Utilizing nasal-tragus length to estimate optimal endotracheal tube depth in neonates: A prospective randomized control study.

BACKGROUND: Determination of the optimal depth of endotracheal tube insertion in neonates is challenging. Various formulae have been proposed and are being commonly used for this purpose. There is no single formula that is ideal or can be applied across different populations. AIM: To compare weight and nasal-tragus length-based formulae as a guide to endotracheal tube insertion depth in term neonates undergoing surgery. Ther primary objective of the study was to determine the position of the endotracheal tube using either weight-based or nasal-tragus length-based formulae and the secondary objective was to determine the incidence of repositioning of the endotracheal tube. METHODS: A total of 120 full term neonates were divided into two groups with 60 neonates each (group N = NTL + 1 cm and group W = Weight + 6 cm). Endotracheal tube was inserted according to the pre-calculated value and fixed. A neonatal flexible fiberoptic bronchoscope was used to confirm the position of the endotracheal tube tip by measuring its distance from the carina. Repositioning was done if the distance from carina to endotracheal tube tip was less than 20 mm. Chi-squared and Mann-Whitney tests were used for the analysis. RESULTS: The mean distance measured from carina to endotracheal tube tip in group N was 9.41 ± 6.65 mm and in group W was 3.21 ± 3.45 mm (p value = <.001). A higher incidence of optimal endotracheal tube placement was observed in group N which led to repositioning in 88.3% of neonates in group N and 100% in the group W (53/60 and 60/60, respectively, p value < .05). CONCLUSION: Based on the results from the studied sample, NTL +1 cm formula is a better predictor than Weight + 6 cm formula to determine endotracheal tube insertion depth in term Indian neonates.

Cardiac dysrhythmia complicating total parotidectomy.

Sudden severe dysrhythmias during anaesthesia can be life- threatening for the patient. We describe a case in which ventricular dysrhythmias and severe bradycardia occurred during dissection and mobilization of the deep lobe of the parotid gland during total parotidectomy under general anaesthesia. We believe that these dysrhythmias were caused by a trigemino- vagal reflex similar to the oculocardiac reflex, but with afferent innervation from mandibular division of the trigeminal nerve. The case report is presented to illustrate a possible existence and importance of reflex bradycardic responses that may occur during surgical procedures involving the parotid gland.

Comparing Opioid with Opioid-free Anesthesia Technique in Neonates Undergoing Tracheoesophageal Fistula Repair.

Objectives: Tracheoesophageal fistula (TEF) is a congenital disorder that presents as a surgical emergency in neonates. In regions where neonatal intensive care unit facilities and resources are inadequate and skilled personnel are scarce, not extubating neonates on table, contributes to mortality. Our aim was to assess and compare the on-table extubation rate, extubation time, and postoperative pain scores between opioid and opioid-free anesthesia techniques in neonates undergoing surgical repair of TEF. Methods: We conducted a prospective, single-blind, randomized trial over 18 months between January 2021 and June 2022 in Safdarjung Hospital, New Delhi on 60 full-term neonates scheduled for TEF surgeries randomly allocated to two groups according to the mode of analgesia administered. Group O were given fentanyl injection 1 µg/kg intravenous (IV) loading dose with IV injection. acetaminophen at 7.5 mg/kg and top-up of 0.25 µg/kg fentanyl IV si opus sit. Group NO were given pre-surgical local infiltration and intercostal block with 0.25% and 0.5% bupivacaine, respectively, with IV acetaminophen at 7.5 mg/kg. Results: Mean age in days, gender distribution, and weight in both groups were statistically comparable. The difference in the number of neonates extubated on table was statistically significant (p =0.002) in group NO compared to group O. Lower mean extubation time was seen in group NO (9.0 min 40.0 secs±3.0 min 3.0 secs) compared to group O (16.0 min 45.0 secs±8.0 min 5.0 secs) (p < 0.001). There was a statistically significant (p =0.010) lower Neonatal Infant Pain Scale score in group NO with mean and SD as 1.8±0.8 compared with group O, 2.5±1.1 at 90 min. Conclusions: In neonates undergoing TEF repair, opioid-free anesthesia is a safe and effective method, providing a better extubation rate, faster time to extubation, and better postoperative pain control.

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.

A Boy Who Knows No Pain: Anaesthetic Management of Congenital Insensitivity to Pain With Anhidrosis.

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare disorder with an absence of pain perception, anhidrosis, heat intolerance, and varying degrees of mental retardation. Though cases of CIPA have innate analgesia, they have been known to have tactile hyperesthesia, thus making anesthesia necessary in case of any surgery. Perioperative complications due to abnormal autonomic functions like bradycardia, hypotension, and hyperthermia are major challenges in the anesthetic management of these cases. Here, we report a case on the anesthetic management of CIPA.

Comparison of Morphine and Clonidine as Adjuvants in Paravertebral Block.

BACKGROUND: General anesthesia (GA) has been considered as the gold standard for breast cancer surgery. The problem of postoperative pain as well as the high incidence of nausea and vomiting has led to the search for a better modality for pain management with fewer side effects. In the last few years, paravertebral block (PVB) has gained immense popularity either in combination with GA or by itself for the anesthetic management of patients undergoing breast surgery. CONTEXT: Paravertebral block in breast surgery. AIMS: This study aims to evaluate the efficacy and duration of postoperative analgesia provided by ultrasound (USG)-guided PVB with bupivacaine and morphine versus bupivacaine and clonidine in patients undergoing modified radical mastectomy (MRM). SUBJECT AND METHODS: In the study, 70 patients who were scheduled for MRM were enrolled and randomly divided into Group M (n = 35) and Group C (n = 35). Both groups received USG-guided PVB at T2-T3 after administering GA. Group M received 2 mg/kg 0.5% bupivacaine with 0.05 mg/kg morphine and Group C received 2 mg/kg 0.5% bupivacaine with 1 µg/kg clonidine in the block. Postoperatively, pain intensity was recorded using the visual analog scale (VAS) (0-10 scale) at 1, 2, 6, 18, and 24 h duration when patients were resting and during a standardized movement. Modified Post Anaesthesia Discharge Scoring System was assessed at 1, 2, 6, 18 and 24 h after surgery. RESULTS: In this study conducted on 70 patients, VAS scores (both at rest and on movement) were found comparable at postoperative 1, 2, 6, 18, and 24 h (P > 0.05). There was no statistical difference in comparing postanesthesia discharging scoring in both the groups. No incidence of postoperative nausea and vomiting was seen in any group. CONCLUSIONS: Morphine and clonidine in PVB are equally effective, and there is no superiority of one agent over the other. Hence, both drugs may be used with equal efficacy as adjuvants to bupivacaine in PVB for providing postoperative analgesia.