The Comparison Between Supreme Laryngeal Mask Airway and Endotracheal Tube With Respect to Adequacy of Ventilation in Patients Undergoing Laparoscopic Cholecystectomy Under General Anesthesia-A Prospective, Randomized, Double-Blind Study, and Comparative Study.

BACKGROUND: Laparoscopic cholecystectomy is a commonly performed surgical procedure. Most anesthesiologists advocate tracheal intubation. Laparoscopic cholecystectomy is becoming a day care surgery, hence many anaesthesiologists have started using laryngeal masks to decrease airway manipulation seen with conventional laryngoscopy and endotracheal intubation and avoid hemodynamic pressor responses and postoperative sore throat. The Supreme laryngeal mask airway (LMA) is an innovative, sterile, single use, supraglottic airway management device which provides access to and functional separation of the respiratory and digestive tracts. In this study, there are two objectives-(1) primary objective: to assess the adequacy of ventilation when using LMA-Supreme^(TM) (LMA-S) and endotracheal tube (ETT), and (2) secondary objective: the first is to give the time for achieving effective airway and number of attempts for securing airway. The second is to assess haemodynamic parameters (heart rate and blood pressure). The last is to show the incidence of gastric distension, regurgitation and postoperative sore throat. METHODS: A total of 132 American Society of Anesthesiologists (ASA) I-II patients were randomly assigned to LMA-S and ETT for intraoperative ventilation. After induction of general anaesthesia, the device was inserted, correct placement was checked, and parameters were recorded. SPSS version 20.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A P-value less than 0.05 is statistically significant. RESULTS: Ventilatory parameters such as inspiratory and expiratory leak volumes, and peak airway pressure values were comparable between the groups throughout the entire time interval. The number of attempts for successful insertion were comparable, but the mean time required for achieving effective airway was significantly longer in ETT than LMA-S (25.2 ± 8.3 sec vs. 18.6 ± 5.1 sec, respectively [P ＜ 0.05]). There was no situation in which the patient from the LMA-S group had to be intubated. The haemodynamic responses to insertion, pneumoperitoneum inflation and deflation, and removal of the device were greater for the ETT than the LMA-S. There were no complications like gastric distension or regurgitation in either groups. The postoperative sore throat at 2 hours and 24 hours was significantly lower in group LMA-S than group ETT. CONCLUSIONS: Positive pressure ventilation with a correctly placed LMA-S allows adequate pulmonary ventilation, without the untoward hemodynamic and postoperative adverse effects of endotracheal intubation, in laparoscopic cholecystectomy surgery.

Successful anesthetic management of a massive thoracoabdominal impalement injury.

We describe the management, focusing on the anesthetic preparedness, of a 44-year-old man who presented with impalement of a 1 m long serrated rod through the right supraclavicular fossa extending up to the right iliac fossa, along with rib fractures and laceration of the liver and diaphragm.

Decreasing hospital length of stay and enhancing recovery in Total Knee Arthroplasty.

BACKGROUND: Patients undergoing Total Knee Arthroplasty (TKA) typically have early postoperative pain and decreased mobility, especially so in the first 24 h. Achieving a pain free knee in the immediate postoperative period and reducing complications using multimodal pain and blood management protocols forms a keystone in early mobilization and functional recovery. Enhanced Recovery after Surgery pathways (ERASp) since their inception, have significantly improved perioperative care and functional outcomes, thereby reducing the average length of stay (ALOS), complications and overall healthcare costs. ERASp modified suitably for TKA have had encouraging results. We have retrospectively analyzed the outcomes of the ERASp for TKA at our tertiary care centre with equal emphasis on pre-hospital preparations, in-hospital care, and post-hospital discharge. METHODS: All TKA patients operated by the senior author between July 2016 and January 2018 with a minimum one year follow up were included. The outcomes measured were: Visual Analogue Score (VAS) for pain at rest and on movement, milestones, transfusion requirements, postoperative complications, ALOS and functional scores at one year follow-up. RESULTS: 775 patients (392 unilateral TKA {UTKA} and 383 bilateral {BTKA}) met our inclusion criteria. Both groups were comparable demographically. Mean VAS pain scores at rest were 3.15 ±â€¯2.15 on the day of surgery, 2.5 ±â€¯1.86 on the first postoperative day and 2.08 ±â€¯1.81 on the second day, and 6.2 ±â€¯2.38, 5.77 ±â€¯2.34 and 4.71 ±â€¯2.48 on movement respectively in the UTKA group. In the BTKA group, the mean VAS pain scores at rest were 4.39 ±â€¯2.25 on the day of surgery, 3.98 ±â€¯2.36 on the first postoperative day and 3.05 ±â€¯2.12 on the second day and 6.21 ±â€¯2.38, 5.77 ±â€¯2.34 and 4.71 ±â€¯2.48 on movement respectively. 85.49% of UTKA and 77.22% of BTKA patients walked on the day of surgery. Decrease in haemoglobin and transfusion rates were 1.25 ±â€¯0.41 g% and 0.5%, 1.85 ±â€¯0.62 and 3.9% in the UTKA and BTKA groups respectively.The average length of hospital stay (LOS) was 3.98 days. LOS was 3.17 and 4.78 days with 1.55% and 6.05% major complications in the UTKA and BTKA groups respectively.There was a significant improvement in Oxford Knee and WOMAC scores at 3, 6 and 12 months in both groups. CONCLUSIONS: Pain following TKA is a major deterrent in early mobilization thereby delaying functional recovery and increasing ALOS. We recommend our multimodal interdisciplinary protocol to achieve early mobilization, better pain scores and minimize complications, resulting in overall reduced LOS.

Correlation of Bedside Airway Screening Tests With Airway Obstruction During Drug-Induced Sleep Endoscopy

Objective: Obstructive sleep apnoea hypopnoea syndrome associated with obesity poses major perioperative airway challenge. Drug-induced sleep endoscopy (DISE), is a real-time upper airway flexible fiberoptic nasoendoscopy in awake and sedation/anaesthesia-induced sleep. The aim of current study was to assess the correlation of bedside airway screening tests with level of obstruction during DISE. Methods: Study was performed in endoscopy suite. Parameters calculated in 40 study group patients were Berlin questionnaire responses, Apnea hypopnea index (AHI), interincisor distance, Mallampati classification (MPC), neck circumference (NC), thyromental distance (TMD), NC/TMD ratio, sternomental distance (SMD), upper lip bite test, lateral cephalometry derived gonial angle and mentohyoid distance (MHD), Muller's manoeuvre during awake nasoendoscopy, Croft­Pringle grade of airway obstruction during DISE and effect of jaw thrust. Results: All patients were American Society of Anesthesiologists physical status 1 and 2 with AHI > 30. Positive responses to Berlin questionnaire, body mass index and AHI increased with increasing grade of DISE. DISE grades 1­5 were observed in 0% (0), 5% (2), 37.5% (15), 27.5% (11) and 30% (12) patients respectively. Muller's manoeuvre showed lateral wall collapse in 40% (16) patients and concentric collapse in 40% (16) patients. Airway patency improved with jaw thrust in 60% (24) patients. Significant association of DISE was found with MPC (p = 0.028), TMD (p = 0.003), MHD (p = 0.008) and NC/TMD ratio (p = 0.002), effect of Muller's manoeuvre (p =0.002), and effect of jaw thrust (p = 0.000). Conclusions: Bedside screening tests MPC, TMD, NC/TMD ratio and MHD correlate significantly with level of obstruction during DISE.

Calming the Electrical Storm: Use of Stellate Ganglion Block and Thoracic Epidural in Intractable Ventricular Tachycardia.

Imbalances in the autonomic nervous system contribute to ventricular tachyarrhythmias. Sympatholysis with thoracic epidural analgesia or a stellate ganglion block attenuates myocardial excitability and the proarrhythmic effects of sympathetic hyperactivity.

General anaesthesia for insertion of an automated implantable cardioverter defibrillator in a child with Brugada and autism.

A 14-year-old autistic boy presented with acute gastroenteritis and hypotension. The electrocardiogram showed a ventricular fibrillation rhythm - he went into cardiorespiratory arrest and was immediately resuscitated. On investigation, the electrocardiogram showed a partial right bundle branch block with a "coved" pattern of ST elevation in leads v(1)-v(3). A provisional diagnosis of Brugada syndrome was made, for which an automated implantable cardioverter defibrillator (AICD) implantation was advised. Although the automated implantable cardioverter defibrillator implantation is usually performed under sedation, because this was an autistic child, he needed general anaesthesia. We performed the procedure uneventfully under general anaesthesia and he was discharged after a short hospital stay.

Pulmonary alveolar proteinosis with respiratory failure-anaesthetic management of whole lung lavage.

SUMMARY: Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by accumulation of amorphous acellular phospholipid material in the lungs. Whole lung lavage is the standard therapy which gives dramatic clinical improvement and offers a long term survival to these patients. A 43-year-old man suffering from PAP presented to casualty with NYHA grade IV dyspnoea with oxygen saturation (SaO(2)) on pulseoximetry 67% on room air and 78% with O(2) 6 L/min. He underwent whole lung lavage under general anaesthesia using one lung ventilation with 37 F left end bronchial double lumen tube. The lung lavage was initially performed for the left lung and for the right lung 4 days later. The patient was discharged home with oxygen saturation of 96 % on room air.