Indu Sen

Cricoid pressure: Where do we stand?

In 1961, Sellick popularized the technique of cricoid pressure (CP) to prevent regurgitation of gastric contents during anesthesia induction. In the last two decades, clinicians have begun to question the efficacy of CP and therefore the necessity of this maneuver. Some have suggested abandoning it on the grounds that this maneuver is unreliable in producing midline esophageal compression. Moreover, it has been found that application of CP makes tracheal intubation and mask ventilation difficult and induces relaxation of the lower esophageal sphincter. There have also been reports of regurgitation of gastric contents and aspiration despite CP. Further, its effectiveness has been demonstrated only in cadavers; therefore, its efficacy lacks scientific validation. These concerns with the use of CP in modern anesthesia practice have been briefly reviewed in this article.

A left paraglossal approach for oral intubation in children scheduled for bilateral orofacial cleft reconstruction surgery – a prospective observational study

Background:  Children with orofacial cleft defects are expected to have difficult airways. Conventional midline laryngoscopic approach of oral intubation can lead to iatrogenic tissue trauma. In this study, we evaluated the feasibility of left paraglossal laryngoscopy as a primary technique for airway management in these children.

Efficacy of subtenon block in infants – a comparison with intravenous fentanyl for perioperative analgesia in infantile cataract surgery

General anesthesia with opioids provides good perioperative analgesia in infantile ocular surgeries but is associated with the risk of respiratory depression and postoperative emesis. This study aimed to assess the effectiveness of subtenon block for providing perioperative analgesia in infants undergoing cataract surgeries.

Ultrasound-guided supraclavicular brachial plexus anaesthesia improves arteriovenous fistula flow characteristics in end-stage renal disease patients

Background: Surgical construction of an arteriovenous fistula is preferred for end-stage renal failure patients requiring long-term haemodialysis. Methods: Patients were randomised into two groups: brachial plexus group (n = 30) or local infiltration group (n = 30). In all patients, a radiocephalic arteriovenous fistula was created by an experienced surgeon using a standard surgical technique. In both groups 20 ml of 0.375% ropivacaine was used. Doppler assessment of vessels was performed at fixed time intervals.
 Results: 
Primary patency rate was 100% in the brachial plexus block group whereas there was 10% fistula failure rate in the local infiltration group (p-value = 0.237). Diameter of the vessels, peak systolic velocity, mean diastolic velocity, and blood flow at 30 minutes, 48 hours, 2 weeks, and 6 weeks after the fistula creation was significantly greater than the preoperative diameter in all patients (p-value < 0.05). Intergroup comparison revealed that vascular parameters were significantly better in the brachial plexus analgesia group versus local infiltration group at all observation points up to and including six weeks post fistula creation (p-value < 0.05). Conclusion: Brachial plexus anaesthesia significantly dilates the vessel diameter and increases blood flow whereas local infiltration has a negligible effect on vessel diameter and blood flow.

Colloid cohydration and variable rate phenylephrine infusion effectively prevents postspinal hypotension in elective Cesarean deliveries

Background: Prevention of post-spinal hypotension in obstetric patients can be accomplished using intravenous fluid expansion and prophylactic use of sympathomimetic drugs. The affect of combination of colloids and phenylephrine infusion on maternal hemodynamics has not been widely studied and there is no consensus about the dosage required and time of starting its administration. Materials and Methods: This prospective, randomized, double-blind study enrolled 90 healthy term parturients undergoing elective Cesarean delivery under lumbar subarachnoid block (0.5% hyperbaric bupivacaine 10 mg with fentanyl 25 μg). Patients in Group A received prophylactic intravenous phenylephrine infusion (60 μg/minute) along with hydroxyl-ethyl-starch cohydration (6% HES 130/0.42;15 ml/kg) immediately after subarachnoid block. In Group B, patients received 6% HES cohydration and intermittent intravenous 50 μg boluses of phenylephrine. The efficacy of these in maintaining maternal SBP at 90-110% of baseline and neonatal well-being was evaluated. Results: In Group B, 75.5% of patients required rescue phenylephrine boluses to maintain SBP while maternal hemodynamics were well maintained in Group A and rescue drug was not needed. Reactive hypertension occurred in one patient (2.2%) and bradycardia in two patients (4.4%) in Group A. Six patients complained of nausea in Group B (13.3%) compared to one in Group A. All the newborns had normal Apgar scores and Umbilical arterial pH > 7.2. Conclusion: A combination of colloid cohydration and prophylactic phenylephrine infusion initiated at 60 μg/minute maintained maternal hemodynamics and neonatal well-being during Cesarean deliveries requiring minimum interventions by the anesthesiologist.

Preinduction hemodynamic fluctuations in renal transplant recipients-Comparison of two combined anesthesia regimens

An ideal anesthetic technique for a renal allograft recipient must ensure hemodynamic stability, enhance graft reperfusion, and provide good postoperative pain relief. Hence, a combined general and epidural anesthesia is preferred. In our clinical practice, it has been observed that in chronically ill end-stage renal disease (ESRD) patients, a bolus injection of epidural local anesthetics invariably necessitated the use of vasopressor agents. Such hemodynamic fluctuations may not be favorable for the graft. A prospective, randomized, double-blind study was conducted on 50 ESRD adults, 18-55 years, scheduled for elective live related kidney transplantation. The patients randomly received either epidural fentanyl (50 μg) and normal saline (10 mL) or epidural fentanyl (50 μg) and bupivacaine (0.5%; 10 mL) followed by standardized general anesthesia. Perioperative hemodynamics and vasopressor requirements were compared with both regimens. Early graft function was assessed by the onset of diuresis after declamping, serial creatinine values, glomerular filtration rate, and 24-hour urine output estimation. In the preoperative period, statistically significant reduction in the mean arterial pressure and the cardiac index occurred in 60% of the patients receiving epidural bupivacaine boluses. These hypotensive episodes required a therapeutic intervention prior to general anesthesia, that is, intravenous mephenteramine (3-6 mg; 9.60±2.32 mg) and crystalloid infusion (189.28±21.29 mL). Intraoperative hemodynamic parameters, surgical blood loss, and transplanted kidney function were comparable between the groups. We concluded that the use of regional anesthetics needed to administered cautiously in renal transplant recipients to maintain hemodynamic parameters.

Intubation Success through I-Gel® and Intubating Laryngeal Mask Airway® Using Flexible Silicone Tubes: A Randomised Noninferiority Trial

Introduction. The study aims to test whether flexible silicone tubes (FST) improve performance and provide similar intubation success through I-Gel as compared to ILMA. Our trial is registered in CTRI and the registration number is “CTRI/2016/06/006997.” Methods. One hundred and twenty ASA status I-II patients scheduled for elective surgical procedures needing tracheal intubation were randomised to endotracheal intubation using FST through either I-Gel or ILMA. In the ILMA group (n = 60), intubation was attempted through ILMA using FST and, in the I-Gel group (n = 60), FST was inserted through I-Gel airway. Results. Successful intubation was achieved in 36.67% (95% CI 24.48%–48.86%) on first attempt through I-Gel (n = 22/60) compared to 68.33% (95% CI 56.56%–80.1%) in ILMA (n = 41/60) (p = 0.001). The overall intubation success rate was also lower with I-Gel group [58.3% (95% CI 45.82%–70.78%); n = 35] compared to ILMA [90% (95% CI 82.41%–97.59%); n = 54] (p < 0.001). The number of attempts, ease of intubation, and time to intubation were longer with I-Gel compared to ILMA. There were no differences in the other secondary outcomes. Conclusion. The first pass success rate and overall success of FST through an I-Gel airway were inferior to those of ILMA.

Double lumen central venous catheter for pediatric airway management in laryngeal papillomatosis: caution is warranted

1 Verghese ST, McGill WA, Patel RI et al. Comparison of three techniques for internal jugular vein cannulation in infants. Paediatr Anaesth 2000; 10: 505–511. 2 Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study. Anesth Analg 2005; 100: 21–24. 3 Botero M, White SE, Younginer JG et al. Effects of trendelenburg position and positive intrathoracic pressure on internal jugular vein cross-sectional area in anesthetized children. J Clin Anesth 2001; 13: 90–93. 4 Verghese ST, Nath A, Zenger D et al. The effects of the simulated Valsalva maneuver, liver compression, and/or Trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children. Anesth Analg 2002; 94: 250–254. 5 Kayashima K, Imai K, Sozen R. Ultrasound detection of guidewires in-plane during pediatric central venous catheterization. Pediatr Anesth 2013; 23: 79–83.

Nasopharyngeal airway as an aid to remove i-gel™ after endotracheal intubation through the device

572 Journal of Anaesthesiology Clinical Pharmacology | October-December 2014 | Vol 30 | Issue 4 3. Lin TS, Chen CH, Yang MW. Folding of the epiglottis an unusual complication to be recognized after laryngoscopic endotracheal intubation. J Clin Anesth 2004;16:469-71. 4. Takenaka I, Aoyama K, Nagaoka E, Seto A, Niijima K, Kadoya T. Malposition of the epiglottis after tracheal intubation via the intubating laryngeal mask. Br J Anaesth 1999;83:962-3. 5. Takenaka I, Aoyama K, Abe Y, Iwagaki T, Takenaka Y, Kadoya T. Malposition of the epiglottis associated with fiberoptic intubation. J Clin Anesth 2009;21:61-3.

DIRECT CPR- Mnemonic to remember 2010 AHA BLS CPR guidelines

The 2010 American Heart Association Guidelines (AHA) for cardiopulmonary resuscitation (CPR) and emergency cardiac care, published on the 50th anniversary of modern CPR, recommend a change in the Basic Life Support (BLS) sequence of steps from A-B-C to C-A-B.[1] This requires all of us to relearn CPR according to the new recommendations. Memory-aids are known to improve our technical abilities and confidence in providing CPR.[2] We suggest a mnemonic “DIRECT CPR” to remember the sequence of assessments and actions to be taken by BLS provider in accordance with the Adult Chain of Survival of the 2010 AHA guidelines for CPR. The mnemonic is expanded as follows: D - Detection (Collapsed person, all is not well). I - Interrogation (Are you OK? Can you hear me?). R - Respiration (Assess for 5-10 seconds). E - Emergency call (Get AED and Equipment for resuscitation). C - Check Carotid pulsations (5-10 seconds) → If absent, start Chest Compressions. (rate of at least 100/minute, depth of at least 5 cm, and allow complete chest recoil). T - Two Breaths (Each breath over one second). C- Continue Compression and Ventilation in a ratio of 30:2 for five cycles. P - Pulse check after five cycles (two minutes). R - Rotate compressors after five cycles (two minutes). Deliver shock if indicated, as soon as AED is ready. Resume CPR starting with chest compressions. Rhythm analysis after five cycles (two minutes).