Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students.

Background: Postpartum hemorrhage (PPH) is an obstetric emergency, and training of health-care providers for early diagnosis and intervention improves morbidity and mortality. Regular simulation-based training modules are conducted in our institute for health-care providers. The objective of this study was to assess the final-year medical students on their subjective improvement in the management of PPH after an off-site simulation-based training which was conducted after a conventional lecture. Methods: A survey was administered on medical students and their subjective retrospective analysis of both pre and post off-site simulation was collected. The survey was analyzed, and results were formulated. Results: Forty-six students completed the survey. Although students felt their confidence level in enumerating the steps in management of PPH less than 50% before the drill, it increased to 70% after the drill. The confidence of the students in carrying out the procedures of PPH also increased. The results showed a considerable subjective improvement in skill and cognitive enhancement after an off-site simulation-based training. There was a significant improvement in the pre and postsimulation training scores in the test. The faculty felt that there was an enhancement in learning after the simulation training. Conclusion: Off-site simulation of an emergency condition improves both knowledge and skill in students.

Evaluation of four supraglottic devices used by paramedical staff for securing airway in simulated emergency airway management.

BACKGROUND: Prehospital emergency airway management challenges every paramedic. Emergencies evacuated from difficult areas by armed forces need airway maintenance throughout evacuation. Effective use of supraglottic airway (SGA) devices during prehospital transfer is life saving. This study compared use of four commonly available SGAs by Armed Forces paramedics in simulated emergency situations. METHODS: This prospective observational study conducted in a tertiary care institution, included 58 volunteer paramedics. They were trained on manikins before the study in basic airway skills and insertion of the four SGA devices under study viz. Classic laryngeal mask airway (cLMA), laryngeal tube (LT), I-gel, and Combitube. SGA device insertions were performed on 474 patients scheduled for short elective surgical procedures under general anesthesia. All volunteers inserted and assessed the four SGA devices equal number of times in different patients. Overall success rate, time for successful insertion, first attempt success rate, number of attempts for successful insertion, oro-pharyngeal leak pressures, ease of insertion, durability of device, and complications were recorded. RESULTS: Differences among the four groups were statistically significant in all parameters. Intergroup comparison revealed that both I-gel and LT were comparable to each other, however superior to cLMA and Combitube in all outcome measures except ease of insertion and durability of device where I-gel was better and oro-pharyngeal seal pressures where Combitube was better. CONCLUSION: Considering all parameters, I-gel proved superior with minimal complications compared with other SGA devices tested. I-gel may be recommended for emergency airway rescue use in patients by military paramedics.

Neuroanesthesia and pregnancy: Uncharted waters.

An incidence of 30-40 deaths per triennium in pregnant patients is reported because of brain pathology. Over the last two decades, the obstetric cause of mortality in the pregnant patient has declined, but the trend is rising for non-obstetric cause of mortality. Pregnancy is associated with a host of anatomical and physiological alterations that complicate the conduct of anesthesia. The brain is one of the vital organs of the body, and physiological changes during pregnancy alter the anesthesia management if associated with brain pathology. Malignant brain tumors and trauma remain a leading cause of indirect maternal mortality. Review of literature revealed paucity of evidence-based neuroanesthesia management for such patients. Navigating these uncharted waters remains a challenging exercise. With the lack of guidelines, the management is based largely on few case reports or case series.

Comparative evaluation of effects of intrapleural block with adjuvants on analgesia and pulmonary function after intercostal drainage: A pilot study.

BACKGROUND: Inter-costal chest drain (ICD) used for varied thoracic pathologies causes continuous pain and irritation of the pleura, which limits respiratory efforts and impairs ventilatory function. Intrapleural block deposits local anaesthetic between the layers of pleura and may improve ventilatory function especially in non surgical patients. METHODS: Twenty eight ASA I-III patients treated with ICD, who could perform incentive spirometry, were included for study. They were randomized to 'Group C' (control group); 'Group B' (Bupivacaine); 'Group M' (Bupivacaine + Morphine) and 'Group D' (Bupivacaine + Dexmedetomidine). The drugs were administered via the ICD itself and clamped thereafter for 15 min. The success of the block was assessed by time for first analgesic demand, maximum inspiratory volume generated and Numerical Rating Scale score for pain; by patients. RESULTS: Effective analgesia was observed in Group B, M and D. Addition of an adjuvant significantly prolonged time for rescue analgesic demand. Patients who received local anaesthetic alone or with an adjuvant had significantly improved maximal inspiratory volume and required lesser rescue analgesics. No significant complications were observed in any group. Pain relief in post-surgical patients using intraplural block is masked by systemic analgesics. However its application in patients with ICD for non surgical indications was explored in this study and was found to improve patient comfort and ventilation. CONCLUSION: Intra-pleural blockade is safe and effective in relieving the constant pleural irritation and pain of ICD, thus enabling the patient to improve ventilatory effort and faster recovery of respiratory function.

Anaesthesiologist and social media: Walking the fine line.

Social media use is pervasive in society and has been rapidly amalgamated into the lives of anaesthesiologists. Using social media as an educational resource and ensuring an appropriate online presence is essential for professional growth. However, there are huge lacunae in editorial responsibility, peer review, and accountability of educational content on social media networks. The anaesthesiologist needs to be aware of the numerous shortcomings and must use social media responsibly. Following etiquettes, adopting a code of conduct and a high sense of professionalism is expected from the anaesthesiologist while posting on social media. Anaesthesiologists need to decide on their social media goals, like interaction with colleagues, continuing medical education or patient education, and then register for social media accounts accordingly. The need of the hour is comprehensive social media guidelines for anaesthesiologists, endorsed by institutions, societies, and professional health-care associations in India.

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.

Dapsone-induced methemoglobinemia: "Saturation gap"-The key to diagnosis.

Two cases of Acquired Methemoglobinemia are presented. The significance of a high index of suspicion for diagnosisis emphasized, especially in the presence of a "saturation gap". The various causes of acquired methemoglobinemia are enumerated and the management reviewed.

Anterior sagittal anorectoplasty: An alternative to posterior approach in management of congenital vestibular fistula.

BACKGROUND: Better exposure, possibility of extension if needed and precise placement of the anal canal within the external sphincter complex have made the posterior and anterior sagittal approaches more popular and established for the correction of anovestibular fistula. The mini posterior sagittal anorectoplasty (PSARP) was the procedure of choice for female ARM at our center till date. As an alternative surgical option, we performed anterior sagittal anorectoplasty (ASARP) in 15 cases of anovestibular fistula and compared them with 12 cases of vestibular fistula operated by PSARP technique. PATIENTS AND METHODS: Fifteen female infants with vestibular fistula who had anterior sagittal anorectoplasty (ASARP) procedure were reviewed. The procedure and its outcome were evaluated. RESULTS: The manoeuvering during anesthesia and operative access were quite easier in ASARP compared to PSARP. Delineation of plane in ASARP between rectum and vagina was easier and clearer in comparison to PSARP. Rent occurred in the posterior vaginal wall in three cases of ASARP and two cases of PSARP. There were two cases of wound infection in each group. Three cases of PSARP group developed anal stenosis and constipation while one in the ASARP group developed constipation. CONCLUSION: Anesthesia and access in ASARP makes it an easier alternative option to PSARP in the management of anovestibular fistula in girls.

Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue.

Operative hysteroscopy has emerged as an effective alternative to hysterectomy and has become standard surgical treatment for varied gynaecological conditions like abnormal uterine bleeding and uterine myomas. This procedure requires distention of the uterine cavity for adequate visualization of the operative field. 1.5% glycine is a widely used distention medium because it has good optical properties and is non-conductive. However, the intraoperative absorption of this electrolyte-free fluid can cause hyponatraemia, hypoosmolality, hyperglycinaemia and volume overload, including pulmonary oedema. We report a case of operative hysteroscopy intravascular absorption (OHIA) syndrome, presenting abruptly during hysteroscopic myomectomy, employing 1.5% glycine as the fluid distention medium. Successful management of the case and prevention strategies are discussed.

Simple new method of protecting the septum during oxygen delivery via a nasal canula.

Epistaxsis and crustation are common problems associated with long-term use of oxygen through nasal prongs in patients suffering from chronic obstructive pulmonary disease. The nasal prong can cause direct trauma to the septal mucosa. We describe a simple solution to this problem with use of the disposable ear tip used in tympanometry.