Multimodal blood loss prevention bundle for endoscopic resection of juvenile nasopharyngeal angiofibroma: A case series.

Surgery for excision of juvenile nasopharyngeal angiofibroma (JNA) carries the possibility of massive life-threatening haemorrhage. Anaesthetic management aims to maintain haemodynamic stability and reduce blood loss. This case series describes the application of the bundled approach as a multimodal blood loss prevention bundle (MBLPB). Twenty patients underwent 23 surgeries with MBLPB. The blood loss and the number of units of blood transfused were recorded. The surgeon satisfaction score was assessed. The median [interquartile range (IQR)] estimated blood loss was 1300 (650-2350) ml. Patients with tumours in stages I and II had a median (IQR) blood loss of 550 (270-750) ml compared to patients with higher grades of tumours (stages III, IV) with a median (IQR) blood loss of 2100 (1300-2500) ml. Median (IQR) units of packed red cells transfused was 1 (0-3). The surgeon's satisfaction score was high when MBLPB was applied for JNA. However, it does not appear to reduce blood loss markedly.

Utility of cerebral oximetry in balloon mitral valvotomy and its correlation with post-procedure neurological complications: A pragmatic prospective observational study.

Background and Aims: Neurological complications (NCs) are significantly associated with reduced regional cerebral saturation (rSO2) in patients undergoing cardiac surgeries, as assessed with cerebral oximetry (COx). However, limited evidence is available in patients undergoing balloon mitral valvotomy (BMV). Thus, we evaluated the utility of COx in patients undergoing BMV, the incidence of BMV-related NCs and the association of >20% reduction in rSO2 with NCs. Methods: This pragmatic, prospective, observational study was performed after ethical approval, over November 2018 to August 2020, in the cardiology catherization laboratory of a tertiary care hospital. The study involved 100 adult patients undergoing BMV for symptomatic mitral stenosis. The patients were evaluated at initial presentation, pre-BMV, post-BMV and 3 months after the BMV. Results: The incidence of NCs was 7%, including transient ischaemic attack (n = 3), slurred speech (n = 2) and hemiparesis (n = 2). A significantly greater proportion of patients with NCs had a > 20% decrease in the rSO2 (P value = 0.020). At >20% cut-off, the COx had a sensitivity and specificity of 57.1% and 80%, respectively, in the prediction of NCs. Female sex (P value = 0.039), history of cerebrovascular episodes (P value < 0.001) and number of balloon attempts (P value < 0.001) were significantly associated with NCs. Patients with and without NCs had a significantly greater post-BMV mean % change in rSO2 than pre-BMV (both right and left sides), but the magnitude of mean % change was greater in those with NCs. Conclusions: COx alone has low sensitivity and specificity in the prediction of NCs and cannot reliably predict the development of post-BMV NCs.

Utility and Predictive Value of CHIIDA Score in Pediatric Traumatic Brain Injury: A Prospective Observational Study.

BACKGROUND: The Children's Intracranial Injury Decision Aid (CHIIDA) is a tool designed to stratify children with mild traumatic brain injury (mTBI). The aim of this study was to assess the utility and predictive value of CHIIDA in the assessment of the need for intensive care unit (ICU) admission in pediatric patients with mTBI. METHODS: This prospective observational study included 425 children below 18 years of age admitted to the ICU of a tertiary care hospital with mTBI (Glasgow Coma Scale 13 to 15). The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Sensitivity, specificity, predictive values and likelihood ratios were calculated at CHIIDA scores 0 and 2. RESULTS: Among 425 children with mTBI, 210 (49%) had a CHIIDA score 0, 16 (4%) scored 2 points, and 199 (47%) scored more than 2 points. Thirty-six (8.47%) patients experienced the primary outcome, and there were 3 deaths. A cutoff CHIIDA >0 to admit to ICU had a sensitivity of 97.22% (95% confidence interval [CI], 97.05%-97.39%) and a negative predictive value of 99.54% (95% CI, 99.50%-99.56%). A cutoff of score >2 had a sensitivity of 97.22% (95% CI, 97.05%-97.39%), and negative predictive value of 99.56% (95% CI, 99.54%-99.59%). The post-test probability at cutoff score of 0 and 2 was 16.65% and 16.27%, respectively. CONCLUSIONS: CHIIDA score does not serve as reliable triage tool for identifying children with TBI who do not require ICU admission.

Current practice patterns of supraglottic airway device usage in paediatric patients amongst anaesthesiologists: A nationwide survey.

BACKGROUND AND AIMS: Supraglottic airway devices (SGADs) are increasingly being used for airway management in paediatric patients undergoing general anaesthesia. This survey was designed to assess the nationwide practice patterns of SGAD usage in paediatric patients. METHODS: A questionnaire of 28 questions was circulated amongst 16,532 members of the Indian Society of Anaesthesiologists through online survey engine Google Forms® and served manually to 500 delegates attending the Asian Society of Paediatric Anaesthesiologists conference 2017. Percentage, mean and standard deviation were calculated using Microsoft Excel 2016 (Redmond, WA, USA). RESULTS: Four hundred and five (2.3%) valid responses were obtained. The most commonly used device was i-gel© (60.74%). Three hundred and four (75.06%) respondents had access to second-generation SGADs. Second-generation devices (60.74%) were more commonly used than first-generation devices (39.26%). Anaesthesiologists utilised SGADs in various challenging scenarios such as in the difficult airway (53.33%), remote locations (55.47%), ophthalmologic (38.77%) and long-duration surgeries (17.53%). Sixty per cent respondents did not use SGADs in laparoscopic surgery. Disposable SGADs were reused by 77.28% respondents. Oropharyngeal seal and intracuff pressures were not measured by 86.91% and 56.92% respondents, respectively. Difficulty in size selection (84.19%), securing position (82.22%) and maintaining unobstructed ventilation (78.76%) were common problems encountered while using SGADs. CONCLUSION: Although there is a widespread use of second-generation SGADs in Indian paediatric anaesthesia, safe practices such as using capnography, measurement of oropharyngeal seal pressure, cuff pressure and appropriate disinfection are lacking.

A cohort evaluation of clinical use and performance characteristics of Ambu® AuraGain™: A prospective observational study.

BACKGROUND AND AIMS: Ambu® AuraGain™ (AG) (Ambu, Ballerup, Denmark) is a supraglottic device which has a design facilitating its use as a conduit for intubation. We designed this prospective observational study to assess the ease of AG placement in paralysed patients, determine its position and alignment to the glottis and assess its utility as a conduit for intubation. METHODS: One hundred patients, aged 18-60 years, American Society of Anesthesiologists physical status I-II, undergoing elective surgery under general anaesthesia were included in the study. The ease and number of attempts for successful insertion, ease of gastric tube insertion, leak pressures, fibre-optic grade of view, number of attempts and time for tracheal intubation, time for AG removal and complications were recorded. The mean, standard deviation (SD), interquartile range (IQR) and range were calculated. The upper limit of confidence interval for overall failure rate was calculated using Wilson's score method. RESULTS: AG was successfully inserted in all patients. The mean (SD) time taken for insertion was 17.32 (8.48) s. The median [IQR] leak pressures were 24 [20-28] cm of H2O. Optimal laryngeal view for intubation was obtained in 68 patients. Eighty-eight patients could be intubated in the first attempt. Five patients could not be intubated. The overall failure rate of device was 9%. CONCLUSION: AMBU® AuraGain™ serves as an effective ventilating aid, but caution is suggested before using it as a conduit for endotracheal intubation.

Effects of avoiding neuromuscular blocking agents during maintenance of anaesthesia on recovery characteristics in patients undergoing craniotomy for supratentorial lesions: A randomised controlled study.

BACKGROUND AND AIMS: Neuromuscular blocking agents have been one of the cornerstones of anaesthesia. With the advent of newer surgical, anaesthetic and neurological monitoring techniques, their utility in neuroanaesthesia practice seems dispensable. The aim of this prospective, comparative, randomised study was to determine whether neuromuscular blocking agents are required in patients undergoing supratentorial surgery when balanced anaesthesia with desflurane, dexmedetomidine and scalp block is used. METHODS: Sixty patients with the American Society of Anesthesiologists physical status I or II, aged between 18 and 60 years were included in the study. All patients received anaesthesia including desflurane, dexmedetomidine and scalp block. The patients were randomly allocated to receive no neuromuscular blocking agent (Group A) or atracurium infusion to keep train-of-four count 2 (Group B). The two groups were compared with respect to haemodynamic stability, brain relaxation scores and recovery characteristics. Haemodynamic parameters and time taken to achieve Aldrete score >9 and other secondary outcomes were analysed using Student's t-test. Non-parametric data were analysed using the Mann-Whitney test. RESULTS: The mean arterial pressure was comparable between the groups. The intraoperative heart rate was comparable; however, in the post-operative period, it remained higher in Group B for 30 min after extubation (P = 0.02). The brain relaxation scores were comparable among the two groups (P = 0.27). Tracheal extubation time, time taken for orientation and time required to reach Aldrete score ≥9 were comparable among the two groups. CONCLUSION: The present study suggests that balanced anaesthesia using desflurane, dexmedetomidine and scalp block can preclude the use of neuromuscular blocking agents in patients undergoing supratentorial surgery under intense haemodynamic monitoring.

A prospective, comparative, randomised, double blind study on the efficacy of addition of clonidine to 0.25% bupivacaine in scalp block for supratentorial craniotomies.

BACKGROUND AND AIMS: Scalp blocks combined with general anaesthesia reduce pin and incision response, along with providing stable perioperative haemodynamics and analgesia. Clonidine has proved to be a valuable additive in infiltrative blocks. We studied the efficacy and safety of addition of clonidine 2 µg/kg to scalp block with 0.25% bupivacaine (Group B) versus plain 0.25% bupivacaine (Group A) for supratentorial craniotomies. METHODS: Sixty patients were randomly divided into two groups to receive scalp block: Group A (with 0.25% bupivacaine) and Group B (with 0.25% bupivacaine and clonidine (2 µg/kg). Bilateral scalp block was given immediately after induction. All the patients received propofol based general anaesthesia. Intraoperatively, propofol infusion was maintained at 75 to 100 µg/kg/h up to dura closure and reduced to 50-75 µg/kg/h up to skin closure with atracurium infusion stopped at dura closure. Heart rate (HR) and mean arterial pressure (MAP) were monitored at pin insertion, at 5 minute intervals from incision till dura opening and again at 5 minute interval from dura closure up to skin closure. Fentanyl 0.5 µg/kg was given if a 20% increase in either HR and/or MAP was observed. Postoperative haemodynamics and verbal rating scores (VRS) were recorded. When the VRS score increased above 3, rescue analgesia was given. Any intraoperative haemodynamic complications were noted. RESULTS: Group A showed a significant increase in haemodynamic variables during the perioperative period as compared to group B (P < 0.05). Addition of clonidine 2 µg/kg in the infiltrative block also provided significantly prolonged postoperative analgesia. CONCLUSIONS: Addition of clonidine to scalp block provided better perioperative haemodynamic stability and significantly prolonged analgesia.