Habib Md Reazaul Karim

High flow nasal cannulae versus non-invasive ventilation in moderate hypercapnic respiratory failure: Different roads, same destination but doubtful equality

Nasal high flow oxygen (NHF) is a growing therapy in many forms of hypoxemic respiratory failure. The impact of NHF in chronic respiratory failure has been yet controversial. In this line we read the report from Lee and colleagues with interest,1 but there are several areas that warrant comment. This article is protected by copyright. All rights reserved.

Correlation of different parity and school education with acceptance of labor analgesia among antenatal women: A questionnaire-based study

Background and Aim: Pain relief is nearly regarded as the right of patients in modern day health care. Women undergo excruciating pain during normal vaginal delivery (NVD). However, the acceptance of labor analgesia (LA) has remained very poor. The present study was aimed to assess the correlation of previous exposure to such pain (parity) and school education with LA acceptance. Methods: The present comparative study was conducted with a total 400 consented participants. A questionnaire was used to collect sociodemographic variables, acceptance/nonacceptance of LA, and the reasons for not opting for LA in upcoming delivery were noted. Participants were divided into primiparous, multiparous, and nulliparous (control). They were also grouped as per school education and compared taking illiterates as controls. Data are presented in absolute number. Fishers exact test is used for comparison; P < 0.05 was considered statistically significant. Results: Seventy (17.5%) multiparous and 38% primiparous participants were compared with 44.5% nulliparous women. Only 2.75% participants were illiterate. 69.50% were rural inhabitant and 81.50% believed in Hinduism. 87.14% multiparous, 84.21% primiparous, and 88.76% nulliparous women declined LA (P > 0.05). The desire to experience NVD without LA as a reason for nonacceptance was significantly less among primiparous and multiparous as compared to nulliparous (P < 0.0001), but not among literate and illiterate participants (P > 0.295 in all). Conclusion: Previous labor pain significantly reduces the desire to experience NVD without LA, but still more than 80% parturients of any parity do not want LA due to one or more reasons. School education has no impact on LA acceptance.

A randomised comparative study on customised versus fixed sized pillow for tracheal intubation in the sniffing position by Macintosh laryngoscopy

Background and Aims: The sniffing position has been most commonly used for positioning of the head and neck to facilitate tracheal intubation. However, the optimum degree of head elevation for the optimal laryngeal view is not well studied, especially in non-Western countries. The present study was aimed to compare the use of a fixed height pillow versus a customised pillow (CP) height for head elevation, in terms of glottis visualisation and time required for tracheal intubation. Methods: With research and ethics committee approval from the institute, this randomised study was conducted among patients of both sexes aged 16 years or more and American Society of Anesthesiologists physical Status I to IV. A total of 134 patients were randomly allocated into routinely used fixed-sized pillow (FP) and CP group (to achieve horizontal alignment of external auditory meatus [EAM] and sternal notch). Primary and secondary outcomes were Cormack–Lehane (C–L) grade of glottic visualisation and time required for tracheal intubation, respectively. They were compared using unpaired t-test and Fishers exact test as applicable; P < 0.05 was considered statistically significant. Results: One hundred and nineteen patients completed the study. Both groups were similar in terms of demographic and external airway measurements. The mean ± standard deviation height of pillow required in Group CP was 6.26 ± 0.97 cm. Group FP had C–L Grade 3 view more often than Group CP (28.33% vs. 13.56%). In patients with modified Mallampati (MMP) Grade ≥3, the C–L grades and time required for intubation were both significantly lower in group CP. The time required for tracheal intubation was significantly lower in group CP (P = 0.04), even though the C–L grades were similar. Conclusion: Customising pillow for head elevation to horizontally align the EAM and the sternal notch gives better glottic visualisation and intubating conditions in patients with higher MMP grades.

Abnormal routine pre-operative test results and their impact on anaesthetic management: An observational study

Background and Aims: One of the reasons for continued routine pre-operative testing practice is the identification of hidden problems which may affect perioperative management. This study was aimed to assess the prevalence of abnormal test results, their impact on perioperative management and cost-effectiveness for detecting such abnormalities. Methods: This observational study was conducted by screening the files of the patients attending pre-anaesthetic check-up during December 2016–January 2017. Patients physical status, surgery grade, normal and abnormal test results and different impacts were noted and expressed in absolute numbers/percentage. Number needed to investigate (NNI) to detect a significant abnormality was calculated. Results: Data of 414 patients (46.3% male) with mean ± standard deviation age 43.78 ± 17.24 years and 58.65 ± 12.93 kg weight were analysed. Patients were mostly American Society of Anesthesiologists II and underwent National Institute of Clinical and Health Excellence Grade 3 surgeries. Totally, 345 (11.6%) test results were abnormal. Only 56 (16.2%) abnormalities had an impact in terms of referral, further investigations or delay. Twenty were significant in terms of changing perioperative anaesthetic management. Laboratory abnormalities with non-significant impact resulted in median delay of 3 days (range 1 to 12 days). The NNI for a significant impact and detecting new abnormality was 21 and 28, respectively. Conclusion: Majority (57.2%) of the patients had at least one abnormal routine test result but only 1.8% abnormalities had significant impact. The NNI to find a significant impact or hidden comorbidity was more than 20.

Insight to the growing utilizations of high flow nasal oxygen therapy over non-invasive ventilation in community teaching hospital: alternative or complementary?: In response to: Mihaela S. Stefan, Patrick Eckert, Bogdan Tiru, Jennifer Friderici, Peter K. Lindenauer & Jay S. Steingrub (2018) High flow nasal oxygen therapy utilization: 7-year experience at a community teaching hospital, Hospital Practice, 46:2, 73-76, DOI: 10.1080/21548331.2018.1438739

In the last 10 years, there is a growing application of high flow nasal cannula (HFNC) oxygen therapy as the first line or complementary use during noninvasive mechanical ventilation to avoid endotracheal intubation and improve short hospital outcome [1]. Some well-known advantages such as easy applications, patient comfort are key determinants with a scarce number of epidemiological studies about real world applications. In this line, we have read the article by Stefan MS, et al with great interest [2]. The article reports about the trends in HFNC oxygen therapy, noninvasive ventilation (NIV) and invasive ventilation. Although this shows local experience, form the clinical and practical point of view, there are some key aspects that need considerations. Firstly, HFNC is shown in this study as an alternative or complementary therapy with NIV, but the authors did not clarify methodology to exchange from one to another. This is important from the methodology point of view in terms of pathophysiologic/pressure setting (HFNC is flow dependent device and NIV is pressure dependent device). Secondly, although the authors have dealt with the data well to address a key issue of whether HFNC is an alternative or complementary intervention in hypoxemic patients, they only tabulated the use of each individual modality. What they should have provided was a Boolean description of their data, i.e. IMV, IMV + NIV, IMV + HFNC, IMV + HFNC + NIV, NIV, NIV + HFNC, HFNC. This would have been more meaningful and they could have done that with their database. This would provide corroborating data to their Venn diagram. Thirdly, although there is a rational physiology behind the use of HFNC in COPD and found to be effective in acute respiratory failure with hypercapnia [3], authors did not define well simple acute COPD with or without pneumonia or associated with heart failure. They could have further broken down the use in separate diagnostic groups or more precise diagnostic groups could have been used for better information. Fourthly, the authors developed HFNC oxygen therapy program in their community teachinghospital, which may explain more available for use of new technology during the study period, i.e. 2008 and 2014. We agree that the required training of staff would be negligible for HFNC and probably not an issue with NIV too. The authors did not consider how educational and skills, abilities, could influence a number of applications for ‘noninvasive ventilator support’ (HFNC and NIV) and compare with invasive mechanical ventilation (IMV) and team members (physicians/nurse/respiratory therapist). Finally, the authors also found increases in NIV utilization by 10.2% annually, while IMV’s utilization increased by 1.6% annually. However, this IMV utilization is not clear whether it was associated with NIV or HFNC failures. Therefore, further clinical trends, trials and survey need to confirm if these trends could be applicable for all hospitals or health systems.

Impact of sleep alterations on weaning duration of mechanically ventilated patients: how much is bad?

Sleep alterations and deprivation are common in mechanically ventilated patients in the intensive care unit (ICU). However, there is scarce information on how this is associated with mechanical ventilation and outcomes [1]. We therefore read with great interest the report on the effects of sleep alteration on weaning by Thille et al. [2]. Those authors have shown that atypical sleep is associated with longer weaning duration but there are some key aspects to take into account in this regard. Sleep disturbance/atypical sleep is common in critically ill patients; however, precise classification of atypical sleep and clinical implication establishment will require direct future research http://ow.ly/pYSF30ketxz

Perioperative challenges for same sitting bilateral upper limb surgery in a patient of obstructive sleep apnoea, morbid obesity, hypothyroidism, and orthopnea

BackgroundAnalgesia, sedation, and anesthesia all can be dangerous in patients with obstructive sleep apnoea and have been associated with critical events during perioperative management. The risk further increases when obstructive sleep apnoea is associated with other comorbidities. Although regional anesthesia when feasible is preferred over general anesthesia, it is not a clear cut decision always. The dilemma and challenges for the management of such cases still persist.Case presentationWe present here a case of 58-year-old male, weighing 98xa0kg (body mass index 41.86xa0kg/m2), presented with bilateral forearm bone fractures that was planned for bilateral upper limb surgery in the same sitting. He was newly diagnosed as having obstructive sleep apnoea, a known case of morbid obesity, hypothyroidism, and orthopnea. He was also having anticipated difficult airway. The case was managed successfully under bilateral regional anesthesia. However, patients’ apprehension led to a new challenge which required different management strategies including titrated sevoflurane-based sedation.ConclusionsThe case highlights the dilemmas and challenges faced by anesthesiologists, use of sevoflurane sedation, need of noninvasive ventilator support, and the limitations in the usual anesthesia machine and interface in the management of patients with obstructive sleep apnoea with multiple comorbidities.

Additional factors to consider while providing humidification support to neonates

Optimal humidification in preterm infants during noninvasive ventilation or invasive mechanical ventilation is a crucial therapeutic target to help prevent severe critical care complications. Although, this approach is well accepted, there is very little quality of evidence available, including bench models, to evaluate the complexities of humidification. This makes it difficult to determine the clinical benefits and, or, adverse effects of different methods. This article is protected by copyright. All rights reserved.

Practice and reasons for routine pre-operative investigations among anaesthesiologists and surgeons: An online survey

The cost-benefit ratio of routine pre-operative investigations is not favourable, and the traditional practice of ordering routine pre-operative tests before elective surgery is not recommended.[1,2] Evidence suggests that pre-operative tests are not associated with decreased mortality or better outcomes.[3] However, the practice of routine pre-operative tests before elective surgery has remained widely prevalent.[4,5] Health-care practices not only depend on practitioners’ knowledge but also on the local laws, protocols, administrative policies, etc. The present study was aimed to assess the reasons behind this continued practice.

An observational study on patient admission in the anaesthesia gas monitor and minimum alveolar concentration monitoring: A deficiency with huge impact

Background and Aims: Minimum alveolar concentration (MAC) monitoring is an integral part of modern-day anaesthesia. Both MAC and MAC-awake are age dependant, and age of the patient needs to be entered in the monitor. This study was aimed to assess the practice of patient birth year entry in the anaesthesia monitor and its impact on MAC monitoring. Methods: Sixty volatile anaesthetic-based general anaesthetics (GAs) were observed silently in two tertiary care teaching hospitals with regard to birth year entry in the patient monitor. The impact on MAC for non-entry of age was assessed. The observed MAC reading and the MAC corrected for age (MACage) of the patients were noted. Paired t-test was used to compare the differences in observed MAC and MACagevalues. P <0.05 was significant. Results: Sixty GAs of patients aged between 10 and 68 years were observed; 96.67% anaesthetics were conducted without entering birth year. Thirty-four patients (mean age 35.14 ± 15.38 years) were further assessed for impact of non-entry of age. The observed MAC was similar to MACage in patients aged 40 ± 5 years (36–45 years group). Nearly 79.41% of the observed MACs were incorrect; 55.88% patients were potentially underdosed whereas 23.53% were overdosed. Conclusion: Omitting patient age entry in the monitor results in erroneous MAC values, exposing patients <40 years to underdosing and older patients to overdose.