Pitfalls in internal jugular vein cannulation.

Central venous catheter insertion in the internal jugular vein (IJV) is frequently performed in acute care settings, facilitated by its easy availability and increased use of ultrasound in healthcare settings. Despite the increased safety profile and insertion convenience, it has complications. Herein, we aim to inform readers about the existing literature on the plethora of complications with potentially disastrous consequences for patients undergoing IJV cannulation.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes.

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Relevance of sleep for wellness: New trends in using artificial intelligence and machine learning.

Sleep and well-being have been intricately linked, and sleep hygiene is paramount for developing mental well-being and resilience. Although widespread, sleep disorders require elaborate polysomnography laboratory and patient-stay with sleep in unfamiliar environments. Current technologies have allowed various devices to diagnose sleep disorders at home. However, these devices are in various validation stages, with many already receiving approvals from competent authorities. This has captured vast patient-related physiologic data for advanced analytics using artificial intelligence through machine and deep learning applications. This is expected to be integrated with patients' Electronic Health Records and provide individualized prescriptive therapy for sleep disorders in the future.

Ultrasound-Guided Airway Evaluation: Is It a Game Changer for Predicting Difficult Endotracheal Intubation?

INTRODUCTION: Airway ultrasound has recently promised to be a valuable addition to preoperative airway assessment tools. This study was undertaken to determine the efficacy of ultrasound-guided measurement of soft tissue thickness (STT) at various levels of the anterior neck in predicting difficult airways in an eastern Indian population. OBJECTIVE:  The primary objective was to find out the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of anterior neck soft tissue thickness at the level of the hyoid (STT-Hyoid) and vocal cords (STT-VC), distance from the skin to the epiglottis midway (DSEM), and the ratio of the depth of the pre-epiglottic space (Pre-E) to the distance from the epiglottis to the mid-point of the vocal cords (E-VC). The secondary objective was to develop a scoring system using these parameters. MATERIALS AND METHODS: One hundred eighty-eight patients aged 18-65 years who received general anesthesia and endotracheal intubation for surgery were included in the study. Anterior neck soft tissue thickness measurements were done preoperatively using ultrasound. The actual difficulty of the airway was graded by the anesthesiologist while performing endotracheal intubation using the intubation difficulty scale (IDS). RESULTS: The incidence of a difficult airway (IDS > 5) was 9.04%. The STT-Hyoid and STT-VC had a moderate correlation with IDS. The DSEM and Pre-E/E-VC ratios had a weak correlation with IDS. For difficult airway prediction, the cutoff points of STT-Hyoid and STT-VC were 7.95 mm and 24.25 mm, respectively. The combined cutoff measurements of STT-Hyoid and STT-VC (29.95 mm) were better predictors of difficult airway. CONCLUSION: Preoperative airway ultrasound examination measuring the soft tissue thickness at the hyoid and vocal cord levels is an effective modality in predicting a difficult airway. However, further studies are needed to validate this finding in populations of varied ethnicity and demographic distribution.

Myasthenia Gravis for Spine Surgery: An Ardous Anaesthetic Journey.

Myasthenia gravis (MG) is a neurological disorder involving the post-synaptic neuromuscular junction and is caused by the autoimmune destruction of acetylcholine receptors with ensuing muscular weakness. Rarely is the disease process in MG compounded with other comorbidities and distinctive surgical challenges, such as the prone position in spine surgery, presenting unique challenges in the anesthetic management of such cases. This case series and the ensuing discussion describe the successful perioperative management of two cases of MG undergoing neuro-surgical management for lumbar spine pathologies.

Post-partum complete acute uterine inversion: A coordinated multi-disciplinary approach ameliorates an obstetric nightmare, a case report.

Acute uterine inversion is a rare life-threatening complication of third stage of labour. In majority of cases, exact aetiology is unknown. It should be strongly suspected when the triad of haemorrhage, shock and severe abdominal pain with bearing down sensation is present after delivery of placenta. It can occur even after active management of third stage of labour. Diagnosis is essentially clinical. Expeditious manual repositioning of uterus and simultaneous liberal use of uterotonics is the management of choice. This was successfully attempted in the present case where a 26-year-old multiparous woman, without any identifiable risk factors, developed acute puerperal uterine inversion after active management of labour. It was observed that quick and accurate clinical judgement and timely intervention can prevent maternal mortality. The role of a multidisciplinary team including primary health care provider, obstetrician, anaesthesiologist and critical care experts has significant effects on outcome especially in intractable cases.

A Single-Level Epidural Blood Patch for Multiple Cerebrospinal Fluid Leaks: How it Works.

Spontaneous intracranial hypotension caused by cerebrospinal fluid (CSF) leak is a rarely encountered cause of persistent postural headaches in the absence of trauma or dural puncture. It presents with postural headache and is characterized by radiological findings of spinal CSF leak. The mainstay of management is an epidural patch with the patient's own blood (epidural blood patch [EBP]) and/or a fibrin glue product. We report here a case of spontaneous intracranial hemorrhage presenting with persistent headaches and bilateral subdural hematomas secondary to CSF leaks at multiple levels along the spinal cord, which was successfully managed with a single lumbar EBP.

Fiberoptic bronchoscopy versus video laryngoscopy guided intubation in patients with craniovertebral junction instability: A cinefluroscopic comparison.

BACKGROUND: Manipulation during endotracheal intubation in patients with craniovertebral junction (CVJ) anomalies may cause neurological deterioration due to underlying instability. Fiberoptic-bronchoscopy (FOB) is better than video laryngoscope (VL) for minimizing cervical spine movement during intubation. However, evidence suggesting superiority of FOB in patients with CVJ instability is lacking. We prospectively compared dynamic movements of the upper cervical spine during intubation using FOB with VL in patients with CVJ anomalies. METHODS: A prospective, randomized, and clinical trial was conducted in 62 patients of American Society of Anaesthesiologist Grade I-II aged between 12 and 65 years with CVJ anomalies. Patients were randomized for intubation under general anesthesia with either VL or FOB. The intubation process was done with application of skeletal traction and recorded cinefluroscopically. The dynamic interrelationship of bony landmarks (horizontal, vertical, and diagonal distances between fixed points on posterior C1 and C2) was analyzed to indirectly calculate alteration of the upper cervical spinal canal diameter (at CVJ). Atlanto-dental interval (ADI) was calculated wherever possible. RESULTS: The alteration in canal diameter (using bony landmarks) at CVJ during intubation was not significant with the use of either VL or FOB (P > 0.05). In 41 patients, where ADI could be measured, ADI was reduced (increased spinal canal diameter) in a greater number of patients in VL group when compared to FOB group (P < 0.05). CONCLUSION: Using rigid skull traction, intubation under general anesthesia with VL offers similar advantage as FOB in terms of the spinal kinematics in patients with CVJ anomalies/instability. Nevertheless, greater number of patients intubated with VL may have an advantage of increased cervical spinal canal diameter when compared to FOB.

Optic Nerve Sheath Diameter: Correlation With Intra-Ventricular Intracranial Measurements in Predicting Dysfunctional Intracranial Compliance.

Background Ultrasonographic (USG) measurement of optic nerve sheath diameter (ONSD) has been proposed as a non-invasive, bedside method to detect raised intracranial pressure (ICP) in various clinical settings. We aimed to correlate the ONSD obtained from ultrasonography with the gold standard, intraventricular ICP, and to find out the cut-off point which predicts ICP accurately at different levels. Methodology A prospective double-blind study was carried out by performing ocular ultrasounds in 30 adult patients with features of intracranial hypertension. The ONSD was measured by USG intraoperatively along with direct intraventricular pressure measurement. The ONSD was compared with the intraventricular ICP and correlations were derived. The optimum cut-off of ONSD to predict ICP > 20 mm Hg, 25 mm Hg, 30 mm Hg, and 35 mm Hg was sought. Results There was a significant correlation of ONSD with ICP (r = 0.532, p = 0.002). An ONSD threshold of 5.5 mm predicted ICP > 20 mm Hg with high sensitivity (100%) and specificity (75%) (area under receiver operating characteristic [ROC] curve = 0.904, p=0.01). The optimum ONSD cut-off predicting ICP at values of 25 mm Hg, 30 mm Hg, and 35 mm Hg was 6.3 mm, 6.5 mm, and 6.7 mm, respectively. Conclusion Our study confirms the utility of optic nerve ultrasound in the diagnostic evaluation of patients with known or suspected intracranial hypertension. We recommend an ONSD cut-off of 5.5 mm for predicting ICP > 20 mm Hg.

Combined Spinal-Epidural Anaesthesia for Caesarean Delivery in Takayasu's Arteritis: A Viable Alternative.

Takayasu's arteritis (TA), also known as "pulseless disease", is a nonspecific inflammatory arteritis of large and medium caliber arteries of unknown aetiology with a predilection for young women of childbearing age. Although the evolution of the disease is not affected during pregnancy, it can result in uncontrolled hypertension, multiple organ dysfunction, and stenosis that hinder regional blood flow. Associated pregnancy, therefore, poses an increased risk to the mother and foetus due to the many cardiovascular complications that can occur in the course of the disease, making anaesthesia for caesarean delivery especially challenging to the anaesthesiologist. We report the successful anaesthetic management of a case of TA undergoing caesarean section in view of a previous caesarean delivery. We also engage in a brief review of the related literature.

An anaesthetic quandary: Caesarean section during cardiac failure in a case of peripartum cardiomyopathy complicated by preeclampsia.

Anaesthetic management of cardiac disorders in pregnancy has always been complicated and challenging. A rare but extremely fatal entity, peripartum cardiomyopathy (PPCM) is a life-threatening disease affecting the parturient with mortality rates as high as 35-50%. Developing in late pregnancy or immediately after delivery, this unique disorder endangers not only the mother but the baby as well. We report here a case of a 28-year-old female parturient presenting at 37 weeks of gestation for caesarean delivery with recently diagnosed peripartum cardiomyopathy (ejection fraction of 28%) complicated by severe preeclampsia. She developed cardiac failure just before the induction of anaesthesia. She was successfully resuscitated, operated under general anaesthesia and shifted to the critical care unit for further management.

An Inquiry on Airway Management by McCoy Blade with Elevated Tip and Miller Straight Blade with Paraglossal Technique: Relevance for Difficult Airway Management in Current Infectious Times.

Background: Modifications of curved and straight laryngoscope blades have been used for airway management since a long time. While McCoy blade with an elevated tip is commonly used to intubate patients with anticipated difficult airway, the Miller's straight blade is used for intubations in children and less commonly adults. In this study, we revisit the paraglossal technique of Miller's straight blade as a method to improve laryngeal view especially in difficult intubations. Aim: This study aimed to compare laryngoscopic view and ease of intubation (EOI) using McCoy blade elevated tip and Miller's straight blade paraglossal technique. Materials and Methods: A prospective single-blind study was conducted on 170 patients undergoing elective surgery under general anesthesia. They were randomly allotted to two groups. In Group A, laryngoscopy was performed by Miller's blade paraglossal approach, whereas in Group B, laryngoscopy was performed by McCoy blade with an elevated tip. Laryngeal view was graded using the modified Cormack-Lehane grading, and EOI was graded using EOI score. These were compared with preoperative intubation prediction score. Statistical analysis was done using "Medcalc" version 19.0.3. Numerical and categorical data were analyzed by Student's t-test and Chi-square test, respectively. A P < 0.05 was considered statistically significant. Results: The paraglossal approach with Miller's blade offered better laryngoscopic view as compared with McCoy blade with an elevated tip in normal (54.1% vs. 25.9%) and difficult airway (44.7% vs. 11.8%). Tracheal intubation was easier with McCoy blade with an elevated tip although the success rate of intubation improved with the assistance of a bougie with Miller's straight blade paraglossal approach. Conclusion: The laryngeal view was significantly better with the paraglossal approach of Miller's straight blade even in difficult airway. McCoy blade with an elevated tip was also found to be a useful tool to have in difficult airway, as EOI is significantly higher. The study also highlights the usefulness of adjuncts such as a gum elastic bougie while intubating.

Emergent airway management in blunt tracheal trauma: A novel use of the mini-tracheostomy kit.

AIM: To report and discuss a novel way of managing the airway in a difficult case of anterior tracheal wall disruption caused by blunt trauma to the neck. BACKGROUND: Tracheal injury resulting in laceration of the windpipe may present with either one or many of the multitude of problems such as respiratory distress, hoarseness of voice and subcutaneous emphysema. Most often it requires surgical intervention. CASE DESCRIPTION: We hereby present the novel use of a mini-tracheostomy kit as an aid in the cannot-intubate-cannot-ventilate situation of a 30-year-old patient presenting with severe features of blunt tracheal injury. The airway was established critically with the use of the mini-tracheostomy kit in a "cannot-intubate-cannot-ventilate" situation during surgical tracheostomy and a potentially disastrous cardiorespiratory arrest situation was averted. CONCLUSION: Timely presence of airway equipment, adequate preparation, a willingness to innovate and a team approach are of paramount importance in dealing with difficult airway situations that are presented in myriad and complex ways. CLINICAL SIGNIFICANCE: The stylet of mini-tracheostomy kit can be used in emergent airway management especially in clinical situations mimicking ours specifically as a guide for insertion of the standard tracheostomy tube.

Intubating Laryngeal Mask Airway-assisted Flexible Bronchoscopic Intubation Is Associated With Reduced Cervical Spine Motion When Compared With C-MAC Video Laryngoscopy-guided Intubation: A Prospective Randomized Cross Over Trial.

BACKGROUND: In the evolving research into cervical spine mechanics during airway intervention, new devices are being constantly added to the armamentarium of anesthesiologists. In this study we compared cervical spine movement during orotracheal intubation using an intubating laryngeal mask airway (LMA Fastrach) assisted flexible bronchoscope or video laryngoscope. MATERIALS AND METHODS: In total, 40 consenting patients without history of abnormalities of cervical spine and planned for elective neuroradiologic interventions in the angiography suite were enrolled in this randomized crossover trial. Every patient was subjected to LMA Fastrach-guided flexible bronchoscopic as well as video laryngoscopy guided intubation. Cervical spine motion at the occipital bone, C1-C5 vertebrae, the occiput-C1, C1-C2, C2-C3 and C4-C5 junctions was investigated using continuous fluoroscopy during intubation. The primary outcome of the study was combined craniocervical motion from occiput to C5 between the 2 intubation techniques. RESULTS: There was less (62%) combined craniocervical movement from occiput to C5 during the LMA Fastrach-flexible bronchoscopy-guided technique as compared with video laryngoscopy-guided intubation (17.55±14.23 vs. 28.95±11.58 degrees, respectively; P<0.001). The LMA Fastrach flexible bronchoscopy-guided technique also produced significantly less movement as compared to the video laryngoscope at the occiput-C1 (9.75±8.59 vs. 15.00±10.48 degrees; P=0.000) and C1-C2 level (3.95±7.51 vs. 7.53±9.1 degrees; P=0.003). CONCLUSIONS: There was significantly less movement in the craniocervical and upper cervical spine during LMA Fastrach assisted flexible bronchoscopic intubation compared to video laryngoscopic intubation.

Intracranial pressure monitoring: Gold standard and recent innovations.

Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.

Adjuvants to local anesthetics: Current understanding and future trends.

Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).

Biochemical changes in the injured brain.

Brain metabolism is an energy intensive phenomenon involving a wide spectrum of chemical intermediaries. Various injury states have a detrimental effect on the biochemical processes involved in the homeostatic and electrophysiological properties of the brain. The biochemical markers of brain injury are a recent addition in the armamentarium of neuro-clinicians and are being increasingly used in the routine management of neuro-pathological entities such as traumatic brain injury, stroke, subarachnoid haemorrhage and intracranial space occupying lesions. These markers are increasingly being used in assessing severity as well as in predicting the prognostic course of neuro-pathological lesions. S-100 protein, neuron specific enolase, creatinine phosphokinase isoenzyme BB and myelin basic protein are some of the biochemical markers which have been proven to have prognostic and clinical value in the brain injury. While S-100, glial fibrillary acidic protein and ubiquitin C terminal hydrolase are early biomarkers of neuronal injury and have the potential to aid in clinical decision-making in the initial management of patients presenting with an acute neuronal crisis, the other biomarkers are of value in predicting long-term complications and prognosis in such patients. In recent times cerebral microdialysis has established itself as a novel way of monitoring brain tissue biochemical metabolites such as glucose, lactate, pyruvate, glutamate and glycerol while small non-coding RNAs have presented themselves as potential markers of brain injury for future.

Mechanical ventilation in neurological and neurosurgical patients.

Approximately 20% of all patients requiring mechanical ventilation suffer from neurological dysfunction. It is imperative in the ventilatory management of such patients to have a thorough understanding of the disease pathology that may require institution of mechanical ventilation as well as in realizing its effects on the injured brain. These patients have unique challenges pertaining to the assessment and securing of the airway, maintenance of mechanical ventilation, as well as weaning and extubation readiness. This manuscript aims to present the current evidence in ventilatory management of the important subset of patients with neuronal injury. The indications for ventilatory management include both neurological and neurosurgical causes.