Comparison of cuff inflation method with curvature control modification in thermosoftened endotracheal tubes during nasotracheal intubation - A prospective randomised controlled study.

BACKGROUND AND AIMS: Thermosoftening of endotracheal tube (ETT) is a simple method which reduces risk of epistaxis during nasotracheal intubation (NTI). This method, however, decreases the stiffness of ETT and necessitates frequent manipulation with Magill forceps. Cuff inflation technique has been found effective for navigating ETTs during NTI. Another method is using an ETT, modified with a silk thread which can be used to control its curvature. We conducted the present study to compare the ease of navigation of thermosoftened ETT using curvature control modificationwiththe cuff inflation technique. METHODS: Depending on the method used for navigating thermosoftened ETT to glottis, 70 patients undergoing general anaesthesia with NTI were randomly divided into two groups. The primary outcome was ease of navigation of thermosoftened ETT. Secondary outcomes were time taken for moving tube from oropharynx to glottis and incidence of epistaxis during NTI. RESULTS: Both techniques resulted in successful navigation of thermosoftened ETT in all patients with majority of cases resulting in smooth engagement to glottic inlet. The difference in ease of navigation between the groups was 7% [95% CI (-9.21% to 23.28%)] and it was not found to be statistically significant (P = 0.395). Cuff inflation method resulted in faster alignment to glottis compared to use of modified tube (12. 39 ± 7 Vs 18.73 ± 11.5 sec; P = 0.003). CONCLUSION: For thermosoftened ETT, both cuff inflation method and the technique of curvature controlled modified ETT can be used for navigation of tube to glottis with ease.

Correlation of Patient Profiles and Biomarkers with Outcomes in Covid-19 Icu Patients: A Retrospective Analysis.

Background: COVID-19 is a novel disease with a highly variable and unpredictable clinical course. Various clinicodemographic factors and numerous biomarkers have been identified in studies from the West and marked as possible predictors of severe illness and mortality which may be used to triage patients for early aggressive care. This triaging becomes even more significant in resource-limited critical care settings of the Indian subcontinent. Methods: This retrospective observational study recruited 99 cases of COVID-19 admitted to intensive care from 1 May to 1 August 2020. Demographic, clinical and baseline laboratory data were collected and analysed for association with clinical outcomes, including survival and need for mechanical ventilatory support. Results: Male gender (p=0.044) and diabetes mellitus (p=0.042) were associated with increased mortality. Binomial logistic regression analysis revealed Interleukin-6 (IL6) (p=0.024), D-dimer (p=0.025) and CRP (p<0.001) as significant predictors of need of ventilatory support and IL6 (p=0.036), CRP (p=0.041), D-dimer (p=0.006) and PaO2FiO2 ratio (p=0.019) as significant predictors of mortality. CRP >40 mg/L predicted mortality with sensitivity of 93.3% and specificity of 88.9% (AUC 0.933) and IL6> 32.5 pg/ml with a sensitivity of 82.2% and specificity of 70.4% (AUC 0.821). Conclusion: Our results suggest that a baseline CRP >40 mg/L, IL6 >32.5 pg/ml or D-dimer >810 ng/ml are early accurate predictors of severe illness and adverse outcomes and may be used to triage patients for early intensive care.

Preventing inadvertent Endobronchial intubation: Upper incisor to manubriosternal joint length as a predictor of airway length in children.

BACKGROUND: Malpositioning of the endotracheal tube within the airway can lead to serious complications. The estimated insertion depth of the endotracheal tube should be accurate and reliable. AIMS AND OBJECTIVES: To study whether the upper incisor-manubriosternal joint length in the extended head position can be used as a predictor of airway length to guide the depth of insertion of endotracheal tube in children and to evaluate the correlation of upper incisor-manubriosternal joint length with the upper incisor-carina length in the neutral head position, in Indian pediatric population. MATERIALS AND METHODS: After induction of anesthesia, upper incisor-manubriosternal joint length was measured using a flexible metallic tape. Endotracheal tube was inserted and secured in the midline over the upper incisors. The degree of the maximum head extension was recorded with a goniometer, and the upper incisor-carina length was measured with the help of a fiberoptic bronchoscope. RESULTS: Analysis revealed a positive correlation between upper incisor-carina length and upper incisor-manubriosternal joint length (R = .456, R2  = .208, P = .000) and also between upper incisor-carina length and the height of the patient (R = .528, R2  = .279, P-value .000). The degree of maximum head extension did not influence the upper incisor-carina length and the upper incisor-manubriosternal joint length relationship. CONCLUSION: The upper incisor-carina length shows a positive correlation with the patient's upper incisor-manubriosternal joint length and the patient's standing height, while the degree of maximum head extension has no significant bearing on this relationship. The upper incisor-manubriosternal joint length can be used as a predictor of airway length and the depth of insertion of endotracheal tube in children.

Preoperative pregnancy testing in surgical patients: How useful is policy of routine testing.

Surgery in a patient with unrecognised pregnancy has serious ethical and medicolegal implications. There are no guidelines in India for preoperative pregnancy testing (POPT) in surgical patients. This review was undertaken to ascertain utility of routine POPT and whether any specific indication for POPT could be suggested. We performed a literature search to identify publications pertaining to POPT in surgical patients. Searches included PubMed, Google Scholar and internet search for national guidelines. Studies pertaining to incidence of unrecognised pregnancy, cost-effectiveness of POPT, effect of surgery and anaesthesia on pregnancy are included. We excluded articles which were available in languages other than English and those whose full texts were unavailable. Most of the literature about reproductive outcomes after anaesthesia exposure is based on old data. The evidence for teratogenic effect of anaesthetic drugs on human foetus is still inconclusive. Apart from anaesthesia and surgery, the outcome after surgery in unrecognised pregnant patient depends on other factors such as indication for surgery, high incidence of foetal loss in early pregnancy, stress and lifestyle of patient. As it is difficult to unsnarl the effect of these factors, POPT should be offered to all patients who based on history could be possibly pregnant. The cost-effectiveness of POPT appears doubtful, but considering costs associated with miscarriages and medicolegal litigations due to unclear association with anaesthesia, it may indeed be cost-effective.

Patient with Persistent Low Oxygen Saturation for Emergency Cesarean Section.

A 24-year-old woman with previous undiagnosed congenital methemoglobinemia presented for the emergency cesarean section in view of fetal distress. The patient had a persistent low oxygen saturation on pulse oximetry with normal heart rate and blood pressure. Arterial blood gas values were normal. The patient was asymptomatic and respiratory and cardiovascular system examination was normal. The patient underwent cesarean section under general anesthesia and was shifted to the Intensive Care Unit postoperatively. The oxygen saturation was low throughout the intraoperative and postoperative period. A complete evaluation was done postoperatively. Mass spectrophotometry was done, which confirmed methemoglobinemia in the patient.

Post-caesarean analgesia: What is new?

Adequate post-operative analgesia after caesarean section (CS) is vital as it impacts the distinct surgical recovery requirements of the parturient. Although newer analgesic modalities and drugs for post-caesarean analgesia have been introduced over the recent years, review of the literature suggests suggests that we are far from achieving the goals of optimum post-operative analgesia. We conducted a systematic review of recent advances in modalities for post-caesarean analgesia. After systematic search and quality assessment of studies, we included a total of 51 randomised controlled trials that evaluated the role of opioids, transversus abdominis plane (TAP) block, wound infiltration/infusion, ketamine, gabapentin and ilioinguinal-iliohypogastric nerve block (II-IH NB) for post-caesarean analgesia. Administration of opioids still remains the gold standard for post-operative analgesia, but the associated troublesome side effects have led to the mandatory incorporation of non-opioid analgesics in post-CS analgesia regime. Among the non-opioid techniques, TAP block is the most investigated modality of the last decade. The analgesic efficacy of TAP block as a part of multimodal analgesia is established in post-CS cases where intrathecal morphine is not employed and in CS under general anaesthesia. Among non-steroidal anti-inflammatory drugs, COX-I inhibitors and intravenous paracetamol are found to be useful in post-operative analgesic regimen. The perioperative use of ketamine is found useful only in CS done under spinal anaesthesia; no benefit is seen where general anaesthesia is employed. Wound infiltration with local anaesthetics, systemic gabapentin and II-IH NB need further trials to assess their efficacy.

Role of transcutaneous electrical nerve stimulation in post-operative analgesia.

The use of transcutaneous electrical nerve stimulation (TENS) as non-pharmacological therapeutic modality is increasing. The types of TENS used clinically are conventional TENS, acupuncture TENS and intense TENS. Their working is believed to be based on gate control theory of pain and activation of endogenous opioids. TENS has been used in anaesthesia for treatment of post-operative analgesia, post-operative nausea vomiting and labour analgesia. Evidence to support analgesic efficacy of TENS is ambiguous. A systematic search of literature on PubMed and Cochrane Library from July 2012 to January 2014 identified a total of eight clinical trials investigating post-operative analgesic effects of TENS including a total of 442 patients. Most of the studies have demonstrated clinically significant reduction in pain intensity and supplemental analgesic requirement. However, these trials vary in TENS parameters used that is, duration, intensity, frequency of stimulation and location of electrodes. Further studies with adequate sample size and good methodological design are warranted to establish general recommendation for use of TENS for post-operative pain.

A comparative randomized study of paravertebral block versus wound infiltration of bupivacaine in modified radical mastectomy.

BACKGROUND: Paravertebral block (PVB) has the potential to offer long-lasting pain relief because it can uniquely eliminate cortical responses to thoracic dermatomal stimulation. Benefits include a reduction in postoperative nausea and vomiting (PONV), prolonged postoperative pain relief, and potential for ambulatory discharge. AIMS: To compare PVB with local infiltration for postoperative analgesia following modified radical mastectomy (MRM). METHODS: Forty patients undergoing MRM with axillary dissection were randomly allocated into two groups. Following induction of general anesthesia in group P, a catheter was inserted in the paravertebral space and 0.3 ml/kg of 0.25 % of bupivacaine was administered followed by continuous infusion, while in group L, the surgical incision was infiltrated with 0.3 ml/kg of 0.25 % bupivacaine. STATISTICAL ANALYSIS: The statistical tests were applied as unpaired student 't' test/nonparametric test Wilcoxon Mann Whitney test for comparing different parameters such as VAS score and consumption of drugs. The categorical variables such as nausea and vomiting scores, sedation score, and patient satisfaction score were computed by Chi square test/Fisher exact test. RESULTS: VAS score was significantly lower in group P than in group L throughout the postoperative period. The mean alertness score (i.e., less sedation) was higher in group P in the postoperative period than group L. The incidence of PONV was less in PVB group. CONCLUSION: PVB at the end of the surgery results in better postoperative analgesia, lesser incidence of PONV, and better alertness score.

Awake fibreoptic intubation in the sitting position in a patient with a huge goitre.

A 46-year-old woman was anesthetized for total thyroidectomy. The thyroid was massive, deviating the trachea to the right and causing attenuation of the trachea radiologically. She had symptoms of respiratory obstruction in the supine position. Awake FOB-guided intubation was done in sitting position after airway topicalisation, and the airway was intubated with difficulty with 7.0 mm cuffed orotracheal tube. We describe this case in detail and discuss the significance of careful approach to planning and preparation in the management of such a case.

Peripartum cardiomyopathy: a short review.

Peripartum cardiomyopathy is an unusual form of dilated cardiomyopathy, which manifests as acute heart failure in the last trimester of pregnancy or early postpartum period. Its aetiology is currently unknown. The presenting signs and symptoms are those of congestive heart failure and more specifically those of left ventricular failure. Its importance lies in the fact that it has a high mortality rate and strikes the patient in the prime of life. Peripartum cardiomyopathy has far reaching implications for the anaesthesiologist. The reason for this is that many of the signs and symptoms of normal pregnancy are indistinguishable from mild cardiac failure so that the condition may remain undiagnosed and can present suddenly at the time of induction of anaesthesia or in the peri-operative period. The goals of anaesthetic management include avoidance of drug induced myocardial depression and prevention of increases in ventricular preload and afterload. Vigilant monitoring is essential throughout the surgery and in the postoperative period and the need for invasive monitoring should be assessed according to the clinical condition of the patient. It is important to recognise the association of cardiac failure and pregnancy as a separate syndrome so that peripartum cardiomyopathy can also be kept as a differential diagnosis for cardiac failure occurring in the peripartum period and a high index of suspicion should be maintained for the timely detection and management of this condition.