Aloka Samantaray

Tracheal intubation in the prone position with an intubating laryngeal mask airway following posterior spine impaled knife injury

A prone position is not a standard position for anesthesia induction and associated with problems like difficult mask fit, impairment of orotracheal intubation by direct laryngoscopy, and reduction of pulmonary compliance. However anesthetic management of trauma victims presenting with penetrating posterior lumbar spine injury requires airway securement and induction of anesthesia in the prone position to avoid further neurological impairment. We herein present the first reported case of an adult trauma patient presented with an impaled knife protruding out of lower back, who underwent endotracheal intubation with an intubating laryngeal mask airway under general anesthesia in the prone position. Our experience indicates that this technique would be easier and less risky compared to direct laryngoscopy or awake fiber optic intubation and might be considered in an emergency situation.

Amiodarone for the Prevention of Reperfusion Ventricular Fibrillation

OBJECTIVE The purpose of this study was to evaluate the efficacy of prophylactic single-dose amiodarone administered through the pump circuit before releasing the aortic cross-clamp (ACC) in preventing the occurrence of reperfusion ventricular fibrillation (RVF). DESIGN A prospective, randomized double-blind, placebo-controlled efficacy study. SETTING A tertiary level teaching hospital. INTERVENTION Seventeen patients received 150 mg of amiodarone in 10 mL of normal saline by way of the pump 3 minutes before releasing the ACC, and a control group of 17 patients received 10 mL of normal saline. MEASUREMENT AND MAIN RESULTS The primary outcome of the study was the incidence of ventricular fibrillation requiring defibrillation during the 30-minute period after myocardial reperfusion. A large decrease in RVF (65% to 18%) was observed in the amiodarone-treated group with the number needed to treat only 2.1.The myocardial performance in terms of cardiac output was better in the amiodarone group; this could be attributed to the lower incidence of RVF and subsequent direct current shock therapy. CONCLUSIONS The observations showed that single-dose prophylactic amiodarone administered through the pump circuit 3 minutes before ACC release was an effective therapy to reduce the incidence of post-ACC release ventricular arrhythmias.

The effect on post-operative pain of intravenous clonidine given before induction of anaesthesia.

Background: Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications. Aim: This study was designed to test the effect of pre-induction administration of clonidine, given as a single intravenous dose, on post-operative pain scores and fentanyl consumption in patients after thoracic surgery. Setting and Design: Tertiary referral centre. Prospective, randomised, double-blind, placebo-controlled trial. Methods: Sixty patients were randomly allocated to receive clonidine (3 mcg/kg) or saline pre-operatively before induction of anaesthesia. The primary endpoint was pain on coughing (visual analogue scale (VAS) 0–100 mm) 120 min after surgery, time to first analgesic injection in the post-anaesthesia care unit (PACU) and 24-h fentanyl consumption. Statistical Analysis: For between-group comparisons, t-test and U-test were used as appropriate after checking normality of distribution. The incidence of complications between the groups was compared by Fishers exact test. Results: The post-operative VAS for the first 120 min and the fentanyl consumption at 24 h was significantly greater in the placebo group compared with the clonidine group (P<0.05). The sedation score was increased in the clonidine group during study drug infusion, but did not differ significantly on admission to the PACU. Conclusions: A single intravenous dose of clonidine (3 mcg/kg) given before induction of anaesthesia significantly reduced the post-operative VAS score in the initial period and fentanyl consumption during 24 h after thoracic surgery.

Comparison of two ventilation modes in post-cardiac surgical patients

Background: The cardiopulmonary bypass (CPB)-associated atelectasis accounted for most of the marked post-CPB increase in shunt and hypoxemia. We hypothesized that pressure-regulated volume-control (PRVC) modes having a distinct theoretical advantage over pressure-controlled ventilation (PCV) by providing the target tidal volume at the minimum available pressure may prove advantageous while ventilating these atelactic lungs. Methods: In this prospective study, 36 post-cardiac surgical patients with a PaO2/FiO2 (arterial oxygen tension/Fractional inspired oxygen) < 300 after arrival to intensive care unit (ICU), (n = 34) were randomized to receive either PRVC or PCV. Air way pressure (Paw) and arterial blood gases (ABG) were measured at four time points [T1: After induction of anesthesia, T2: after CPB (in the ICU), T3: 1 h after intervention mode, T4: 1 h after T3]. Oxygenation index (OI) = [PaO2/ {FiO2 × mean airway pressure (Pmean)}] was calculated for each set of data and used as an indirect estimation for intrapulmonary shunt. Results: There is a steady and significant improvement in OI in both the groups at first hour [PCV, 27.5(3.6) to 43.0(7.5); PRVC, 26.7(2.8) to 47.6(8.2) (P = 0.001)] and second hour [PCV, 53.8(6.4); PRVC, 65.8(7.4) (P = 0.001)] of ventilation. However, the improvement in OI was more marked in PRVC at second hour of ventilation owing to significant low mean air way pressure compared to the PCV group [PCV, 8.6(0.8); PRVC, 7.7(0.5), P = 0.001]. Conclusions: PRVC may be useful in a certain group of patients to reduce intrapulmonary shunt and improve oxygenation after cardiopulmonary bypass-induced perfusion mismatch.

Effects of fentanyl on procedural pain and discomfort associated with central venous catheter insertion: A prospective, randomized, double-blind, placebo controlled trial.

Context: Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics. Aim: The aim of this study is to evaluate the efficacy of fentanyl along with LA field infiltration in controlling pain and discomfort associated with CVC insertion. Settings and Design: A prospective, randomized, double-blind, placebo-controlled trial was conducted at tertiary referral center. Materials and Methods: Fifty-four patients scheduled for planned CVC were randomly assigned to receive either fentanyl (2 μg/kg) or 0.9% normal saline. Pain and discomfort using a verbal numeric rating pain scale at 5 times points during CVC insertion were assessed and analyzed. Results: The median interquartile range pain score is worst for placebo group after LAI (5 [3-6]) and in the immediate postprocedure period (5 [4-5]) which was significantly attenuated by addition of fentanyl (3.5 [2-5] and 3 [2-4]) (P = 0.009 and 0.001 respectively). Overall, fentanyl and placebo group were not statistically different with median discomfort score except at T10 (P = 0.047). Conclusions: Preprocedural bolus fentanyl infusion provides adequate analgesia and can be safely used for alleviating pain during CVC insertion in conscious patients.

Spinal anaesthesia in poliomyelitis patients with scoliotic spine: A case control study

Background: There is limited data to predict the course of sub-arachnoid block in poliomyelitis patients with scoliotic spine. So we intended to study the course of intrathecal anaesthesia in these patients in comparison to patients with normal spine using 0.5% bupivacaine (heavy). Methods: In this prospective observational study, 41 poliomyelitic patients scheduled for lower limb corrective surgeries under spinal anaesthesia were enrolled. Patients were studied in two groups (Scolotic spine, n=20; Normal spine, n=21). All patients were injected 2 ml of 0.5% bupivacaine heavy intrathecally in the sitting position. The extent of block, bilateral spread, regression of sensory block and motor block were recorded. Demographic data were analysed using the unpaired t test or the chi square test as applicable. Block characteristics were analysed using the Mann Whitney U test. Results: There was statistically significant difference in bilateral spread of sensory block in between the groups. However, there was no significant difference in the maximum extent of the sensory block and the time taken for two segment regression of sensory block. There was no significant difference in time taken to reach complete motor block and for complete recovery from motor block to its preoperative value. Conclusions: Bilateral symmetrical spread of local anaesthetics through intrathecal route cannot be predicted accurately in patients with scoliotic spine. Spinal anaesthesia can be safely administered in poliomyelitis patients with scoliosis with less adverse effects.

Effects of dexmedetomidine on procedural pain and discomfort associated with central venous catheter insertion

Background and Aim: Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anaesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics. The aim of this study was to evaluate the efficacy of dexmedetomidine along with LA field infiltration in controlling pain and discomfort associated with CVC insertion. Methods: A prospective, randomised, double-blind, placebo-controlled trial of 54 patients scheduled for planned CVC insertion was undertaken. Patients were randomly assigned into two groups of 27 each, to receive either dexmedetomidine (1 μg/kg) or 0.9% normal saline, along with LA field infiltration. Pain and discomfort score was measured at 5 time points. Results: The median pain score was worst for placebo group at local anaesthetic injection (6 [4-7]) and at the end of procedure (5 [4-5]), which was significantly attenuated in the dexmedetomidine group (4 [4-5] and 4 [3-5]; P = 0.007 and 0.040 respectively). The lower procedure related discomfort score in the immediate post-procedural period was statistically significant in dexmedetomidine group compared to placebo (4 [4-5] vs. 5 [4-6]; P = 0.008). Conclusions: Pre-procedural bolus dexmedetomidine infusion provides adequate analgesia and patient comfort for CVC insertion along LA field block. However, the tendency for excessive sedation and bradycardia associated with dexmedetomidine render it less desirable for this purpose.

Anaesthetic management of excision of a functioning pancreatic beta cell tumour.

Upper lip bite test is useful as a single bedside predictor of difficult intubation because it is easy to perform, lacks interobserver variability and does not need any special equipment to perform it. Practically, ULBT with MPG can be the best combination to predict difficult intubation in bedside practice. Combination of ULBT, MPG and TMD can be a reliable clinical prediction model for difficult endotracheal intubation.

Comparison of bacterial colonization of central venous catheters introduced through two different routes - A prospective, randomized, observational study

Background: Central venous catheterizations are commonly used in critically ill patients and may cause different complications including infections. Methods: This prospective, randomized observational study was conducted in 60 patients admitted to respiratory intensive care unit (RICU) in a tertiary care hospital to compare the incidence and character of bacterial colonization between internal jugular (IJV) and subclavian (SCV) catheterization after seven days of placing the central venous catheter. Results: The incidence of catheter tip colonization (CTC) was statically higher in IJV compared to SCV (p = 0.030) whereas, there was no significant difference in blood cultures (p = 0.671) between the groups. The incidence of CTC and growth on blood culture increased with increase in number of attempts. Common microorganism colonizing the central venous catheters (CVCs) was non fermenting Gram negative bacteria and Klebsiella spp. Two cases of catheter related blood stream infection (CRBSI) were reported in the SCV group. Microorganisms causing CRBSI were Pseudomonas spp and Staphylococcus aureus. Conclusions: Despite sterile precautions bacterial colonization of central venous catheter tip is seen, more in the IJV group but CRBSI was common in SCV group. Catheter tip culture positivity does not confirm infection. As the number of attempts increase there are more incidences of positive blood culture and CRBSI.

Air leak with intact cuff inflation system: A case report with brief review of literature.

Sir, Tracheal re-intubation because of air leak after a successful tracheal intubation is not very uncommon in anaesthesia practice. The most common illustrated causes for air leaks are related to a defect in the cuff, inflation tube/lumen, pilot balloon, or the spring loaded inflation valve. Here, we report an unexpected product quality compromise leading to appreciable air leak without a defect in cuff inflation system. The trachea of a 38-year-old lady posted for elective transsphenoidal excision of pituitary adenoma was successfully intubated with a 7 mm internal diameter disposable flexometallic endotracheal tube (ETTfm) (Sterimed™) and was secured with elastic adhesive plaster at lip line corresponding to 21 cm on the ETTfm tube. A few minutes later while positioning the patient, we noticed audible air leak from the mouth. Hence, we followed a stepwise approach to ascertain and fix the cause. In the first step, we pushed 2 ml air (in addition to 5 ml air used to inflate the cuff initially) and found that the pilot balloon was holding the air that ensured an intact cuff and a competent inflation valve. However, the air leak was still audible from patients oral cavity with each mechanised positive pressure breath. In the next step, we ascertained the correct position of tracheal tube with check laryngoscopy which confirmed that the entire cuff is below the vocal cord. In the final step, we presumed that the tube may be too small for the trachea of the patient. However auscultation over trachea was negative; but to give the benefit of doubt we re-intubated the patient with a new ETTfm tube and with this, there was no air leak. After uneventful completion of surgery and subsequent extubation, we re-examined and compared both the ETTsfm to localise the cause of air leak. On careful physical examination, we found a small defect near the insertion point of the inflation tube in the first ETTfm [Figure 1], suggesting air leak from the wall of the tube despite the pilot balloon appearing to be firmly inflated. Figure 1 The red in colour arrow pointing toward the oval defect in the wall of the flexometallic tube. The flexometallic endotracheal tube is straightened to make the defect more appreciable Normally, cuff leak or leak around the cuff can be identified by looking at pilot balloon, palpation of the cuff over suprasternal space, auscultation over trachea and bubbles coming out from the oral and nasal cavity if secretions are present. However, the leak from the wall of the ETTfm at the insertion point of pilot balloon is difficult to identify unless we look for it because the junction is situated 18 cm from tip of the ETTfm just behind the incisor and possibly much above the accumulated secretion if any, to form the bubbles. Literature search illustrated few more case reports implicating improper fixation of the tube by adhesive plaster,[1] repeated use and attempt to remove the adhesive plaster,[2] bitten notch on re-sterilised tube[3] and low product quality compliance[4] as the cause of unexpected air leak from after tracheal intubation. In all these reports, the recommended in vitro test failed to detect such type of occult leak.[5] However, one author reported that such occult leak can be detected if, the tube was examined by flexing it opposite to its natural curve immersed in a bowl of water.[6] Our case report along with the discussed literature re-affirms that air leaks may be present in all types of ETT (both flexometallic and polyvinyl chloride) irrespective of their trade mark. The structural defect leading to air leak may be there in a newly opened ETT or may be caused by repeated use of re-sterilised tube. The small cuts and holes on the convex surface of the ETTfm and near the entry point of the inflation tube usually go undetected by routine in vitro test. Considering the fact that a small air leak at the beginning of the surgery may become larger leading to dangerous inadequate ventilation, an ideal solution for this type of problem would be use of a magnifying glass to verify structural integrity of cuff, insertion point and pilot balloon. However, as it is practically not possible to check each and every tube using a magnifying glass, such problems do occur irrespective of manufacturer. Hence, anaesthesiologist should be aware of such possibilities, and this should be kept in the mind as a diagnosis of exclusion, for which the best solution is change of the tube. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.