Air-Q ILA as a conduit for orotracheal intubation in children: A randomized control trial for comparison between supine and lateral patient positions

Background and Aims

Airway management in children is always challenging and becomes a concern if required in the lateral position. We evaluated the efficacy of orotracheal intubation using the Air-Q intubating laryngeal Airway (Air-Q ILA) in supine and lateral positions in children.

Material and Methods

This study included 100 children weighing 7-30 kg, scheduled for elective surgeries under general anesthesia. They were randomized into the supine (S) group or lateral (L) group. After anesthesia induction, the child was placed in a standard sniffing position for conventional laryngoscopy in the S group, and the child was turned into the lateral position in the L group. Both Air-Q ILA and endotracheal tube were placed blindly in the supine position in the S group and lateral position in group L. The grading of glottic view, success rate, insertion time of the Air-Q ILA, and endotracheal intubation were noted in both the groups.

Results

The Air-Q ILA was successfully placed at the first attempt in 47 children in group S and 48 in group L. The overall blind orotracheal intubations, including first and second attempts, were successful in 45 children in the S group and 47 in the L group (P = 0.715). Eighty percent of patients in group L and 70% in group S had glottis grade 1 or 2 compared to grade 3, 4,5 (P = 0.249). The mean time of Air-Q ILA placement in groups S and L was 15.73 ± 5.64 s and 14.42 ± 4.16 s (P = 0.195). The mean duration of blind endotracheal intubation through the Air-Q ILA was 24.88 ± 14.75 s in group S and 17.57 ± 5.35 s in group L (P = 0.002). In both the groups, none of the children had bronchospasm, laryngospasm, desaturation, or aspiration. The airway trauma evident by blood staining on the Air-Q ILA on removal was revealed in 2 cases in group S, and 3 cases in group L. None of the children in group S and 4 children in group L had postoperative stridor. Postoperative hoarseness was reported in 3 children in group S and none in group L within 24 hours.

Conclusion

The Air-Q ILA can be used as a conduit for blind orotracheal intubation in children in both supine and lateral positions while maintaining an effective airway seal.

Ultrasound is a reliable and faster tool for confirmation of endotracheal intubation compared to chest auscultation and capnography when performed by novice anaesthesia residents - A prospective controlled clinical trial

Background

Anesthesia trainee may initially take longer time to intubate and unintentionally place the endotracheal tube (ETT) in the esophagus. The present study determined if ultrasound is the fastest method of confirmation of correct placement of ETT compared to capnography, and chest auscultation in trainees.

Methods

First year anesthesia residents performed intubation in 120 patients recruited after ethical clearance and informed consent. Time to visualize flutter in trachea, double trachea sign, time to appearance of first and sixth capnography, and time to execute chest auscultation was noted.

Results

Ultrasonography was statistically fastest method to determine endotracheal intubation (36.50 ± 15.14 seconds) vs unilateral chest auscultation (50.29 ± 15.50 seconds) vs bilateral chest auscultation (51.90 ± 15.98 seconds) vs capnography first waveform (53.57 ± 15.97 seconds) vs capnography sixth waveform (61.67 ± 15.88 seconds).

Conclusion

When teaching endotracheal intubation to novice anesthesia residents using conventional direct laryngoscopy, ultrasonography is the fastest method to confirm correct ETT placement compared to capnograph and chest auscultation. Mentor can guide trainee to direct ETT towards trachea and can promptly detect esophageal intubation by double trachea sign.

Most Hemodynamically Stable Method for Change From High to Low Anesthesia Flow: A Randomized Controlled Trial Comparing State Entropy, High Fresh Gas Flow for 10 Minutes, and 0.8 Ratio of End-Expired Agent Concentration to Inspired Agent Concentration

This study was undertaken to determine the most hemodynamically stable method to low-flow anesthesia (LFA) between 10-minute administration of high fresh gas flow, 0.8 equilibration ratio (Fe/Fi), and state entropy (SE) between 40 and 60, a marker for adequate depth of anesthesia. Change from high fresh gas flow to LFA was done in 3 groups of 30 patients each: group T (time): 10 minutes; group R (ratio): Fe/Fi = 0.8, and group SE: SE = 40 to 50. A decrease in mean blood pressure or heart rate was treated with ephedrine or atropine, with study termination at more than 2 boluses of either. In group SE, no patient required ephedrine or atropine. The requirement for ephedrine was statistically higher in groups R and T than group SE. Atropine requirement was statistically higher in group R vs groups T and SE. In group R, the mean (SD) time to LFA was 43.9 (20.37) minutes, and in group SE was 151.9 (74.4) seconds. Hypotension or bradycardia did not occur when LFA was started at SE of 40 to 50 after anesthesia induction compared with LFA at 10 minutes, which caused hypotension, and Fe/Fi of 0.8, which caused hypotension and bradycardia.

Oral Ketamine or Midazolam or Low Dose Combination for Premedication in Children

This randomized controlled trial was designed to evaluate whether the combination of low dose oral midazolam (0.25 mg/kg) and low dose oral ketamine (3 mg/kg) provides better premedication than oral midazolam (0.5 mg/kg) or oral ketamine (6 mg/kg). Seventy-eight children of ASA physical status I or II scheduled for elective ophthalmic surgery were randomly divided into three groups and given premedication in the holding area 30 minutes before surgery. Two subjects from each group vomited the medication and were excluded, leaving 72 subjects for further analysis.

The onset of sedation was earlier in the combination group than the other two groups. At 10 minutes after premedication 12.5% in the combination group had an acceptable sedation score compared with none in the other two groups. After 20 minutes 54% in the combination group had an acceptable sedation score, 21% in the midazolam group and 16% in the ketamine group (P<0.05). There were no significant differences in the parental separation score, response to induction and emergence score. The mean time for best parental separation score was significantly less in the combination group (19±8 min) than either the midazolam (28±7) or ketamine (29±7 min) groups (P<0.05). Recovery was earlier in the combination group, as the time required to reach a modified Aldrete score of 10 was significantly less in the combination group (22±5 min) than in the oral midazolam (36±11 min) or ketamine (38±8 min) groups. The incidence of excessive salivation was significantly higher in the ketamine alone group (P<0.05). In conclusion, the combination of oral ketamine (3 mg/kg) and midazolam (0.25 mg/kg) has minimal side effects and gives a faster onset and more rapid recovery than ketamine 6 mg/kg or midazolam 0.5 mg/kg for premedication in children.

Addition of Fentanyl to Ropivacaine Infusion in Continuous Thoracic Paravertebral Infusion Does Not Improve Its Analgesic Effect Following Modified Radical Mastectomy: A Randomized Controlled Trial

A randomized controlled trial was conducted to evaluate pain scores in patients given continuous thoracic paravertebral (TPV) block with ropivacaine alone or with fentanyl in modified radical mastectomy (MRM). Forty female patients ASA classes 1 and 2, aged 18 to 60 years, undergoing MRM were recruited. Preanesthesia with 0.5% ropivacaine, 20 mL, was injected at the T4 TPV space. After 2 hours, patients were randomly assigned to receive a 0.1 mL/kg/h infusion of either 0.2% ropivacaine (group R) or 0.19% ropivacaine plus fentanyl, 2 µg/mL (group RF). Postoperatively, patient-controlled analgesia (PCA) with fentanyl was provided. Visual analog scale (VAS) pain scores at rest and movement were significantly less in group RF at 8 AM on postoperative day 1 (R vs RF: rest: 2 [interquar-tile range, 0-7] vs 1 [0-6]; P = .016; movement: 2.5 [1-8] vs 2 [1-8], P= .042) and on movement 60 minutes postoperatively (R vs RF: 2 [0-9] vs 2 [1-2]; P = .01). Mean total fentanyl consumed via PCA in group R was significantly more (206 ± 31.68 µg vs RF 82.5 ± 35.07 µg, P < .001). Mean total fentanyl consumed via PCA plus TPV infusion was comparable (R: 206 ± 31.68 µg vs RF: 211 ± 25.52 µg, P < .2). Because the mean VAS score was below 3 in all timeframes, addition of fentanyl to ropivacaine in continuous TPV infusion in MRM had no clinical advantage.

Perioperative complications of cochlear implant surgery in children

Cochlear implant is a commonly performed surgery for hearing loss in pre-school and school children. However, data on anesthesia management and anesthesia-related complications are sparse. We retrospectively reviewed the data of our institute from January, 2007 to December, 2012. Medical records and anesthesia charts of all the patients who had undergone cochlear implant under general anesthesia between this period were reviewed. Information related to the demographic profile, preoperative evaluation, anesthetic techniques, and perioperative complications were collected and analyzed. A total of 190 patients underwent cochlear implant surgery for pre-lingual (175) and post-lingual (15) deafness. General endotracheal anesthesia with inhalational agents was used in all the cases. Difficult intubation was encountered in three patients. Anesthesia-related complications were laryngospasm at extubation (4.73 %), emergence agitation (2.63 %), and postoperative nausea and vomiting (1.05 %). Major surgical complications were CSF leak without meningitis (3.15 %), device migration/failure (1.05 %), and flap infection (1.57 %). Cochlear implant under general anesthesia in small children is safe and anesthesia-related complications were minimal. Surgical complications, although more frequent, were predominantly minor and self-limiting.

Hemiparesis after robotic laparoscopic radical cystectomy and ileal conduit formation in steep Trendelenburg position

Robotic surgery is becoming popular for minimally invasive surgical procedures as robotic devices allow unprecedented control and precision. We report a case of robotic radical cystectomy with ileal conduit urinary diversion surgery having perioperative neurological complications related to prolonged surgery in the steep head-down position. There was a neurological deficit in the form of hemiparesis, which resolved with conservative management. We suggest that duration and positioning should be optimized for such prolonged surgery in the steep head-down position, and make some recommendations. Moreover, in such surgeries great vigilance must be observed in the perioperative period.

Perioperative concerns of recurrent urinary bladder phaeochromocytoma with skeletal metastasis

We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary bladder phaeochromocytoma with vertebral and rib metastasis following partial cystectomy and nephrectomy. His blood pressure was controlled with antihypertensive agents. Epidural analgesia was avoided in view of vertebral metastasis; instead, analgesia was provided with fentanyl infusion. Intraoperative hypertensive episodes were managed with nitroglycerine, sodium nitroprusside and esmalol. However, after surgery, the patient required inotropic support and was moved to the intensive care unit. Analgesia was maintained with fentanyl infusion, and inotropic support was gradually weaned off. Nuclear ablative therapy was planned for bony metastasis. We recommend that recurrences of extra-adrenal phaeochromocytoma be investigated for bony metastasis and cautiously managed in the perioperative period so as to avoid neurological complications.

Low- versus high-dose combination of midazolam-ketamine for oral premedication in children for ophthalmologic surgeries

INTRODUCTION

Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication.

METHODS

This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKL received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted.

RESULTS

A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. At 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in Group MKL and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation scores, mean response to induction and mask acceptance. The time to reach Aldrete score of 10 was shorter in Group MKL (22 +/- 5 min) and Group M (36 +/- 1 min) compared to Group MKH (52 +/- 2 min). Group MKH had a higher incidence of excessive salivation compared to the other groups.

CONCLUSION

A combination of low-dose midazolam and ketamine is as effective as high-dose midazolam and ketamine for achieving optimum anxiolysis and a faster recovery, with a lower incidence of excessive salivation in children undergoing ophthalmic surgery.

Low-dose spinal anaesthesia for a parturient with Takayasu's arteritis undergoing emergency caesarean section

Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetiology. Anaesthesia for patients with Takayasu's arteritis is complicated by severe uncontrolled hypertension leading to end-organ dysfunction, stenosis of major blood vessels affecting regional circulation, and difficulties in the monitoring of arterial blood pressure. The anaesthetic approach for parturients with Takayasu's arteritis has not been standardised in the literature, and previous reports have documented the use of general as well as regional anaesthesia. There are few instances in the literature where low-dose spinal anaesthesia alone is used in patients with Takayasu's arteritis undergoing emergency caesarean section. We present a case of the successful management of a parturient with Takayasu's arteritis, who underwent an emergency caesarean section under low-dose spinal anaesthesia.

Perianesthetic management of the first robotic partial cystectomy in bladder pheochromocytoma. A case report

The authors report the perianesthetic considerations of a rare case of pheochromocytoma of the urinary bladder for which the first reported robotic partial cystectomy and ureteric reimplantation were performed. A 59-year-old male patient, known to be hypertensive, was posted for transurethral resection of a bladder tumor. In the operation room, after attaching the monitors, a subarachnoid block was given. Upon manipulation of the tumor, the blood pressure and heart rate increased markedly. A pheochromocytoma was suspected and was later confirmed by raised urine catecholamine levels and meta-iodobenzyl-guanidine scan. The patient was started on tablet prazosin and atenolol. After optimization, a robotic partial cystectomy was planned. In the operating room, an epidural catheter and a radial artery cannula were inserted. After the induction of anesthesia and the securing of the airway, surgery was started. After the insertion of the verres needle, pneumoperitoneum was created very slowly, and then the patient was positioned in 40 degrees Trendelenburg. Surges in arterial blood pressure (ABP) were managed with titrated doses of sodium nitroprusside and nitroglycerine and boluses of esmolol and labetalol. ABP drops postoperatively were managed with fluid and dopamine infusion. Robotic surgery is a safe alternative to the open technique for pheochromocytoma of the urinary bladder. Care should be taken during the positioning of the patient for robot placement and during pneumoperitoneum creation.

Unpredicted neurological complications after robotic laparoscopic radical cystectomy and ileal conduit formation in steep trendelenburg position: two case reports

Robotic surgery is becoming popular for minimally invasive surgical evolution as robotic devices allow unprecedented control and precision in minimally invasive procedures. Two cases of robotic radical cystectomy with ileal conduit urinary diversion surgeries having perioperative neurologic complications related to prolonged surgery in steep head down position are presented. In these patients, neurological deterioration occurred after extubation probably due to cerebral edema. We suggest the duration and positioning should be optimized for such prolonged surgery in steep head down position and some recommendations should be made. Moreover, in such surgeries a great vigilance has to be observed in the perioperative period.

Case report: Airway management of a patient with popping pedunculated subglottic laryngeal polyp

Management of airway is a great challenge to anesthesiologists. Sometimes though airway is apparently normal but lesion around it may give a concern for securing airway. Patient, 52 years, ASA grade I presented to otolaryngology clinic with important complaints of stridor and dyspnoea. There was no comorbidity. Routine investigations were normal. Indirect laryngoscopic examination revealed pedunculated mass (polyp) arising from subglottic region, with a size of 0.7 x 0.5 cm and its pedicle was around 1.5 cm long delicate structure. This polyp was not visible during inspiration but it popped out of the vocal cords during expiration. Microlaryngeal surgery was planned to remove this polyp. Intubation of trachea was a great challenge as polyp was visible only during expiration. Tracheal intubation under controlled ventilation and neuromuscular blockade might have caused rupture of polyp pedicle or dislodgement of polyp in the trachea (as its pedicle was quite thin and delicate) which would have resulted in respiratory obstruction in the patient. Fiberoptic guided awake intubation was planned during expiratory phase of spontaneous respiration in order to avoid any injury or damage to the polyp or its pedicle.

Passage of peritoneal fluid into lumbar epidural catheter during pelvic exenteration

Migration of an epidural catheter into either paravertebral tissues or pleural cavity has already been described. Up to now, no case of passage of peritoneal fluid into the epidural space has been reported. Here we report such an event in a patient submitted to pelvic exenteration, and discuss its diagnosis and management.

Stress ulcer prophylaxis in patients on ventilator

The objective of the study was to assess the efficacy of the H2-receptor antagonists and sucralfate for the prophylaxis of stress ulcer in patients on a ventilator in an intensive care unit in the general intensive care unit of our institute. A randomized, clinical controlled trial was conducted. Fifty-two critically ill patients, who required mechanical ventilation for more than 24 hours, were randomly divided into 3 groups. Group I received ranitidine 50 mg (intravenous) 8 hourly, group II received tablet sucralfate 1 g 8 hourly through a Ryle's tube, whereas group III was not given any drug. The incidence of upper gastrointestinal bleed, change in gastric pH and growth of gram-negative organisms in the gastric juice and bronchoalveolar lavage (BAL) culture were noted and analysed. The treatment groups were similar with respect to the baseline characteristics. The incidence of upper gastrointestinal bleeding was similar in the ranitidine (12.5%) and sucralfate groups (14.35%) but was high in the control group (57.14%). The mean gastric pH was significantly low in the control group (mean pH 2.07) compared to the ranitidine (mean pH 5.25) and sucralfate groups(mean pH 3.54)(p < 0.05). The incidence of positive culture for gram-negative organisms was significantly high in the ranitidine group (75%) in comparison with the sucralfate group (33.33%) (p < 0.002). However, the incidence of positive growth in the BAL culture was similar in all three groups. We conclude that both ranitidine and sucralfate are equally effective in decreasing the incidence of upper gastrointestinal haemorrhage and other stress- related lesions. Though ranitidine was more effective in increasing the gastric pH, the incidence of gastric colonization was higher in the ranitidine group compared to the sucralfate group.