Hm Krishna

Insertion of LMA Classic™ with and without digital intraoral manipulation in anesthetized unparalyzed patients.

Background: The standard recommended insertion technique for LMA Classic™ requires the insertion of index finger into the oral cavity. Several anesthesiologists are reluctant to do this. We conducted this study to evaluate the modified technique of insertion of LMA Classic™ (not requiring insertion of fingers into the patients mouth) against the standard index finger insertion technique. Materials and Methods: This prospective, randomized, comparative study was conducted on 200 consenting patients. Patients suitable for anesthetic with LMA Classic™ were randomized to standard technique group (standard insertion technique) and modified technique group (technique not requiring digital intraoral manipulation). Laryngeal mask airway (LMA) was inserted by five designated anesthesiologists. Anesthetic protocol was standardized. Time taken to achieve an effective airway, ease of insertion, glottic view obtained through LMA, and incidence of sore throat were assessed. Results: Patient characteristics and duration of surgery were comparable between the groups. Time to achieve an effective airway was comparable [18.5 (8) s with standard technique and 19.7 (10) s with modified technique; data are mean (standard deviation)]. Ease of insertion (92 easy with standard technique and 91 easy with modified technique), success rate (99% in both the groups), glottic view with fiberoptic bronchoscope, and sore throat incidence (six patients with standard technique and eight patients with modified technique) were comparable. The first attempt success rate was significantly higher with the standard technique (98 patients in the standard technique group and 91 patients in the modified technique group). Conclusions: LMA Classic™ can be inserted successfully without the need to insert index finger into patients mouth, though the first attempt success rate is higher with the standard technique.

Does the newer preparation of propofol, an emulsion of medium ⁄ long chain triglycerides cause less injection pain in children when premixed with lignocaine?

Background:  Injection pain during propofol administration can be particularly distressing in children. The newly available emulsion of propofol in medium and long chain triglycerides (LCT) is reported to cause less injection pain because of lower concentrations of free propofol. This study compared the incidence of injection pain during administration of propofol emulsion of LCT and propofol emulsion of medium and long chain triglycerides (MCT/LCT) both premixed with lignocaine in children.

Premedication with gabapentin, alprazolam or a placebo for abdominal hysterectomy: Effect on pre-operative anxiety, post-operative pain and morphine consumption

Background and Aims : Utility of gabapentin for pre-operative anxiolysis as compared to commonly administered alprazolam is not evident. The aim of the present study was to compare the effects of pre-operative oral gabapentin 600 mg, alprazolam 0.5 mg or a placebo on pre-operative anxiety along with post-operative pain and morphine consumption. Methods: Seventy five patients scheduled for abdominal hysterectomy under general anaesthesia were included. Groups gabapentin, alprazolam and placebo, received oral gabapentin 600 mg, alprazolam 0.5 mg and one capsule of oral B-complex forte with Vitamin C respectively, on the night prior to surgery and 2 h prior to surgery. Visual analogue scale (VAS) was used to measure the anxiety and post-operative pain. All patients received patient-controlled analgesia. Statistical tests used were Kruskal-Wallis test, Wilcoxon signed rank test and one-way ANOVA. Results: Alprazolam provided significant anxiolysis (median [interquartile range] baseline VAS score 35 [15.5, 52] to 20 [6.5, 34.5] after drug administration; P = 0.007). Gabapentin did not provide significant decrease in anxiety (median [interquartile range] VAS score 21 [7.5, 41] to 20 [6.5, 34.5]; P = 0.782). First analgesic request time (median [interquartile range in minutes]) was longer in group gabapentin (17.5 [10, 41.25]) compared to group placebo (10 [5, 15]) (P = 0.019) but comparable to that in group alprazolam (15 [10, 30]). Cumulative morphine consumption at different time periods and total morphine consumption (mean [standard deviation]) at the end of study period (38.65 [18.04], 39.91 [15.73], 44.29 [16.02] mg in group gabapentin, alprazolam and placebo respectively) were comparable. Conclusion: Gabapentin 600 mg does not have significant anxiolytic effect compared to alprazolam 0.5 mg. Alprazolam 0.5 mg was found to be an effective anxiolytic in the pre-operative period. Neither alprazolam nor gabapentin, when compared to placebo showed any opioid sparing effects post-operatively.

Patients with postpartum hemorrhage admitted in intensive care unit: Patient condition, interventions, and outcome

Background: We conducted this study to analyze the data of patients admitted to intensive care unit (ICU) following postpartum hemorrhage (PPH) during one-year period, the interventions they received, and the outcome. Materials and Methods: Case records of patients admitted to ICU with PPH were analyzed. Data retrieved were as follows: Primary admission or referred case, duration between onset of PPH and arrival, condition at admission, resuscitative measures, procedures to manage PPH, presence of disseminated intravascular coagulation (DIC) and its management, duration of ICU stay, and the outcome. Results: Of 21 patients with PPH, 15 were admitted in the ICU. All were referred from other hospitals. Duration between onset of PPH and arrival was 6 (15) hours (mean [standard deviation]). All were conscious on arrival. In 10 patients, blood pressure was not recordable. Tachycardia was a common feature. One patient had bradycardia (54 bpm/BP not recordable). Resuscitative measures included oxygen supplementation and fluid resuscitation. Eight patients underwent uterine artery embolization, 2 patients underwent embolization followed by surgery, and 11 patients underwent surgical intervention only. Twelve patients had DIC on admission which was managed with blood component therapy. Duration of stay in ICU was 12.6 (5.4) days (mean [standard deviation]). Two patients expired following intractable DIC and multiorgan dysfunction syndrome. Though these 2 patients had severe shock on presentation, they did not have DIC at the time of presentation. Conclusions: Despite early resuscitation and intensive care management, DIC is a major cause of mortality. Late onset DIC (onset after admission to ICU) was associated with poor outcome in this study.

Re-expansion pulmonary oedema - differential lung ventilation comes to the rescue.

Re-expansion pulmonary oedema (REPE) is a rare complication following re-inflation of a chronically collapsed lung, which is often fatal. We present a case of a 22-year-old male who presented to the hospital with severe respiratory distress and a history of blunt abdominal trauma 3 months back. He was diagnosed to have left sided diaphragmatic hernia with a mediastinal shift to the right, and was posted for emergency repair of the same. After surgical decompression of the left hemi-thorax and reduction of the abdominal contents, re-expansion of the left lung was achieved, following which patient developed REPE. A left sided double lumen tube was then inserted to prevent flooding and cross contamination of the right lung and ventilation of both lungs was maintained intraoperatively. Post-operatively, REPE was successfully managed by differential lung ventilation with a lung salvage strategy to the left lung and a lung protective strategy to the right lung.

Unrecognized blunt tracheal trauma with massive pneumomediastinum and tension pneumothorax.

Blunt neck trauma with an associated laryngotracheal injury is rare. We report a patient with blunt neck trauma who came to the emergency room and was sent to ward without realizing the seriousness of the situation. He presented later with respiratory distress and an anesthesiologist was called in for emergency airway management. Airway management in such a situation is described in this report.

Tracheal intubation through laryngeal mask airway CTrach™ with polyvinyl chloride tube: Comparison between two orientations of the tracheal tube

Background and Aims: Higher success rate of intubation is observed with the reverse orientation of polyvinyl chloride (PVC) tracheal tube while intubating through laryngeal mask airway (LMA) Fastrach™. It is not clear whether the same is true during intubation through LMA CTrach™ visualizing the process of intubation. The primary aim of this study was to compare the influence of the PVC tracheal tube orientation on the success rate of intubation while intubating through LMA CTrach™. Material and Methods: One-hundred and fifty patients belonging to American Society of Anesthesiologists status I–II, undergoing elective surgery under general anesthesia were randomized to either group normal orientation or group reverse orientation. A maximum of 3 intubation attempts within a span of 3 min was allowed in each group before the change over to the other group. If intubation failed with the other orientation of the tube also, then intubation through LMA CTrach™ was abandoned and intubation done by direct laryngoscopy. The success of intubation, time, maneuvers, postoperative sore throat, and hoarseness were recorded. Results: Tracheal intubation through LMA CTrach™ with PVC tube was successful in 94.5% of patients in group normal orientation and in 98.6% of patients in group reverse orientation. The first attempt success rate was 75.3% and 86.3% in group normal and group reverse orientation, respectively. The incidence of a sore throat was higher in the group normal orientation than in the reverse orientation (31.8% and 26.5%, respectively). Conclusions: Overall success rate of intubation was comparable between the two groups. Though statistically insignificant, the first attempt success rate was higher in group reverse orientation.

Klippel–Feil Syndrome: Interchange of Plan A and B for Airway Management in the same Patient Under Different Circumstances

1. Bakshi S, Mapari A, Paliwal R. Ultrasound-guided rectus sheath catheters: A feasible and effective, opioid-sparing, post-operative pain management technique: A case series. Indian J Anaesth 2015;59:118-20. 2. Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005;94:7-17. 3. Murthy T, Pratyush G, Prabhakar T, Singh P, Mohan C. Anaesthetic Implication of Von Hippel Lindau disease. Med J Armed Forces India 2006;62:181-3. 4. Tighe SQ, Greene MD, Rajadurai N. Paravertebral block. Contin Educ Anaesth Crit Care Pain 2010;10:133-7. 5. Fanelli A, Montoya MI, Francesca Ghisi DE. Ultrasoundguided thoracic paravertebral block: classic approach. In Bigeleisen P (Ed), Ultrasound Guided Regional Anesthesia and Pain Medicine.(p-156-161) Baltimore, MD: Wolters Kluwer Health/Lippincott Williams & Wilkin. 2010. 6. Renes SH, Bruhn J, Gielen MJ, Scheffer GJ, van Geffen GJ. In-plane ultrasound-guided thoracic paravertebral block: A preliminary report of 36 cases with radiologic confirmation of catheter position. Reg Anesth Pain Med 2010;35:212-6.

Comparison between intravenous dexmedetomidine and local lignocaine infiltration to attenuate the haemodynamic response to skull pin head holder application during craniotomy

Background and Aims: Skull pin application is intensely painful and can be accompanied by detrimental haemodynamic changes. We compared intravenous (IV) dexmedetomidine with local infiltration of lignocaine at pin application sites to attenuate haemodynamic changes associated with pin application. Methods: Fifty-two patients undergoing craniotomy were randomised to either group dexmedetomidine (received 1 μg/kg dexmedetomidine over 10 min starting at induction of anaesthesia) or group lignocaine (received 3 ml of 2% lignocaine infiltration at pin application sites before pin application). Anaesthetic protocol was standardised. Heart rate (HR) and mean arterial pressure (MAP) were recorded at the following time intervals, pre-induction baseline, pre-infiltration, post-infiltration, pre-pin application and post-pin application at 1, 2, 3, 4, 5, 10 and 15 min. Statistical analysis was done using independent samples t-test, Fisher exact test and Chi-square test. Results: HR and MAP were comparable between the groups at all the study intervals. The incidence of adverse haemodynamic effects attributable to pin application (tachycardia and/or hypertension) was comparable between the groups (2 patients in group dexmedetomidine and 5 in group lignocaine). However, the incidence of hypotension and/or bradycardia was significantly greater in the dexmedetomidine group (19 patients in group dexmedetomidine and 5 patients in group lignocaine; P = 0.0007). Conclusion: IV dexmedetomidine 1 mcg/kg over 10 min is comparable to local infiltration of 2% lignocaine at pin application sites to attenuate the haemodynamic response associated with skull pin application. However, use of dexmedetomidine is associated with significantly higher incidence of hypotension and bradycardia.

Difficult intubation in an infant with Hallermann–Streiff syndrome–easy with Airtraq laryngoscope

Hallermann–Streiff syndrome (oculo mandibulo dyscephaly) is a rare congenital disorder with approximately 150 cases reported (1). Cardinal features are dyscephaly with bird facies, frontal/parietal bossing, dehiscence of sutures, hypotrichosis, cutaneous atrophy of scalp and nose, microphthalmia, congenital cataracts, blue sclera, nystagmus, mandibular hypoplasia, forward displacement of temporomandibular joints, high-arched palate, small mouth, multiple dental anomalies, and proportionate small stature (2). We describe the airway management of a 9-month-old infant with Hallermann–Streiff syndrome scheduled for right eye lens aspiration. A 9-month-old female infant weighing 7.3 kg was scheduled for right eye lens aspiration for bilateral developmental cataract. Parents had noticed decreased vision and nystagmus since birth. History of snoring during sleep was present. The motor and social development was normal. Physical examination revealed short stature (65.5 cm-5th percentile), weight of 7.3 kg (10th percentile), microcephaly (head circumference39.5 cm), prominent forehead, bitemporal hollowing, flat occiput, fibrous closure of anterior fontanel, small nose with prominent columella, bilateral cataract, nystagmus, and clinodactyly. Airway examination revealed adequate mouth opening, single prominent upper incisor, retrognathia, double chin, and high-arched palate. Examination of the cardio-respiratory system was normal. Hallermann–Streiff syndrome was diagnosed by the geneticist based on these features. Anticipating difficult airway, we kept the difficult airway cart ready (1–3). Before shifting to the operating room (OR), the infant was fasting adequately and had an intravenous (IV) access secured. Plan of anesthesia was inhalational induction followed by tracheal intubation without the use of muscle relaxants. In the OR, inhalational induction of anesthesia with 1–8% v/v sevoflurane in 100% oxygen was begun, simultaneously applying the standard monitoring. IV glycopyrrolate 0.07 mg was injected. After attaining adequate depth of anesthesia, ventilation was gently assisted to confirm the ease of ventilation. Because there was no evidence of airway obstruction, anesthesia was deepened with IV propofol 10 mg before attempting direct laryngoscopy. Direct laryngoscopy with Macintosh laryngoscope revealed thick stout unliftable epiglottis, with no part of glottis visualized (Cormack and Lehane grade 3b), despite optimal external laryngeal manipulation and attempts to optimize head and neck position. One attempt at blind intubation by maneuvering the styletted tracheal tube behind the epiglottis failed. Anesthesia was deepened with sevoflurane in oxygen and ease of mask ventilation was reconfirmed. To minimize airway trauma that could result from multiple attempts, we decided to use Airtraq laryngoscope (Airtraq optical laryngoscope; Prodol Meditec S.A., Las Arenas, Vizcaya, Spain) for second attempt at intubation. With Airtraq laryngoscope, the view obtained was Cormack and Lehane grade 2a. The thick and stout epiglottis still remained in the field of vision, though unhampering the glottic view. Tracheal intubation with a 3.5 mm internal diameter uncuffed PVC tube was easy. Correct placement of the tracheal tube was confirmed. Subsequent anesthetic management was uneventful. Several factors contribute to ‘difficult airway’ associated with Hallermann–Streiff syndrome. The ascending ramus of the mandible is either underdeveloped or absent resulting in a small mouth cavity. The temporomandibular joint can be easily dislocated. Small nostrils, deviated nasal septum, high-arched palate, and anterior larynx may preclude even blind nasal intubation in these cases (3). In this case, besides several findings associated with Hallermann–Streiff syndrome, the infant had the following predictors of difficult airway: history of snoring, high-arched palate, and receding mandible. As difficult intubation and difficult mask ventilation have been described in two cases reported, we decided to secure the airway under deep inhalational anesthesia preserving the spontaneous ventilation (2,3). We attempted intubation using Macintosh laryngoscope based on our preference. We did not try intubation using a Miller blade or bougie to minimize the attempts at intubation. Our other options of airway management at this point of time were fiberoptic aided intubation under general anesthesia and use of laryngeal mask airway. As review of literature had shown that Airtraq laryngoscope is useful in cases with receding mandible, we used it after failure of the first attempt (4,5). As evident here, intubation with Airtraq laryngoscope was successful and easy when intubation Correspondence