Comparing the posture and comfort of anaesthesiologists during laryngoscopy and tracheal intubation in the head-elevated laryngoscopy position in supine position and with a 25° backup: A randomised clinical crossover trial.

Background and Aims: The head-elevated laryngoscopy position (HELP) and a 25° backup have been proposed to enhance glottic visualisation, yet concerns about ergonomic discomfort hinder their widespread adoption. This study compares the comfort and posture adopted by anaesthesiologists while performing laryngoscopy and tracheal intubation with patients in HELP while in a supine position or with 25° backup. Methods: The study included 48 patients aged 18-60 years with normal airways and 12 experienced anaesthesiologists. Patients were randomised into two groups using permuted block randomisation. Anaesthesiologists performed laryngoscopy and intubation in supine HELP and 25° backup HELP positions. Anaesthesiologist's posture was determined by measuring the angles of neck, wrist, elbow, back and knee joints, which were compared using Student's t-test, and subjective comfort assessed on a Likert scale was compared using the Chi-square test. As mentioned by the anaesthesiologist, Cormack- Lehane grading was also noted and compared using a Chi-square test between groups, taking a P value <0.05 as significant. Results: Both positions demonstrated comparable anaesthesiologist posture (P = 0.919) and comfort (P = 0.644). However, the 25° backup HELP positions significantly improved Cormack-Lehane grades, with 68% achieving grade 1 compared to 31% in the supine HELP group (P = 0.012). Haemodynamic stability and tracheal intubation time showed no significant differences between the groups (P = 0.475 and 0.117, respectively), and no complications were reported in either group. Conclusion: Anaesthesiologists' posture and comfort during laryngoscopy and tracheal intubation are similar between supine and 25° backup in patients with easy airways.

Competency-based postgraduate training: Mentoring and monitoring using entrustable professional activities with descriptive rubrics for objectivity- A step beyond Dreyfus.

Background At Sri Balaji Vidyapeeth, a competency-based learning and training (CoBaLT©) model for postgraduate (PG) curriculum, within the regulatory norms, was implemented in 2016 after adequate faculty development programmes. This focused on well-defined outcomes. Methods A review of the outcomes was undertaken in 2018 as part of internal quality assurance receiving feedback from all stakeholders, viz. students, alumni and faculty. Recent publications were also reviewed. A major problem identified was lack of clarity in definition of levels leading to subjectivity in assessment while grading. It was also noted that the process needed to be aligned with the programme outcomes. Further refinements were, therefore, made to align and objectivize formative assessment using entrustable professional activities (EPA) with the aid of descriptive rubrics of sub-competencies and milestones. Addition of detailed rubrics for objectivity takes assessment a step beyond the Dreyfus model, aligning overall to the programme outcomes. Results Achievement of appropriate grades in EPAs by individual candidates ensures entrustability in professional activities by the time of completion of the PG programme. The modification was found more transparent and objective with reference to grading by the teachers and more conducive to reflections by the residents on their performance and how to improve it. Conclusions The use of descriptive rubrics along with EPAs brings transparency and plays a key role as an objective assessment tool, which can lend direction to individual resident learning and entrustability. This is an important component of outcome-based education.

Selective blockade of supraclavicular nerves and upper trunk of brachial plexus "The SCUT block" towards a site-specific regional anaesthesia strategy for clavicle surgeries - A descriptive study.

BACKGROUND AND AIMS: Commonly, the superficial cervical plexus and interscalene block were combined to provide surgical anaesthesia for procedures on the clavicle, which are neither selective nor site-specific considering the innervation of the clavicle. The aim was to analyse effectiveness and block dynamics of selectively blocking supraclavicular (SC) nerves and upper trunk (UT) of brachial plexus (SCUT BLOCK) as a site-specific regional anaesthesia strategy for clavicle surgery. METHODS: SC nerves and UT were blocked with 3-ml and 5-ml local anaesthetic, respectively, in 70 American Society of Anesthesiologists I and II patients aged above 18 years, undergoing clavicle surgery. Sensory-motor conduction blockade was assessed in both the plexus territories, following which surgery ensued. Number of patients who exhibited complete conduction blockade of the targeted nerves, number of surgeries completed under the block, intraoperative rescue analgesics, duration of postoperative analgesia and complications were recorded. RESULTS: Sensory and motor mapping showed complete conduction blockade of the targeted nerves in all patients, all other branches were spared. The surgery was completed exclusively under block in 67 (Strategy success rate 96%) out of 70 patients. Intraoperatively, two patients required supplementation of block with a local infiltration and general anaesthesia was administered for one patient. The mean duration of postoperative analgesia was 5 (1.2) hours [mean (standard deviation)]. Only one patient developed ptosis; no other complications were noted. CONCLUSIONS: "The SCUT block" is an effective site-specific regional anaesthesia strategy for clavicle surgery.