Blind Nasal Intubation Revisited: No Longer a Blind Technique?

BACKGROUND: Advancements in airway management have made the practice of blind nasal intubation obsolete. We report on successful blind nasal intubation performed with the help of capnography and real-time ultrasonography in two patients with tempormandibular joint ankylosis. CASE REPORT: Blind nasal intubation was performed in a 12-year-old patient and a 17-year old patient under general anesthesia with spontaneous respiration. Capnography was used as an aid during insertion and dynamic ultrasonography was performed to guide and confirm proper tracheal tube placement. Use of capnography helps in following the correct path toward the glottic opening, with quick detection of any obstruction, and with confirmation of final placement of the tracheal tube. Ultrasonography aids with entry into the glottis and with identifying the correct placement. We recommend the use of this modified blind nasal intubation in patients with limited mouth opening when equipment, such as a fiberoptic scope, is not available or is nonfunctional in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Adapting this technique will add to the armamentarium available for airway management in emergency medicine, particularly in maxillofacial injuries with limited mouth opening.

Evaluation of Peripheral Versus Central Route of Ondansetron as Pretreatment to Prevent Pain on the Injection of Propofol: A Randomized Controlled Study.

Objective: We evaluated whether systemic ondansetron was also useful in the attenuation of propofol injection pain similar to ondansetron pretreatment. Methods: Eighty patients were enrolled. Patients in group S received ondansetron 4 mg in saline in the right hand followed 30 min later by 5 mL saline in the left hand along with venous occlusion. Group L patients received 4 mL of saline in the right hand followed by 5 mL 4 mg ondansetron in the left hand after 30 min. Two minutes later the occlusion was released. Patients received one-fourth of the calculated total dose of propofol, and their level of pain was graded on a scale of 0 to 3, with 0 denoting no discomfort. Mean blood pressure and heart rates were also recorded. Continuous variables were checked for normality using Shapiro-Wilks test. Normal continuous variables were expressed as mean standard deviation and non-normal continuous variables were expressed as median interquartile range. T-test for the difference in the mean and paired test were used for normally distributed continuous variable whereas Mann-Whitney U test-Wilcoxon test and sign test were used for non-normally distributed variables. Repeated measure analysis of variance was used for a variable measured over different periods of time to control for the baseline effect on subsequent measures. Results: Our results demonstrated that both systemic administration 30 min before and local venous pretreatment with ondansetron were equally beneficial in reducing pain during propofol injection. Conclusion: A systemic administration of ondansetron may play a role in the attenuation of propofol injection pain.

Intranasal sphenopalatine ganglion block by lignocaine spray for postdural puncture headache following spinal anesthesia: a randomized clinical trial.

INTRODUCTION: In a randomized clinical study, we investigated the effectiveness of nasal lignocaine spray and swabs in treating postdural puncture headache (PDPH) after spinal anesthesia. MATERIAL AND METHODS: Group S patients received two puffs of lignocaine 10% spray in both nostrils followed by cotton soaked in normal saline, and group B patients received two puffs of saline spray in both nostrils followed by a cotton swab soaked in lignocaine 2%. Patients were assessed before the procedure and 30 minutes, 60 minutes, 2 h, 24 h, 48 h, and 72 h after the procedure for pain relief with the help of a visual analogue scale (VAS). Hemodynamic parameters and adverse effects were also recorded. Normally distributed continuous variables were expressed as mean (95% confidence interval) whereas non-normally distributed variables were expressed as median (IQR). Repeated measures analysis of variance was used to compare the VAS score at different time points between test and control groups. The difference in means between the two groups was compared using the independent sample t -test. The paired t-test was used to compare the changes in clinical and laboratory variables. RESULTS: At each time point, the mean VAS score for pain was substantially different between the two groups. Moreover, until the second hour, the VAS score was significantly lower in group S than in group B. No significant intervention-related adverse effect was observed in either group. CONCLUSIONS: Without any noticeable side effects, lignocaine 10% spray is more successful in treating PDPH after spinal anesthesia, particularly in the first two hours.

The Valsalva Maneuver Is Not as Effective as Lidocaine for the Attenuation of Pain on Injection of Propofol: A Randomized Controlled Study.

Background and objective Lidocaine pretreatment is considered the gold standard for attenuating pain on injection of propofol. Valsalva maneuver (VM) causes baroreceptor reflex arc-induced antinociception by increasing the intrathoracic pressure. We aimed to evaluate the efficacy of VM in alleviating the pain on injection of propofol in this randomized comparative study. Methods A total of 90 patients were recruited for this randomized study. They were classified into two groups. Patients in group D received 5-mL 4% lidocaine in saline intravenously while the venous drainage was occluded. Then they were asked to press a rubber ball as hard as they could. Patients in group V received 5-ml saline pretreatment. They were then asked to perform VM by blowing into rubber tubing connected to a manometer and raising and holding the pressure up to 40 mmHg. The verbal response and behavioral signs were recorded with a score corresponding to no, mild, moderate, or severe pain. A t-test was performed to compare the mean of variables between the two groups. The Kolmogorov-Smirnov test was used for testing the equality of the distribution function of pain scores between the groups. Repeated measures analysis of variance (ANOVA) was performed to test the heart rate and mean arterial pressure (MAP) at different points of observation. Results The incidence of pain and pain scores were significantly higher among the patients in the VM group as compared to those in the lidocaine with distraction group. Conclusions VM performed immediately before the injection failed to attenuate the pain produced by propofol as compared to lidocaine pretreatment along with distraction.

Comparison between dexmedetomidine and fentanyl bolus in attenuating the stress response to laryngoscopy and tracheal intubation: a randomized double-blind trial.

BACKGROUND AND OBJECTIVES: Laryngoscopy and tracheal intubation lead to a sympathoadrenal response. We compared the efficacy of dexmedetomidine with fentanyl bolus to attenuate this response. METHODS: One hundred patients admitted for routine surgical procedures under general anesthesia were enrolled in this double blind, randomized, controlled study. Patients were randomly assigned to two groups: Group F received injection of fentanyl 2 µg.kg-1 and Group D received injection of dexmedetomidine 0.5 µg.kg-1 diluted up to 5 mL by adding normal saline intravenously over 60 seconds. Five minutes thereafter, following induction with propofol and vecuronium, tracheal intubation was performed after 3 minutes of mask ventilation. Hemodynamic parameters were observed at an interval of 2 minutes before tracheal intubation and at an interval of 1 minute for 5 minutes after tracheal tube cuff inflation. Continuous variables are presented as mean with 95% confidence interval, and t-test was applied for comparing the difference of means between two groups after checking the normality condition. Chi-square test was applied to test the independence of attributes of categorical variables. Repeated measures two-way ANOVA was performed to compare the outcome variables between the two groups. RESULTS: The difference in heart rate and mean arterial pressure of patients in two groups after laryngoscopy and intubation was not statistically significant at any point of time. The hemodynamic changes did not require any intervention in the form of administration of rescue medication. CONCLUSIONS: Dexmedetomidine 0.5 µg.kg-1 is as effective as fentanyl 2 µg.kg-1 in attenuating the hemodynamic response accompanying laryngoscopy and tracheal intubation. CLINICAL TRIAL NUMBER & REGISTRY URL: CTRI/2017/09/009857 [ctri.nic.in].