Comparison of induction of spinal anesthesia in sitting position with legs parallel and crossed for cesarean section: A randomized controlled trial.

Background and Aims: The position of the patient during subarachnoid block has a role in its success. Landmarks of the spine can be easily identified in sitting position. Sitting position with legs parallel (LPSP) produces a reversal of lumbar lordosis. The crossed-leg sitting position (CLSP) is an alternative position. In this study, we compared the ease of performing subarachnoid blocks in these two positions. The objectives were to compare the attempts at subarachnoid placement, patient comfort, ease of landmark palpation, level of block, hypotension, and neonatal outcomes. Material and Methods: This randomized trial was performed in 80 parturients posted for elective cesarean section. Parturients were assigned randomly to two groups. In group LPSP, the subarachnoid block was performed in sitting position with legs parallel and in group CLSP in the CLSP with knees and hips flexed. Results: The percentage of parturients with a successful subarachnoid block in the first attempt was higher in the CLSP than in LPSP group (87.5% versus 55%). The remaining 12.5% parturients in the CLSP group had successful block in the second attempt. In the LPSP group, 32.5% required two attempts and 12.5% required more than two attempts. This difference was statistically significant (P-value of 0.003). The landmark was easily palpable in 92.5 versus 67.5% of parturients in CLSP and LPSP, respectively, with a P-value of 0.014. Conclusion: CLSP is better than a sitting position with legs parallel for reducing the number of attempts and improving the ease of performing the subarachnoid block.

Comparison of aerosol box intubation with styletted endotracheal tube and intubation over bougie: A randomized controlled trial.

Background and Aims: Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is an infectious disease. The use of video laryngoscopes is recommended for intubation of patients with COVID-19. But in resource-poor countries, it is rare to have video laryngoscopes available. In this trial, we have compared the ease of oral intubation by direct laryngoscopy with styletted endotracheal tube and intubation over the bougie, with the use of the aerosol box. The secondary objectives were comparison of the incidence of airway loss, attempts taken to intubate, time for intubation and hemodynamic changes. Material and Methods: 80 non-coronavirus infected patients coming for an elective procedure under general anesthesia were recruited in this randomized control trial. Participants were assigned into groups S and B using a computer-generated random sequence of numbers by closed envelope technique. In both groups, aerosol box was used. In Group S, participants were intubated by direct laryngoscopy with a styletted endotracheal tube and in group B, after direct laryngoscopy, the endotracheal tube was railroaded over the bougie. Results: Ease of endotracheal intubation was good (67.5%% vs. 45%), satisfactory (32.5%% vs. 37.5%), and poor (0% vs. 17.5%) in group S and B respectively (P < 0.011). The attempts required for intubation were similar in both groups. The time for intubation was significantly less in group S than B (23 vs. 55 s). Conclusion: The use of a styletted endotracheal tube made intubation easier and faster than tracheal intubation with bougie when the aerosol box was used in patients without known or predicted difficult airway and significant medical comorbidities.

Usefulness of bougie-preloaded proseal laryngeal mask airway versus digital insertion technique in correct placement of the device.

Background and Aims: Digital technique of proseal laryngeal mask airway (PLMA) insertion carries high chance of failed first attempt successful placement. We aimed to compare the number of attempts taken for correct placement of bougie-preloaded PLMA versus traditional digital insertion technique. Ease of insertion, time taken, hemodynamic responses during insertion, and evidence of trauma were also assessed. Material and Methods: This prospective, randomized, open-label study was performed in 60 patients. All patients were administered general anesthesia according to a standardized protocol.After induction of general anesthesia in group P, proseal insertion was performed following the traditional digital technique. In group B, bougie-preloaded PLMA was used. A soft gum elastic bougie was passed through the gastric channel of PLMA, with 15cm protruding distally through the gastric port. Attempts at successful insertion and ease of insertion were noted. Results: Time taken for successful insertion was significantly shorter in group B compared to group P (15.3 ± 4.5 vs. 57 ± 12.02 s, respectively). The first attempt success in group B was 90% versus 60% in group P. The number of moderate to hard insertion was significantly lesser in group B (10 vs. 40, respectively). Blood stain on device was seen in 3.3% in group B compared to 30% in group P. MAP at insertion and at 1, 3, and 5 min was significantly higher in group P. Heart rates were comparable. Conclusion: Bougie-preloaded proseal insertion has significantly higher first attempt insertion success rates and is significantly faster and less traumatic with blunted blood pressure response compared to traditional digital insertion technique.

Effect of intracuff dexamethasone on incidence and severity of post operative sore -Prospective randomized study.

BACKGROUND AND AIMS: Postoperative sore throat (POST) continues to be a common concern following endotracheal intubation. Objectives of the present study were to compare the effects of intracuff dexamethasone on the incidence and severity of POST, postoperative hoarseness of voice (POHV) and cough (POC). MATERIAL AND METHODS: This prospective, randomized, double blinded study was conducted in 60 patients undergoing short laparoscopic surgery lasting <2 h. Patients were randomly allocated into Group A and B. After intubation, endotracheal tube (ETT) cuffs were filled with saline in group A and with 0.1 mg/kg dexamethasone in group B. All patients received general anesthesia as per a standardized protocol. Incidence and severity of POST, POC, and POHV were assessed. RESULTS: As compared to group A, the number of patients who had sore throat was significantly low in group B at 2, 6, 12, and 24 h (P < 0.001). Though more number of patients in group A had postop cough at all time points and postop hoarseness of voice at 2,6, and 12 h, the difference was statistically significant only at 2 h and 6 h for both. Severity as well as the incidence of POST, POC, and POHV showed a downward trend in both groups with time. In group B, no patient had POST after 12 h, POC after 6 h, and none complained of POHV in the postoperative period. CONCLUSION: Intracuff dexamethasone 0.1 mg/kg significantly reduces incidence and severity of POST, POC, and POHV which occur following general anesthesia with endotracheal intubation in patients undergoing short pelvic laparoscopic procedures lasting <2 h.

Indian Subcontinent's First Proximal Forearm Level Double Upper Extremity Transplantation.

Introduction Vascularized composite allotransplantation (VCA) has added another step to the reconstructive ladder, leading to a paradigm shift in the approach toward management of cases of upper limb amputations. In this article, we discuss in detail the technical aspects of proximal forearm level transplantation, as well as the immediate posttransplant monitoring and immunosuppression protocols. Materials and Methods A 24-year-old male victim of an electric injury presented with a bilateral proximal forearm level amputation. After the mandatory preoperative psychiatric and immunological evaluation, the patient underwent a proximal forearm level double upper extremity transplantation. He was then put on a stringent immunosuppression and physical rehabilitative regime. Discussion Conceptually, the proximal forearm level transplantation is significantly different from distal forearm level transplant. This transplant "reestablishes" the "donor extremity length," maintains the normal functional length of the donor muscles, and the functional return happens only after the newly transplanted donor muscles are reinnervated over a period of time. Conclusion As the sequence of surgical repair and associated decision making could be quite confusing for this level of transplantation, it is highly advisable to do mock cadaver surgical dissections in order to standardize the procedure and make the team familiar with it.

Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation.

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window. The technical considerations for the same have been discussed in detail in this article. Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation. The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient's own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail. Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript. Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.

Hemodynamic response to tracheal intubation in postlaryngectomy patients.

BACKGROUND AND AIMS: Endotracheal intubation in postlaryngectomy patients is usually accomplished by inserting endotracheal tube directly into the laryngectomy stoma. The primary objective of our study was to assess the systolic blood pressure (SBP) response to intubation in postlaryngectomy patients. Secondary objectives included assessment of changes in heart rate (HR), mean arterial pressure (MAP), and to estimate tracheal component of hemodynamic response to intubation in normal patients by finding out the relative reduction in hemodynamic response that might occur in postlaryngectomy patients. MATERIAL AND METHODS: This was a prospective, observational study. Forty postlaryngectomy patients formed group L and 40 normal patients constituted group N. After induction of anesthesia and neuromuscular blockade, direct laryngoscopy and tracheal intubation were performed in group N, whereas an endotracheal tube was passed through the laryngectomy stoma directly into the trachea in group L. Hemodynamic responses were documented. Chi-square test, independent samples t-test, and analysis of covariance (ANCOVA) test were applied. RESULT: Group L patients were significantly older with significantly lower baseline HR with higher SBP and MAP. As baseline values were not comparable, they were taken as covariates and ANCOVA was applied. Adjusted mean values were then compared. Immediately after induction HR, SBP and MAP were comparable in both groups. Subsequent comparison of adjusted mean values showed significantly higher HR, SBP, and MAP in group N immediately after intubation and 1,3,5, and 10 min later (P < 0.001). At 15 min, HR and SBP were significantly higher in group N with comparable MAP. CONCLUSION: Hemodynamic stress response to endotracheal intubation is minimal or absent in postlaryngectomy patients. They mostly present with elevated blood pressure and develop hypotension following induction that persists despite intubation.

Ease of intubation and hemodynamic responses to nasotracheal intubation using C-MAC videolaryngoscope with D blade: A comparison with use of traditional Macintosh laryngoscope.

BACKGROUND AND AIMS: Nasal intubation with traditional Macintosh laryngoscope usually needs the use of Magill's forceps or external laryngeal manipulation. The primary objective of this study was to assess the ease of intubation during C-MAC videolaryngoscope-assisted nasal intubation using D blade and to compare it with traditional Macintosh laryngoscope-aided nasal intubation. The secondary objectives were comparison of intubation time, attempts, trauma, and hemodynamic stress responses. MATERIAL AND METHODS: Sixty patients requiring nasal intubation were randomized into two groups, M and V. Patients in both the groups received general anesthesia as per a standardized protocol. Laryngoscopy was performed using the traditional Macintosh laryngoscope in group M and with Storz® C-Mac videolaryngoscope with D-blade in group V. Chi-square test, Mann-Whitney test, and independent samples t-test were used as applicable for data analysis. RESULTS: Intubation was significantly easy in 70% of the patients in group V compared to only 3.3% in group M. Time to intubate was significantly shorter in group V (24 vs 68 s). Though majority of patients were intubated in the first attempt in both groups, the number was more in group V (96.7 vs 70%). There was no case of esophageal intubation in group V, but 2 patients (6.7%) had esophageal intubation in group M. Mucosal trauma was significantly more frequent in group M. There was no statistically significant difference in hemodynamics in both groups. CONCLUSION: C MAC videolaryngoscope-aided nasotracheal intubation using D blade is superior in view of easier, quicker, and less traumatic intubation compared to the use of traditional Macintosh laryngoscope.

Efficacy of vaptans for correction of postoperative hyponatremia: A comparison between single intravenous bolus conivaptan vs oral tolvaptan.

BACKGROUND AND AIMS: Hyponatremia is one of the most common electrolyte abnormality encountered in postoperative patients especially in the elderly. We aimed to assess the efficacy of single-dose intravenous conivaptan vs. oral tolvaptan therapy for correction of hyponatremia in postoperative patients. MATERIAL AND METHODS: This prospective randomized study was conducted on 40 patients aged 20-70 years, who had undergone major head and neck surgeries with a serum sodium level of ≤130 mEq/L and were symptomatic. Patients were randomly allocated into two equal groups. Patients belonging to group C received single intravenous bolus dose of conivaptan 20mg, whereas group T received oral tolvaptan 15mg on the first day. At 24h, if sodium correction was <4mEq/L, dose of tolvaptan was increased to 30mg in group T or an infusion of conivaptan 20mg over next 24h was started in group C. RESULTS: Chi-square test, independent sample t-test, and paired t-test were used as applicable. Though there was no significant difference in the baseline sodium values in both groups, at 12 and 24 h group C had significantly high values. At 48h sodium values in both the groups were comparable. Intra-group analysis had shown that there was a significant increase in sodium values from the baseline at 12, 24, and 48 h in both the groups. CONCLUSION: Single-dose intravenous conivaptan as well as oral tolvaptan were safe and effective in correcting hyponatremia in postoperative patients. Conivaptan could be considered superior as it resulted in faster sodium correction with effective aquaresis.

First two bilateral hand transplantations in India (Part 2): Technical details.

INTRODUCTION: This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream. MATERIALS AND METHODS: The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient. RESULTS: The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines. CONCLUSIONS: Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

Comparison of margin of safety following two different techniques of preoxygenation.

BACKGROUND AND AIMS: Shortening the duration of efficacious preoxygenation would provide benefit in emergency situations like fetal distress etc. This study aims to compare the margin of safety following preoxygenation using 8 vital capacity breaths (VCB) in 1 min and tidal volume breathing (TVB) for 3 min, by assessing changes in PaO2 and apnea induced desaturation time. MATERIAL AND METHODS: Patients were randomly divided into Group A and B. In Group A, 3 min of TVB using O2 flow of 5 l/min and in Group B, 8 VCB in 60 s using O2 flow of 10 l/min were used. Anesthesia was induced in all patients with propofol followed by succinylcholine 2 mg/kg intravenously. Mask ventilation was not done and following intubation endotracheal tube was kept open to atmosphere. The time taken for the patients to desaturate to 90% was noted and immediately ventilation was resumed. Arterial blood gas samples were taken while patients were breathing room air, immediately after preoxygenation and at 90% desaturation. RESULTS: Baseline PaO2 of both the groups were comparable. After preoxygenation Group B had a significantly high PaO2 value than Group A (439.05 ± 62.20 vs. 345.16 ± 20.80). At 90% desaturation there was no significant difference between groups. Group B showed a significantly high apnea induced desaturation time when compared to Group A (6.87 ± 1.78 vs. 3.47 ± 0.38 min). CONCLUSIONS: Preoxygenation by 8 VCB in 1 min provides a greater margin of safety, as it results in a significantly high PaO2 with an almost doubled apnea induced desaturation time, in comparison with TVB for 3 min.

Transtracheal lidocaine: An alternative to intraoperative propofol infusion when muscle relaxants are not used.

BACKGROUND: Facial nerve monitoring, often required during total parotidectomy, precludes use of long acting muscle relaxants and propofol infusion is used solely to ensure patient immobility. We aimed to compare intraoperative patient immobility, hemodynamic stability and propofol consumption during total parotidectomy following a transtracheal block. MATERIAL AND METHODS: Forty patients were allocated to 2 equal groups. Preoperatively, group A patients received transtracheal block with 4 ml of 4% lidocaine, while no block was given to patients in group B. If there was patient movement, tachycardia or hypertension, group A patients received a bolus of propofol 30 mg and propofol infusion was started (100mg/hr). In group B, propofol infusion was started (100mg/hr) soon after intubation. RESULT: Both group A and B were comparable with respect to patient immobility and hemodynamic stability. There was no intraoperative propofol requirement in group A. CONCLUSION: Transtracheal block is a safe and successful alternative to propofol infusion during surgeries where muscle relaxants are to be avoided.

Evaluation of endotracheal intubating conditions without the use of muscle relaxants following induction with propofol and sevoflurane in pediatric cleft lip and palate surgeries.

BACKGROUND AND AIMS: Children with facial clefts are usually difficult to intubate and it is considered safer to keep them spontaneously breathing while securing the airway. This prospective comparative study was conducted to evaluate endotracheal intubating conditions in pediatric patients undergoing cleft surgeries, without the use of muscle relaxants following induction with propofol and sevoflurane. MATERIALS AND METHODS: Sixty patients aged 1month to 3 years, were randomly allocated into two equal groups. Anesthesia was induced with sevoflurane 8% in oxygen in group 1 and with propofol 3 mg/kg in group 2. Laryngoscopy and intubation were attempted 150 s after induction in both groups and ease of laryngoscopy, position of vocal cords, degree of coughing, jaw relaxation, and limb movements were assessed and scored. Total score of 5 was considered excellent, 6-10 good, 11-15 poor, and 16-20 bad. Total score ≤ 10 was considered clinically acceptable, and >10 as clinically unacceptable. Chi-square and Wilcoxon Mann-Whitney tests were used to analyze data. RESULTS: There was no significant difference between groups when ease of laryngoscopy was compared. Sevoflurane induced patients had significantly better position of vocal cords at intubation and the propofol group had significantly more episodes of coughing. Significantly less number of patients had limb movements in sevoflurane group. There was no significant difference in degree of jaw relaxation between groups. The sevoflurane group had significantly better total scores and clinically acceptable intubating conditions. CONCLUSION: Sevoflurane 8% in oxygen provides clinically acceptable intubating conditions without use of muscle relaxants in pediatric cleft patients.

Safety and efficacy of low molecular weight dextran (dextran 40) in head and neck free flap reconstruction.

BACKGROUND: Antithrombotic agents have been used in microvascular surgeries. Low molecular weight dextran (dextran 40), though used, is not without complications. METHODS: Retrospective analysis of 172 consecutive flaps. A comparison was made between two groups of patients (86 flaps each) with and without the use of dextran 40, in terms of safety and efficacy. RESULTS: The free flap survival rate was 95.9%. The flap survival rates were comparable between the groups. Total flap loss in Group A (patients who received dextran 40) was 3.5% compared with 2.3% in Group B (patients who did not receive dextran 40) (p = 1.00). There was no statistically significant difference in the incidence of thrombotic flap complications between the groups. None of the patients developed acute respiratory distress syndrome or required prolonged ventilator support. No patient had dextran-related anaphylactoid reactions. Thirty-eight patients (43.7%) in Group A had postoperative atelectasis and 21 (25.6%) patients in Group B had this complication (p = 0.01). Six patients in Group A developed postoperative pneumonia, and five patients in Group B developed this complication (p = 0.93). CONCLUSIONS: Though dextran 40 did not result in any significant adverse local or systemic complications, it is not useful as a postoperative antithrombotic agent in head and neck oncologic reconstruction with free tissue transfer.

Anaesthetic Management of a Patient with Multiple Acetyl CoA Dehydrogenase Deficiency: A Case Report.

Multiple acetyl CoA dehydrogenase deficiency is a rare autosomal recessive disorder of amino acid, fatty acid, and choline metabolism. It is a mitochondrial disorder with defective electron transfer flavoproteins or electron transfer flavoprotein dehydrogenases. They are vital for ß-oxidation of fatty acids, an essential fuel for skeletal and cardiac muscles. It is also an important source of energy during starvation for the brain. Acute deterioration of these patients can occur during stressful periods like starvation, surgery, infection, and exercise. The anaesthetic management is a challenge with special emphasis on minimizing starvation, ensuring hydration and glucose supplementation, and considering the various effects of anaesthetic agents on the mitochondrial function. The anaesthetic management of a patient with multiple acetyl CoA dehy- drogenase scheduled for modified radical mastectomy is described. General anaesthesia can be administered safely in these patients with special emphasis on hydration, glucose supplementation, avoidance of stressors, and monitoring of metabolic status.