with sevoflurane using low-fresh gas flow is effective in reducing sevoflurane consumption, without compromising induction time and conditions.

Evaluation of optimum time for intravenous cannulation after sevoflurane induction of anesthesia in different pediatric age groups.

BACKGROUND AND AIMS: The ideal time for intravenous (IV) cannulation following inhalational induction in children is debatable. The effect of age on this time has not been studied. We evaluated the optimum time for IV cannulation after sevoflurane induction of anesthesia in different pediatric age groups. MATERIAL AND METHODS: A prospective interventional study based on Dixon's sequential up and down method was conducted in children of age 1-10 years. They were grouped according to their age - Group 1: 1-3 years, Group 2: >3-7 years, and Group 3: >7-10 years. Anesthesia was induced with 8% sevoflurane in 5 L of 100% oxygen. IV cannulation was attempted at 3.5 min in the first child in each group. The time for cannulation in the next child was stepped up or down by 30 s depending on positive or negative response, respectively, in the previous child. Children were recruited till a minimum of six pairs of failure-success sequence which was obtained in each group. The mean of midpoints of the failure-success sequence was calculated to obtain the time for cannulation in 50% of the children in each group. RESULTS: Total number of children in Groups 1, 2, and 3 were 24, 23, and 24, respectively. The mean (95% confidence level) time for IV cannulation after sevoflurane induction in Groups 1, 2, and 3 was 53.6 (40.0-67.1), 105 (62.6-147.4), and 143.6 (108.8-178.4) s, respectively. This time was significantly shorter in Group 1 compared to those in Groups 2 and 3. CONCLUSION: The optimum time for IV cannulation in 50% of the children after sevoflurane induction of anesthesia was shorter in children of age 1-3 years than in older children.