A prospective single-center observational study to assess the efficacy of the second-generation supraglottic airway device I-gel in laparoscopic surgeries in children.

BACKGROUND AND AIMS: Supraglottic airways used in pediatric surgeries are associated with a lesser number of postanesthesia respiratory complications. However, there is limited literature on the use of i-gel for pediatric laparoscopic surgery. The aim of this study is to assess the adequacy of ventilation of i-gel for pediatric laparoscopic surgery and note any associated adverse event. MATERIAL AND METHODS: This is a single-centered prospective observational study including 119 children, aged 6 months to 18 years, scheduled for laparoscopic surgery, during a 9-month period, in a tertiary care center. I-gel was used for positive pressure ventilation, and if the post-insertion oropharyngeal seal pressure was <25 cm H2O, it was replaced with a tracheal tube. Adequacy of ventilation and adverse events were noted. RESULTS: Data from 102 cases were analyzed (17 cases excluded: tracheal intubation in 11; missing data in 6 cases). The mean oropharyngeal seal pressure was 34.2 ± 5.2 cm H2O and mean airway pressure was 16.1 ± 2.4 cm H2O. The adverse events included transient cough (10.7%), sore throat (4.9%), and desaturation (3.9%). There was no sign of respiratory distress during the recovery and no intervention was required in any child postoperatively. CONCLUSION: I-gel provided adequate ventilation of the lungs in children undergoing laparoscopic surgery with no major adverse event.

'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation.

Nasotracheal intubation could be associated with a variety of complications, of which traumatic complications are commonly encountered. We present a rare case of retropharyngeal submucosal false passage which occurred during nasotracheal intubation inspite of avoiding potential risk factors known for causing nasopharyngeal trauma. Risk factors, preventive measures and probable reason for this complication have been discussed.

A randomized, controlled trial to compare the efficacy and safety profile of a dexmedetomidine-ketamine combination with a propofol-fentanyl combination for ERCP.

BACKGROUND AND AIMS: Moderate to deep levels of sedation and analgesia are required for ERCP. Propofol-based sedation is simple, easy to use, and effective, but is not without cardiovascular and respiratory adverse effects. The combination of dexmedetomidine and ketamine (DK) has shown promising results for sedation in other similar scenarios. The aim of this study was to compare the efficacy and safety of a standard propofol-fentanyl (PF) regimen with a DK combination. METHODS: After approval of the hospital ethics committee, 83 patients (18-75 years of age) were randomized and divided into 2 groups. Forty-two patients received a PF combination (group PF) and 41 patients received DK combination (group DK) for total intravenous anesthesia for ERCP as initial boluses followed by an infusion of PF and DK, respectively. The sedation-related adverse effects and recovery time were noted. RESULTS: The mean values of the hemodynamic and respiratory parameters were in clinically acceptable ranges, but there were more episodes of hypotension (19%), bradycardia (4.7%), and decrease in oxygen saturation (Spo(2) <80% in 11.9% and Spo(2) <90% for >10 s in 42.8%) in group PF. The procedure could be completed in all of the patients but was interrupted in 6 patients in group PF because of desaturation (5) or sudden patient movement (1). The recovery time was longer in group DK than in group PF. CONCLUSION: There were significantly fewer sedation-related adverse effects, but the recovery time was longer with DK.

An assessment of the awareness of local anesthetic systemic toxicity among multi-specialty postgraduate residents.

Local anesthetics (LAs) are extensively used in clinical practice by both anesthesiologists and non-anesthesiologists and are often associated with systemic toxicity. We hypothesize that this awareness is inadequate among medical specialists and entails a risk of misdiagnosis and underreporting of such events. We therefore conducted a cross-sectional questionnaire-based study to assess the level of understanding of LA use and effective management of systemic toxicity among 200 postgraduate residents of various specialties (with the exception of anesthesiology) in a tertiary care hospital in India from October to December 2013. Among those residents who had used LAs (193/200), 27 and 25 % of responders correctly identified the toxic doses of lidocaine and of lidocaine + adrenaline, respectively. Of the responders, 70 % always performed a negative aspiration of blood before injecting the drug, 27 % sometimes aspirated and the remaining 3 % never aspirated. The majority of the responders (93 %) were unaware of the toxic dose of bupivacaine. Only 70 % of responders believed that LAs could be toxic [95 % confidence interval (CI) 65.5-74.5 %], and 81 % of these correctly identified the signs and symptoms of cardiotoxicity. Only 2 % of responders knew that lipid emulsion is a part of its treatment (95 % CI 0.6-3.4 %). Based on these results, there is a definite need to increase the awareness of detection and treatment of local anesthetic toxicity among all medical practitioners who regularly use LAs.

Dexmedetomidine and ketamine combination for a patient with xeroderma pigmentosa.

Patients of xeroderma pigmentosa (XP) have increased sensitivity to ultraviolet light and a defective nucleotide excision repair (NER) mechanism in their DNA. Several types of neurological, dermatological, and ophthalmological complications are common in these patients. There is increasing evidence of delayed recovery and worsening of neurological status following general anesthesia in such patients. Some reports have shown uneventful conduct of total intravenous anesthesia in patients of XP. The authors report a case of XP in a young girl for surgery, previously anesthetized with delayed recovery, managed successfully with a combination of intravenous dexmedetomidine and ketamine.

Control of hospital acquired infections in the ICU: A service perspective.

BACKGROUND: The service setting has some unique strengths and weaknesses that must be kept in mind when organizing Hospital acquired infections (HAI) prevention interventions. METHODS: Following an initial study to gather data regarding HAI in the Surgical intensive care unit (ICU) we put into place various infection control interventions. The present study was carried out to analyse the effect of these interventions on the incidence of HAI in the ICU. RESULTS: The total admissions to the ICU were 253 patients. Eighty eight patients (34.78%) were admitted for more than 48 hr, 165 patients stayed for less than 48 h. The frequency of HAI was 7.95% (95% CI 3.54, 15). Hospital acquired pneumonia was observed in 2 of the 88 patients (2.27%) (95% CI 0.38, 7.30) which amounted to 9.70 infections per 1000 ventilator days. Bloodstream infection was detected in 3 out of 88 patients (3.4%) (95% CI 0.87, 8.99) amounting to 6.54 fresh infections per 1000 Central Venous Catheter days. Urinary tract infection was observed in 2 (2.27%) (95% CI 0.38, 7.30) at 2.86 fresh infections per 1000 catheter days. As compared to the previous study we found that there was a decline of HAI ranging from 60 to 70%. CONCLUSION: Our study demonstrated that by meticulously following infection control protocols especially tailored to the service setting the incidence of HAI's can be reduced. However, the challenge is in maintaining the gains achieved since there is a rapid turnover of manpower in the ICU and a lack of a structured ICU design model.

Small is the new big: An overview of newer supraglottic airways for children.

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

An evaluation of brachial plexus block using a nerve stimulator versus ultrasound guidance: A randomized controlled trial.

BACKGROUND AND AIMS: This study was carried out to evaluate the difference in efficacy, safety, and complications of performing brachial plexus nerve blocks by using a nerve locator when compared to ultrasound (US) guidance. MATERIAL AND METHODS: A total of 102 patients undergoing upper limb surgery under supraclavicular brachial plexus blocks were randomly divided into two groups, one with US and the other with nerve stimulator (NS). In Group US, "Titan" Portable US Machine, Sonosite, Inc. Kensington, UK with a 9.0 MHz probe was used to visualize the brachial plexus and 40 ml of 0.25% bupivacaine solution was deposited around the brachial plexus in a graded manner. In Group (NS), the needle was inserted 1-1.5 cm above mid-point of clavicle. Once hand or wrist motion was detected at a current intensity of less than 0.4 mA 40 ml of 0.25% bupivacaine was administered. Onset of sensory and motor block of radial, ulnar and median nerves was recorded at 5-min intervals for 30-min. Block execution time, duration of block (time to first analgesic), inadvertent vascular puncture, and neurological complications were taken as the secondary outcome variables. RESULTS: About 90% patients in US group and 73.1% in NS group, had successful blocks P = 0.028. The onset of block was faster in the Group US as compared to Group NS and this difference was significant (P 0.007) only in the radial nerve territory. The mean duration of the block was longer in Group US, 286.22 ± 42.339 compared to 204.37 ± 28.54-min in Group NS (P < 0.05). Accidental vascular punctures occurred in 7 patients in the NS group and only 1 patient in the US group. CONCLUSION: Ultrasound guidance for supraclavicular brachial plexus blockade provides a block that is faster in onset, has a better quality and lasts longer when compared with an equal dose delivered by conventional means.

Ketodex, a combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopy in children: a preliminary report.

A combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopies (UGIE) was studied in 46 children aged 2-12 years over a 6-month period. Dexmedetomidine 1 µg/kg and ketamine 2 mg/kg were given as a bolus over 5 min. Heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and sedation scores were noted before induction as baseline and then every 5 min until recovery. The duration and ease of the procedure, time to recovery, and adverse effects, if any, were also recorded. UGIE could be performed with ease in 41 of the 46 cases. The HR, MAP, and SpO2 did not change significantly from the baseline. No airway intervention was required in any patient. There was no laryngospasm or shivering in any of the children, and one, four, and 11 children had hiccup, vomiting, and increased salivation, respectively. The Pediatric Anesthesia Emergence Delirium score was <4 in all except for two cases. The results of this case series show that this drug combination not only promises to be clinically effective but also safe for UGIE in children. Further randomized controlled trials with standard sedation protocols will be required to draw definite conclusions.

Case series: Dexmedetomidine and ketamine for anesthesia in patients with uncorrected congenital cyanotic heart disease presenting for non-cardiac surgery.

The number of patients with uncorrected congenital cyanotic heart disease is less but at times some may present for non-cardiac surgery with a high anesthetic risk. Some of these may even be adults with compromised cardiopulmonary physiology posing greater challenges to the anesthesiologist. The authors have used a combination of dexmedetomidine and ketamine for anesthesia for non cardiac surgery in five patients with cyanotic heart disease and right to left shunt (3-Eisenmenger's syndrome, 2-Tetralogy of Fallot). The sympathoinhibitory effects of dexmedetomidine were balanced with the cardiostimulatory effects of ketamine, thereby maintaining good cardiovascular stability. The analgesia was good and there was no postoperative agitation. This drug combination was effective and safe for patients with cyanotic heart disease for non cardiac surgeries.

Comparison of size 2 i-gel supraglottic airway with LMA-ProSeal™ and LMA-Classic™ in spontaneously breathing children undergoing elective surgery.

BACKGROUND: We compared size 2 i-gel(®) (Intersurgical Inc.), a relatively new supraglottic airway device for use in spontaneously breathing anesthesized children with two different types of laryngeal mask airway-ProSeal™ laryngeal mask airway (PLMA) and Classic™ laryngeal mask airway (cLMA) for the ease of insertion, oropharyngeal sealing pressures (OSPs), and air leak. The hemodynamic effects on insertion of device and postoperative adverse effects were also noted. METHODS: A randomized prospective study was planned in 120 children aged 2-5 years, weighing 10-20 kg, ASA physical status I-II scheduled for routine elective surgeries of <1-h duration. They were randomly divided in three groups (i-gel, PLMA, and cLMA) of 40 each, and a standard protocol for anesthesia was followed. RESULTS: The age, weight, height, and type of surgery were similar in all groups. Success rate for first attempt was 95% for the i-gel group and 90% for the two laryngeal mask airway groups. Insertion was found to be easy in the majority of cases in all groups, and there was no change in blood pressure, heart rate, or oxygen saturation on insertion. The OSP was 26 ± 2.6, 23 ± 1.2, and 22 ± 2.3 cm H(2)O for i-gel, PLMA, and cLMA, respectively. The difference between the i-gel and both laryngeal mask airway groups was statistically significant (P < 0.01). There were no clinically important complications in the postoperative period. CONCLUSION: Pediatric size 2 i-gel is easy to insert and provides higher OSP compared with same size PLMA and cLMA in spontaneously breathing children undergoing elective surgery. It may be a safe alternative to laryngeal mask airways in day care surgeries.

Local anesthetic systemic toxicity (LAST) - Should we not be concerned?

Local anesthetics are one of the most commonly used drugs in the field of medicine. Yet little is known about the systemic toxicity that can occur with their overdose. In the last few years, a lot of research has taken place understanding the etiology of the Local anesthetics systemic toxicity (LAST) and the role of lipid emulsion in treating it. There is a need to increase the awareness about LAST and establish a protocol to treat any serious neuro or cardiotoxicity.