Comparison of Effectiveness of CE Technique and Jaw Thrust Technique for Mask Ventilation on Apneic Anesthetized Adults: A Randomized Controlled Trial.

Background: The two most common techniques for mask ventilation are CE and jaw thrust (JT) technique. However, few studies have validated their efficiency in terms of tidal volume (TV). Aims: This study aimed to compare the effectiveness of the CE technique and JT technique during pressure-controlled ventilation (PCV) by the mean of returned TV on apneic anesthetized adults. Design: This was a prospective, randomized cross over study. Settings: This study was conducted in a tertiary care hospital. Methods: Ethical Committee approval from our institution was taken (ss-1/EC 049/2017) and was registered in Clinical Trials Registry of India (CTRI/2018/04/012958). Sixty-five American Society of Anesthesiologists Physical Status classes I and II adult patients were enrolled in the study. After induction and muscle relaxation, mask ventilation was performed with CE and JT technique on PCV mode (Pinsp 15 cm H2O, respiratory rate 15) for 1 min each. The mean of returned TV of last 12 breaths, gastric insufflation, audible mask leak, and operator comfort in each technique were compared. Statistical Analysis: Statistical software namely IBM SPSS 22.0 and R environment version 3.2.2 (IBM Corp. SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA) were used for data analysis. Microsoft Excel was used to generate graphs and tables. Data were expressed as mean ± standard deviation for continuous variables and number (%) for categorical variables. Student's t-test (two tailed, independent) was used to find the significance of the study parameters on a continuous scale. Chi-square/Fisher's exact test was used to find the significance of the study parameters on a categorical scale between two or more groups. Results: There was a significant increase in mean TV generated by JT technique over CE technique (591.46 ± 140.27 mL vs. 544.59 ± 159.08 mL; P < 0.001). Gastric insufflation (12.9% vs. 14.5%) and mask leak (11.3% vs. 38.7%) were more in CE technique. Operator comfort (79% vs. 19.4%) was more in JT technique. Conclusion: A two-handed JT technique is more effective than a one-handed CE technique for mask ventilation in apneic anesthetized adults.

The Study of Postoperative Recall in Patients under Total Intravenous Anesthesia.

Background: The incidence of postoperative recall under total intravenous anesthesia (TIVA) is not yet fully established. Avoidance of inhalational agent is a known risk factor for awareness. In addition, lack of reliable technique to monitor drug concentration needed for adequate depth of anesthesia makes TIVA challenging. Hence, we intend to evaluate our standard anesthesia practice for postoperative recall. Methodology: This questionnaire-based observational study was done over the period of 2 years. We enrolled 1080 adult (American Society of Anesthesiologists physical status Class I or II) patients undergoing TIVA for Endoscopic retrograde cholangiopancreatography (ERCP). All patients received fentanyl, midazolam and propofol-based anesthesia. Manual boluses of propofol were given to achieve adequate sedation. (Ramsay sedation scale of 5) in accordance with clinical signs as judged by the primary anesthesiologist. Postoperatively within 12-24 h, patients were assessed for recall using Brice questionnaire. Primary outcome was number of patients reporting postoperative recall in the Brice interview. Secondary outcome was the incidence of dreaming. Results: On postoperative interview, none of the patients reported awareness. 12.5% of patients had dreams which were pleasant. None of the dreams was unpleasant. The worst thing about surgery was pain. Conclusion: Our study suggests that if adequate doses of propofol are adhered to and necessary action is taken against responses indicating wakefulness, postoperative recall under TIVA is an uncommon occurrence.

A Comparative Study in Airway Novices Using King Vision Videolaryngoscope and Conventional Macintosh Direct Laryngoscope for Endotracheal Intubation.

BACKGROUND AND OBJECTIVES: Tracheal intubation using laryngoscopy is a fundamental skill, for an anesthesiologist. However, teaching this skill is difficult since Macintosh direct laryngoscope (DL) allows only one individual to view the larynx during the procedure. Hence, this study aimed to determine whether King Vision® videolaryngoscope (KVL) provides any advantage over direct laryngoscopy in teaching this skill to airway novices. MATERIALS AND METHODS: In this prospective randomized crossover study, Ethical Committee clearance was obtained from the institutional review board (MSRMC/EC/2017) and the study was registered with Clinical Trial Registry. After informed consent, 53 medical students were allotted to perform laryngoscopy and endotracheal intubation on a manikin by using either KVL or Macintosh DL. The participants first performed laryngoscopy with either KVL or Macintosh DL following a brief instruction and then crossed over to the second arm of the study to perform laryngoscopy using the other scope. The primary outcome measure was the time for successful endotracheal intubation. The secondary outcome measures were incidence of esophageal intubation (EI), excess application of pressure on maxillary teeth excess maxillary pressure, and success rate. RESULTS: Mean time for endotracheal intubation was significantly faster using KVL than in DL (44.64 vs. 87.72 s; P < 0.001). No significant difference was found in the incidence of esophageal intubation 15.1% in KVL group versus 24.5% in DL group (P = 0.223). In the KVL group, 81.1% did not apply pressure on maxillary teeth versus 26.4% in the DL group (P < 0.001). The success rate of intubation was 100% in the KVL group versus 86.8% in the DL group (P = 0.006). CONCLUSION: The KVL is a more effective tool to teach endotracheal intubation in comparison to Macintosh laryngoscope in airway novice medical students. Clinical trial registry India registration number: CTRI/2017/11/010491.

The Study of Intraoperative Consciousness after Tracheal Intubation.

INTRODUCTION: Awareness following noxious stimuli like intubation could be as high as 25% compared to postoperative recall. The isolated forearm technique (IFT) allows us to assess consciousness by verbal command to move isolated hand. Hence we conducted study to establish IFT responses following intubation under standard general anaesthesia. METHODS: We enrolled 132 adult patients undergoing general anaesthesia. A tourniquet was applied on other arm. Following intravenous induction of anaesthesia, torniquet was inflated 100mmhg above systolic BP. After giving muscle relaxant, three minutes patients were ventilated with oxygen and inhalational agent. Before laryngoscopy first verbal command (Squeeze my hand) was given to the patient. Once intubation and tube confirmation done, second verbal command was given. Lack of paralysis in isolated hand was confirmed with TOF stimuli and tourniquet was deflated. Surgery was carried in routine manner. Postoperatively all patients were evaluated for any explicit recall using Modified Brice questionnaire. The primary outcome is number of patients who responded to verbal command postintubation. Secondary outcome is number of patients responded prelaryngoscopy and number of patients reporting explicit recall in the Modified Brice interview. RESULTS: None of the patients had positive IFT response. On postoperative interview none reported awareness. 10.7% of patients had dreams which were pleasant. Worst thing about surgery was pain.(43%). CONCLUSION: Our study suggests that intraoperative consciousness after intubation and postoperative recall is an uncommon occurrence.

ProSeal Laryngeal Mask Airway Placement: A Comparison of Blind versus Direct Laryngoscopic Insertion Techniques.

BACKGROUND AND OBJECTIVES: The laryngeal mask airway (LMA) ProSeal is most commonly used supraglottic airway device; it is routinely inserted by blind technique. Although blind insertion technique is most widely used, there are many techniques which are available such as priming the drain tube with a guiding instrument such as a suction catheter, a gum elastic bougie, a Flexi-Slip Stylet, direct laryngoscopy, and even a fiber-optic bronchoscope (FOB). The present study was undertaken to compare and assess the placement of LMA ProSeal using blind versus direct laryngoscopy techniques using FOB. MATERIALS AND METHODS: A prospective randomized comparative study of 110 patients divided into two groups of 55 each as Group I (blind insertion) and Group II (direct laryngoscopic insertion) after satisfying the inclusion criteria. The anatomical position was assessed by flexible FOB and evaluated based on fiber-optic scoring system. RESULTS: In the present study, demographic characteristics, vital parameters, Mallampati score, and Wilson's score were comparable in both the groups (P > 0.05). The fiber-optic score (FOS) 1 in Group II was 78.18% compared to 60% in Group I, but the difference was statistically not significant (P > 0.05). Furthermore, the mean FOS in Group II was slightly high (3.84 ± 0.87) compared to Group II (1.62 ± 0.87), but the difference was statistically not significant (P > 0.05). Further hemodynamic parameters (P > 0.05) and complications (P > 0.05) were comparable in both the groups. CONCLUSION: The LMA placement scoring was similar in both blind and direct laryngoscopic techniques. Blind insertion technique is a simpler, easier, and has stood the test of time.

Comparison of modified chin lift technique with EC technique for mask ventilation in adult apneic patients.

BACKGROUND: Mask ventilation (MV) is an essential basic life support skill. We used chin lift maneuver for MV and named as modified chin lift technique (MCL). EC technique is most common technique used for MV. AIMS: The aim of this study is to compare the efficacy of both techniques for MV in term of expired tidal volume (TV). Secondarily, we also assessed the effect of experience on the performance of these both techniques. SETTINGS AND DESIGN: The study area was operation theater of our hospital. This was a prospective, randomized, crossover study. METHODS: A total 108 adults undergoing elective surgery under general anesthesia were recruited. In all patients, operators (novice/anesthesiologist) randomly performed both techniques either to start with EC or MCL technique. Expired TV was measured for one minute for each technique. STATISTICAL ANALYSIS: Paired t-test was used to compare TV. RESULTS AND CONCLUSION: The mean TV was significantly higher in MCL group than EC group (528.08 [104.96] ml vs. 483.39 [103] ml; P < 0.001). The novice (521.89 [117.9] ml vs. 478.70 [130.29] ml; P < 0.001) as well as anesthesiologists (534.27 [110.85] ml vs. 488.08 [111.6] ml; P < 0.001) was able to generate significantly more TV with MCL technique than EC technique. The TV did not differ significantly between novice and anesthesiologist for EC technique (P = 0.474) or MCL technique (P = 0.187). Novices as well as anesthesiologist felt MCL technique more satisfactory (70%). CLINICAL TRIAL REGISTRATION: CTRI/2016/04/006874.

Fascia Iliaca block as the sole anesthesia technique in a patient with recent myocardial infarction for emergency femoral thrombectomy.

Acute limb ischemia is a surgical emergency that precludes prolonged preoperative cardiac evaluation. A 70-year-old female with recent myocardial infarction was posted for emergency transfemoral thrombectomy. We discuss the perioperative anesthetic considerations in these case. Fascia iliaca block can be used as sole anesthesia technique for transfemoral thrombectomy in high-risk patients.

Post- thyroidectomy haematoma causing severe supraglottic oedema and pulmonary oedema - a case report.

Large, long standing goiters present multiple challenges to anaesthesiologist. Post thyroidectomy haematoma is a rare but life threatening complication of thyroid surgery leading to airway obstruction. We report a case of huge goiter that underwent near total thyroidectomy and developed post thyroidectomy haematoma. Within no time it resulted in near fatal airway obstruction, pulmonary oedema and cardiac arrest. The haematoma was evacuated immediately and patient was resuscitated successfully. Pulmonary oedema was further worsened by subsequent aggressive fluid resuscitation. She was electively ventilated with PEEP and was extubated after five days. Except for right vocal cord palsy her postoperative stay was uneventful. This is unique case where a post thyoidectomy haematoma has resulted in fatal supraglottic oedema and pulmonary oedema. Early recognition, immediate intubation and evacuation of haematoma are the key to manage this complication. We highlight on the pathophysiology of haematoma and discuss the strategies to prevent similar events in future.