Divya Jain

Airway changes following labor and delivery in preeclamptic parturients: a prospective case control study

BACKGROUND Preeclampsia is associated with greater narrowing of the airway than normal pregnancy, but it is not known if these changes worsen during labor and delivery. The aim of the study was to evaluate the airway during and after labor in women with or without preeclampsia. METHODS Twenty-five normal and 25 severely preeclamptic pregnant women in early labor were recruited in this single-center, prospective, case-control study. Airway assessment was performed (a) before active labor (b) within one hour of delivery and (c) 24-48 h postpartum. The Mallampati grade was the primary outcome. Sonographic measurements of tongue thickness, anterior neck soft tissue at the level of the hyoid bone and the vocal cords, thyromental distance, and neck circumference, were secondary outcomes. RESULTS The Mallampati score increased from the pre-labor to the post-labor period in both preeclamptic and normotensive patients (P=0.001 and P=0.002 respectively). A significant difference in tissue thickness at the hyoid level was observed between preeclamptic and normotensive patients pre-labor (P=0.035), post-labor (P=0.05) and postpartum (P=0.05). There was no significant difference in thyromental distance or neck circumference between groups at any time. The total duration of labor and a Mallampati change by one grade correlated (Spearman correlation coefficient 0.473). CONCLUSION Airway sonography may provide useful bedside anatomical information for prediction of difficult laryngoscopy. The change in airway dimensions and the Mallampati score during labor may persist for 48 h postpartum in both groups. Those with prolonged labor are more susceptible to changes in airway dimensions.

Evaluation of I-gel™ airway in different head and neck positions in anesthetized paralyzed children

Studies that have compared and quantified the oropharynageal leak pressure (OPLP) and adequacy of ventilation with supraglottic airway devices in different head and neck positions have been done in adult populations. The effects of head–neck position changes on the functioning of I‐gel™ in pediatric population still remain unevaluated.

Evaluation of I‐Gel™ size 2 airway in different degrees of neck flexion in anesthetized children – a prospective, self‐controlled trial

A previous study by our group demonstrated an increase in oropharyngeal leak pressures and a deterioration of ventilation in maximum neck flexion with the I‐Gel™. To ascertain the optimal degree of neck flexion which increases OPLP without compromising ventilation we conducted a prospective self‐controlled trial with the I‐Gel™ in different degrees of neck flexion in anesthetized paralyzed children.

Effect of Low Dose Dexmedetomidine on Emergence Delirium and Recovery Profile following Sevoflurane Induction in Pediatric Cataract Surgeries

This randomized trial was conducted to assess the efficacy and recovery profile of low dose intravenous dexmedetomidine in prevention of post-sevoflurane emergence delirium in children undergoing cataract surgery. Sixty-three children aged 1–6 years were included. Anesthesia was induced with sevoflurane and airway was maintained with LMA. They were randomized to group D 0.15 (received intravenous dexmedetomidine 0.15 μg/kg), group D 0.3 (received dexmedetomidine 0.3 μg/kg), or group NS (received normal saline). The incidence of emergence delirium, intraoperative haemodynamic variables, Aldrete scoring, pain scoring, rescue medication, and discharge time were recorded. Emergence delirium was significantly reduced in dexmedetomidine treated groups with incidence being 10% in group D 0.15, none in group D 0.3, and 35% in the NS group (). Significantly lower PAED scores were observed in D 0.15 and D 0.3 group compared to the NS group (). Discharge time was significantly prolonged in the NS group compared to D 0.15 and D 0.3 (45.1 min ± 4.4 versus 36.8 min ± 3.8 versus 34.4 min ± 4.6), . Intravenous dexmedetomidine in low doses (0.3 and 0.15 μg/kg) was found to be effective in reducing emergence delirium in children undergoing unilateral cataract surgery.

Dexmedetomidine and emergence agitation.

copy, such that anaesthetists could see the epiglottis and intubate the trachea using an Eschmann stylet. Maclean and Ahmad are right to question the clinical significance of differences in intubation time, but standardised measurement of this time allows clinicians to compare results with similar studies on this topic. Swarbrick and Turner question whether time to intubation was even the correct primary outcome to use, but calculating sample size according to differences in success rate might obscure the statistical significance of differences between intubation times, which (as our study shows) can vary markedly. Recalculating our sample size for success rate, 24-99 patients would be required per group, so the sample size used (50 per group) was appropriate for statistically sound conclusions to be drawn about the lack of difference between success rates, too. In response to Mckenna and Ball, we did experience a higher prevalence of strong gag reflex responses among patients undergoing videolaryngoscopic intubation compared with patients undergoing fibreoptic intubation. Although not used in our study, we commend Mckenna and Ball for their detailed comments on supplementing topical anaesthesia with local anaesthetic injections for nerve blockade, and agree that there is no single superior proven technique. Swarbrick and Turner ask for the frequency distribution of anatomically difficult airways and potentially obstructed airways. Most fulfilled more than one criterion for enrolment into the study. More than 60% had limited mouth opening and more than 70% were Mallampati class 4, but there was no difference in the distribution of these criteria between the two groups. In 60% of videolaryngoscopy patients and 48% of fibreoscopy patients, previous intubation attempts predicted future difficult intubation, due to tumours etc; these were not ‘potential’ obstructions’ so much as ‘definite’ obstructions. Only one patient in each group had an obvious tumour on oral inspection without fulfilling one of the other criteria. Finally, Swarbrick and Turner echo the other correspondents in stressing that there is no single technique for difficult airway management that serves all patients, and that alternative equipment should always be available in case of failure, a concern with which we wholeheartedly agree.

Comparison of intubation conditions with CMAC Miller videolaryngoscope and conventional Miller laryngoscope in lateral position in infants: A prospective randomized trial

Endotracheal intubation in lateral position in infants is a challenge. This difficulty may be surmounted to some extent by using videolaryngoscopes but the routine use of these devices as a tool to secure the airway in lateral position remains unevaluated. Therefore, we conducted a prospective, randomized controlled trial to compare the intubation conditions achieved with the CMAC videolaryngoscope and the Miller Laryngoscope in lateral position in infants. We hypothesized that CMAC videolaryngoscope would provide a better laryngoscopic view and reduce the time to intubation compared to the Miller blade.

WHO safe surgery checklist: Barriers to universal acceptance

Development of the Safe Surgery Checklist is an initiative taken by the World Health Organization (WHO) with an aim to reduce the complication rates during the surgical process. Despite gross reduction in the infection rate and morbidity following adoption of the checklist, many health-care providers are hesitant in implementing it in their everyday practice. In this article, we would like to highlight the hurdles in adoption of the WHO Surgical Checklist and measures that can be taken to overcome them.

Comparison of the ProSeal laryngeal mask airway with the I-Gel™ in the different head-and-neck positions in anaesthetised paralysed children: A randomised controlled trial

Background and Aims: Head and neck movements alter the shape of the pharynx, resulting in changes in the oropharyngeal leaking pressures and ventilation with supragottic airway devices. We compared the effect of the different head-and-neck positions on the oropharyngeal leak pressures and ventilation with the I-Gel™ and ProSeal™ laryngeal mask airway (PLMA) in anaesthetised paralysed children. Methods: A total of 70 children were randomly assigned to receive PLMA (n = 35) or I-Gel™ (n = 35) for airway management. Oropharyngeal leak pressure in maximum flexion, maximum extension and the neutral position was taken as the primary outcome. Peak inspiratory pressures (PIPs), expired tidal volume, ventilation score and fibreoptic grading were also assessed. Results: No significant difference was noted in oropharyngeal leak pressures of PLMA and I-Gel™ during neutral (P = 0.34), flexion (P = 0.46) or extension (P = 0.18). PIPs mean (standard deviation [SD]) were significantly higher (17.7 [4.03] vs. 14.6 [2.4] cm H2O, P = 0.002) and expired tidal volume mean [SD] was significantly lower (5.5 [1.6] vs. 6.9 [2] ml/kg, P = 0.0017) with I-Gel™ compared to PLMA. Fibreoptic grading and ventilation score were comparable in both the groups in all the three head-and-neck positions. Conclusion: PLMA and I-Gel™, both recorded similar oropharyngeal leaking pressures in all the three head-and-neck positions. However, higher peak pressures and lower expired tidal volume in maximum flexion of the neck while ventilating with I-Gel may warrant caution and future evaluation.

Reply: Only with an optimal position of the supraglottic airway in situ, valid conclusions can be drawn about oropharyngeal airway pressure

1. Banerjee G, Jain D, Bala I, Gandhi K, Samujh R. Comparison of the ProSeal laryngeal mask airway with the i-gel in the different head-and-neck positions in anaesthetised paralysed children: A randomised controlled trial. Indian J Anaesth 2018;62:103-8. 2. Van Zundert AAJ, Gatt SP, Kumar CM, Van Zundert TCRV. Vision-guided placement of supraglottic airway device prevents airway obstruction: A prospective audit. Br J Anaesth 2017;118:462-3. 3. Okuda K, Inagawa G, Miwa T, Hiroki K. Influence of head and neck position on cuff position and oropharyngeal sealing pressure with the laryngeal mask airway in children. Br J Anaesth 2001;86:122-4. Response to Comments

Giant sacrococcygeal teratoma: Management concerns with reporting of a rare occurrence of venous air embolism

A 24‐hour‐old, term neonate, weighing 3.4 kg, born by cesarean section presented with a huge sacral mass of size 20 cm × 20 cm, involving coccyx, extending to both buttocks, with intact skin [Figure 1]. Tumor resection was planned at 24 h of birth. Preoperative hemoglobin was 16 g/dl, and other investigations were within normal limits. Blood for grouping and crossmatching was sent. Chest roentgenogram was normal. Echocardiography showed a small patent ductus arteriosus with patent foramen ovale with left‐to‐right shunt, and computed tomography scan showed a large heterogeneous sacrococcygeal mass with little intrapelvic extension [Figure 2].