Dheeraj Kapoor

Point of care blood gases with electrolytes and lactates in adult emergencies

Point-of-care testing (POCT) is one of the formidable concept introduce in the field of critical care settings to deliver decentralized, patient-centric health care to the patients. Rapid provision of blood measurements, particularly blood gases and electrolytes, may translate into improved clinical outcomes. Studies shows that POCT carries advantages of providing reduced therapeutic turnaround time (TTAT), shorter door-to-clinical-decision time, rapid data availability, reduced preanalytic and postanalytic testing errors, self-contained user-friendly instruments, small sample volume requirements, and frequent serial whole-blood testing. However, still there is a noticeable debate that exists among the laboratorians, clinicians, and administrators over concerns regarding analyzer inaccuracy, imprecision and performance (interfering substances), poorly trained non-laboratorians, high cost of tests, operator-dependent quality of testing, and difficulty in integrating test results with hospital information system (HIS). On search of literature using Medline/Pubmed and Embase using the key phrases “ppoint-of-care test,” “central laboratory testing,” “electrolytes,” “blood gas analysis,” “lactate,” “emergency department,” “intensive care unit,” we found that POCT of blood gases and selected electrolytes may not entirely replace centralized laboratory testing but may transfigure the clinical practice paradigm of emergency and critical care physicians. We infer that further comprehensive, meaningful and rigorous evaluations are required to determine outcomes which are more quantifiable, closely related to testing events and are associated with effective cost benefits.

Repair of damaged supraglottic airway devices: A novel method

Damage of laryngeal mask airway and other supraglottic airway devices has always been a matter of concern. Although manufacturer recommends maximum 40 uses of LMA (and its congeners) but damage before 40 uses needs to be evaluated. We hereby, describe a novel method of repair of supraglottic devices when damage occurs at mask inflation line or pilot balloon valve assembly.

Real-time ultrasound guided percutaneous dilatational tracheostomy in critically ill patients: A step towards safety!

There are few reports and observational data that support the safety and efficacy of real-time ultrasound guided (USG) percutaneous dilatational tracheostomy (PDT) when compared with unguided tracheostomy. We performed real-time USG PDT in our intensive care unit (ICU) patients with the aim of providing safe and cost effective point-of-care management. Real-time ultrasonography has the potential advantage of enabling the clinicians to define the needle path by showing displacement of tissues ahead of needle.

Intracuff pressure comparison between ProSeal(®) and Supreme(®) laryngeal mask airways.

References 1. Janakiraman C, Hodzovic I, Reddy S, Desai N, Wilkes AR, Latto IP. Evaluation of tracheal tube introducers in simulated difficult intubation. Anaesthesia 2009; 64: 309–14. 2. Simpson JA, Duffy MR. Airway injury and haemorrhage from use of the Frova Intubating Introducer: a case report. Journal of the Intensive Care Society 2012; 13: 151–4. 3. Sellers WFS, Jones GW. Difficult tracheal intubation. Anaesthesia 1986; 41: 93. 4. Frova Intubating Introducer Data Sheet. Cook Medical. Bloomington, USA, 2012. 5. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94. 6. Cummings IM, Howell V, Thoppil A, et al. Chlorhexidine cleaning of re-usable bougies. Anaesthesia 2013; 68: 830–4. 7. Letheren MJR. Sterilisation of gum elastic bougies. Anaesthesia 1994; 49: 921. 8. Eschmann Tracheal Tube Introducer Data Sheet. Smiths Medical. UK: Ashford, 2012. 9. Dawes TJ, Ford PN. The effect of sterilisation on the plasticity of multi-use Eschmann gum elastic bougies: a bench and manikin study. Anaesthesia 2011; 66: 1134–9.

Extubation aid in double lumen tube exchange in difficult airway cases operated for thoracic surgeries

Sir, Double lumen tube (DLT) is used in thoracic surgical procedures. A majority of these surgeries mandate postoperative elective ventilation. It is a common practice that DLT is exchanged with conventional endotracheal tube (ETT) before transferring the patient out of the operating room.[1-3] The exchange of the tracheal tube requires a fiberscope, which is not available in many operation theaters in developing countries.

Anaesthetic management in a child with an atypical triad for reconstructive scoliosis surgery.

Scoliosis may be of varied aetiology and may be associated with severe congenital anomalies. It often poses a challenge in its anaesthetic management. We present anaesthetic management of a child who underwent scoliosis reconstruction with a rare triad of cerebral palsy, glucose-6-phosphate dehydrogenase deficiency and severe mitral regurgitation. Anaesthetic management in these patients should focus primarily on associated co-morbidities and congenital anomalies affecting the course of the perioperative management and thereafter comprehensive pre-operative strategies must be executed to enhance the safety profile during the surgery.

Water in the flowmeters: still a possibility in the modern era!

To the Editor Medical gas distribution systems are extremely safe, reliable, and conform to National Fire Protection Association requirements.1 The quality standards and the safety features in the modern anesthesia workstations further reduce any error in delivering anesthetic gases to the patient.2 There can still be a possibility of flaws in the medical gas distribution system or anesthesia machine leading to catastrophic results.3–6 We report influx of water into the flowmeter assembly of an anesthesia work station (GE Datex Ohmeda Aestiva/5; GE Healthcare, Madison, WI) during the administration of general anesthesia. The incident occurred after induction of general anesthesia in a 30-year-old man, ASA physical status II patient with a Sarah Gardiner, BMBS Glenda Rudkin, MBBS, FANZCA John Field, PhD, AStat Rodney Cooter, MBBS, MD, FRACS Waverley House Plastic Surgery Centre Adelaide, South Australia, Australia sarah.gardiner@health.sa.gov.au

Ultrasound guided femoral nerve block: An essential pain management modality in emergency settings for femur fractures

Femoral nerve block (FNB) can significantly decrease the acute pain of a diaphyseal or distal femoral fracture and fracture neck of femur. This analgesic modality can be administered safely in the hospital emergency department and in the prehospital settings prior to the operative intervention. Profound analgesia is obtained without the adverse effects associated with systemic intravenous analgesics (i.e., respiratory depression, hemodynamic effects, or obtundation of consciousness). This block is also very successfully used to facilitate positioning for placement of neuraxial block in the operating room (OR).[2]

A prospective randomized controlled study to evaluate and compare GlideScope with Macintosh laryngoscope for ease of endotracheal intubation in adult patients undergoing elective surgery under general anesthesia

Background: The aim of the study was to compare the ease the intubation using GlideScope video laryngoscope and Macintosh laryngoscope in adult patients undergoing elective surgery under general anesthesia. Materials and Methods: A total of 200 American Society of Anesthesiologists I–II patients of either sex, in the age group of 18–60 years were included in the study. Patients were randomly allocated to two groups. We assessed ease of intubation depending on time to tracheal intubation, number of attempts, glottic view (Cormack–Lehane grade [CL grade] and percentage of glottis opening [POGO]) and intubation difficulty score (IDS), hemodynamic variables and any intra- and post-operative adverse events. Results: The rate of successful endotracheal intubation (ETI) in both groups was 100% in the first attempt. The time required for successful ETI was 24.89 ± 5.574 in Group G and 20.68 ± 3.637 in Group M (P < 0.001) found to be statistically significant. There was significant improvement in glottic view with GlideScope (as assessed by POGO score 66.71 ± 29.929 and 94.40 ± 10.476 in group G and 75.85 ± 26.969 and 74.20 ± 29.514 Group M and CL grading [P < 0.001]). A comparison of mean IDS between two groups revealed intubation was easier with the use of GlideScope. The hemodynamic response to intubation was significantly lesser with the use of GlideScope when compared with Macintosh laryngoscope. The incidence of adverse events, though minor like superficial lip or tongue bleed, was similar in two groups. Conclusions: GlideScope offers superiority over Macintosh laryngoscope in terms of laryngeal views and the difficulty encountered at ETI in an unselected population.

Fiberscope Assisted Videolaryngoscope Intubation in the Surgical Treatment of TMJ Ankylosis

Temporomandibular ankylosis is characterized by the formation of a bony mass which replaces normal temporomandibular joint (TMJ) articulation. Anaesthetic management in these patients requires expertise and dependable intubation technique that allows successful intubation due to anticipated difficulty in accessing the airway. A novel technique of endotracheal intubation is used for the successful airway management during the surgical treatment in patients with TMJ ankylosis with the assistance of fiberscope and GlideScope® videolaryngoscope. GlideScope® videolaryngoscope is a recently introduced system for tracheal intubation that has a dedicated video camera encased into a laryngoscope blade and provides better panoramic view than the conventional laryngoscopes. This technique avoids complications such as trauma to soft tissue structures surrounding the glottis during the passage of the tube over the fiberscope. It gives a clear view of the tube and its cuff position during intubation. It also abbreviates the time required for intubation which is a crucial determinant in this subset of patients owing to the difficult airway associated with paediatric age group.