Bimla Sharma

Factors influencing development of subcutaneous carbon dioxide emphysema in laparoscopic totally extraperitoneal inguinal hernia repair.

BACKGROUNDnThere is a paucity of published data on the incidence of subcutaneous emphysema and the causative factors responsible for its occurrence during laparoscopic procedures. This study was undertaken to evaluate the incidence and factors associated with the occurrence of subcutaneous emphysema in patients undergoing a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.nnnMATERIALS AND METHODSnThe prospective study included 100 patients who presented with a primary inguinal hernia and underwent an elective laparoscopic TEP hernia repair from November 2003 to May 2005. Various factors, including age, body mass index (BMI), type of hernia (i.e., unilateral or bilateral, indirect or direct), duration of surgery, and end-tidal carbon-dioxide tension (start and peak), were evaluated. A grading system was evolved to document clinically apparent subcutaneous emphysema immediately and at 6 and 24 hours after the surgical procedure.nnnRESULTSnA BMI <25, longer operating time (especially >1 hour), and higher end-tidal carbon-dioxide tension (start, peak, and difference) were found to be significantly associated with the development of subcutaneous emphysema. Age and type of hernia -- unilateral versus bilateral, direct versus indirect -- were not found to be statistically significant factors.nnnCONCLUSIONSnThe incidence of subcutaneous emphysema in laparoscopic extraperitoneal hernia repairs is high and largely under-reported. Once it is noted, the progression of the surgical emphysema during this type of surgery can have serious complications (e.g., cardiovascular and hemodynamic disturbances) unless timely, appropriate measures are taken. Etiology of subcutaneous emphysema is multifactorial, with no single factor having a prominent association.

Extraglottic airway devices: technology update [Corrigendum]

[This corrects the article on p. 189 in vol. 10, PMID: 28860875.].

Extraglottic airway devices: technology update

Extraglottic airway devices (EADs) have revolutionized the field of airway management. The invention of the laryngeal mask airway was a game changer, and since then, there have been several innovations to improve the EADs in design, functionality, safety and construction material. These have ranged from changes in the shape of the mask, number of cuffs and material used, like rubber, polyvinylchloride and latex. Phthalates, which were added to the construction material in order to increase device flexibility, were later omitted when this chemical was found to have serious adverse reproductive outcomes. The various designs brought out by numerous companies manufacturing EADs resulted in the addition of several devices to the airway market. These airway devices were put to use, many of them with inadequate or no evidence base regarding their efficacy and safety. To reduce the possibility of compromising the safety of the patient, the Difficult Airway Society (DAS) formed the Airway Device Evaluation Project Team (ADEPT) to strengthen the evidence base for airway equipment and vet the new extraglottic devices. A preuse careful analysis of the design and structure may help in better understanding of the functionality of a particular device. In the meantime, the search for the ideal EAD continues.

Prolonged Use of the Laryngeal Mask Airway ProSealTM: A Report of SevenCases Lasting 5-11 h

Background: There is controversy concerning use of laryngeal mask airway devices for procedures lasting more than 2 h. The LMA ProSealTM is a laryngeal mask device with a modified cuff to facilitate ventilation and a drain tube to provide airway protection that is better suited for prolonged use than the LMA ClassicTM. nObjectives: We aimed to describe the successful use of the LMA ProSealTM in seven patients in a variety of clinical situations for procedures lasting more than 5 h and provide practical guidelines about its use in this situation. nResults: The cases illustrate the use of the LMA ProSealTM in a variety of clinical situations (supine and prone position) and for a variety of prolonged procedures: as a planned airway device and as an airway rescue device. LMA ProSealTM forms an effective seal with the respiratory tract (10 cm H2O higher) and is therefore suited as ventilator device. It also forms an effective seal with the gastrointestinal tract (30 cm H2O higher), provides protection against aspiration and gastric insufflation and provides easy access to the gastrointestinal tract allowing the passage of a gastric tube reducing again the risk of aspiration. nConclusion: The use of the LMA ProSealTM for prolonged procedures is feasible. In principle, it should be safer and more effective than the LMA ClassicTM.

Anaphylaxis during anaesthesia: Indian scenario

Background and Aims: Anaphylaxis during anaesthesia is a rare but serious problem. In contrast to the developed countries where databases of perianaesthetic anaphylaxis are preserved, none exist in India. We conducted a survey amongst Indian anaesthesiologists to study the incidence and aetiology of anaphylaxis during anaesthesia in India. Methods: A written questionnaire comprising 20 items was mailed electronically or distributed personally to 600 randomly selected Indian anaesthesiologists. The responses were compiled and analysed. Results: We received responses from 242 anaesthesiologists. One hundred and sixty-two (67%) anaesthesiologists had encountered anaphylaxis during anaesthesia. Anaesthetic drugs led to 40% of reactions, and 60% of reactions were attributed to non-anaesthetic drugs. Opioids were the most common anaesthetic drugs implicated in anaphylaxis during anaesthesia, and non-depolarising muscle relaxants were the second most commonly implicated agents. Colloids, antibiotics and blood transfusion were the common non-anaesthetic agents thought to be responsible for anaphylactic reactions during anaesthesia. There were five deaths due to anaphylaxis during anaesthesia. Only 10% of anaesthesiologists ordered for allergy testing subsequently though 38% of anaesthesiologists had access to allergy testing facilities. Conclusions: Our survey reveals that two-thirds of participating Indian anaesthesiologists had witnessed anaphylaxis during anaesthesia. Commonly implicated anaesthetic drugs were opioids and non-depolarising muscle relaxants while colloids, antibiotics and blood transfusion were the common non-anaesthetic agents causing anaphylactic reactions during anaesthesia. Further, our survey reveals low utilisation and paucity of referral allergy centres to investigate suspected cases of anaphylaxis during anaesthesia.

Changes in respiratory mechanics during extraperitoneal insufflation in inguinal hernia surgery

Anaesthesia was induced with midazolam 1 mg, fentanyl 2 μg/kg and propofol 2 mg/kg intravenously. Vecuronium bromide 0.1 mg/kg intravenously was used for muscle relaxation followed by endotracheal intubation. Anaesthesia was maintained with 1-2% sevoflurane in 50% O2 and N2O gas mixture. Intraoperative analgesia was provided with incremental doses of intravenous fentanyl 1 μg/kg and muscle relaxation maintained with intermittent boluses of vecuronium bromide 0.02 mg/kg intravenously.