Jeson R Doctor

The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit.

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in Paediatrics.

The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus). Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA). Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H 2 O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD) or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO 2 should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.

Novel use of epidural catheter: Air injection for neuroprotection during radiofrequency ablation of spinal osteoid osteoma

Osteoid osteoma (OO) is a benign bone tumor, with a male-female ratio of approximately 2:1 and mainly affecting long bones. Ten percent of the lesions occur in the spine, mostly within the posterior elements. Treatment options for OO include surgical excision and percutaneous imaging-guided radiofrequency ablation (RFA). Lesions within the spine have an inherent risk of thermal damage to the vital structure because of proximity to the neural elements. We report a novel use of the epidural catheter for air injection for the neuroprotection of nerves close to the OO of the spine. A 12-year-old and 30 kg male child with an OO of the L3 vertebra was taken up for RFA. His preoperative examinations were within normal limits. The OO was very close to the L3 nerve root. Under general anesthesia, lumbar epidural catheter was placed in the L3-L4 space under imaging guidance. Ten ml of aliquots of air was injected under imaging guidance to avoid injury to the neural structures due to RFA. The air created a gap between neural elements and the tumor and served as an insulating material thereby protecting the neural elements from damage due to the RFA. Postoperatively, the patient did not develop any neurological deficit.

Acupressure versus dilution of fentanyl to reduce incidence of fentanyl-induced cough in female cancer patients: a prospective randomized controlled study.

Background Fentanyl-induced cough (FIC) is a transient condition with a reported incidence of 18% to 65% depending on the dose and route of administration of fentanyl. Nonpharmacological methods to prevent FIC are more cost-effective than medications. Dilution of fentanyl has a proven role in the prevention of FIC. Acupressure can also prevent FIC because it has a proven role in the treatment of cough. Methods This study included 225 female patients with an American Society of Anesthesiologists physical status of I or II who were randomly divided into 3 groups of 75 patients each. Patients in the control group received undiluted fentanyl at 3 µg/kg, patients in the acupressure group received undiluted fentanyl at 3 µg/kg with acupressure, and patients in the dilution group received diluted fentanyl at 3 µg/kg. Coughing was noted within 2 min of fentanyl administration. The severity of FIC was graded as mild (1–2 coughs), moderate (3–4 coughs), or severe (≥5 coughs). The timing of coughs was also noted. Results The incidence of FIC was 12.7% in the control group, 6.8% in the dilution group, and 1.3% in the acupressure group. The difference in the incidence of cough was statistically significant (P = 0.008) between the control and acupressure groups. The difference in the severity of cough among the groups was not statistically significant. The median onset time of cough among all groups was 9 to 12 seconds. Conclusions The application of acupressure prior to administration of fentanyl significantly reduces the incidence of FIC. Dilution of fentanyl also reduces the incidence of FIC, but the difference is not statistically significant.

Republication: All India difficult airway association 2016 guidelines for tracheal intubation in the intensive care unit

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often lifesaving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with under evaluation of the airway and suboptimal response to preoxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; Wherever, robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the (AIDAA) and Indian Society of Anaesthesiologists. Noninvasive positive pressure ventilation for preoxygenation provides adequate oxygen stores during TI for patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnea before hypoxemia sets in. High flow nasal cannula oxygenation at 60–70 L/min may also increase safety during intubation of critically ill patients. Stable hemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

Paraplegia following epidural analgesia: A potentially avoidable cause?

Neurological deficit is an uncommon but catastrophic complication of epidural anesthesia. Epidural hematomas and abscesses are the most common causes of such neurological deficit. We report the case of a patient with renal cell carcinoma with lumbar vertebral metastasis who developed paraplegia after receiving thoracic epidural anesthesia for a nephrectomy. Subsequently, on histo-pathological examination of the laminectomy specimen, the patient was found to have previously undiagnosed thoracic vertebral metastases which led to a thoracic epidural hematoma. In addition, delayed reporting of symptoms of neurological deficit by the patient may have impacted his outcome. Careful pre-operative investigation, consideration to using alternative modalities of analgesia, detailed patient counseling and stringent monitoring of patients receiving central neuraxial blockade is essential to prevent such complications.

Transversus abdominis plane catheters for postoperative pain relief in pediatric patients

Regional techniques provides excellent post operative pain relief in pediatric patients. Transversus abdominis plane (TAP) block is a newer regional technique available. Though there is emerging evidence proving the efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients. TAP catheters were placed in two children following laparotomy with transverse incisions and in both epidural was avoided, with good post operative pain relief. Ultrasound guidance was used in one child, while in the other the catheter was placed under direct vision after dissection of the plane between transversus abdominis and internal oblique. Intermittent boluses of high volumes of local anesthetic (0.6-0.7 ml/kg) were used through the TAP catheter, ensuring that the maximum permissible level of bupivacaine was not exceeded. In adults, continuous abdominal catheters have found a place for post-operative pain management, when epidural analgesia is contraindicated. At present, the use of TAP catheters by pediatric anesthesiologists is limited, though there exists diverse clinical scenarios when these catheters may be of benefit. Contraindication of neuraxial blockade and septic patients are the two scenarios we have reported. In conclusion, TAP catheters are effective analgesia technique for laparotomies with transverse incision in pediatric patients.

Accuracy of ultrasound imaging versus manual palpation for locating the intervertebral level

Background and Aims: Efficacy of epidural analgesia depends on placement of the epidural catheter at the appropriate level. Manual palpation using surface landmarks to identify the desired intervertebral level may not be a reliable method. Ultrasonography (USG) is an alternative technique but requires training and may increase procedure time. The objective of this study was to compare the accuracy of ultrasound (US) imaging with manual palpation for locating the intervertebral level. Material and Methods: We included postoperative adult patients without an epidural catheter who were scheduled to have a chest radiograph in the recovery room. A radio-opaque marker was placed at random at an intervertebral space along the thoracic or lumbar spine of the patient (in the field of the chest radiograph). The level of intervertebral space corresponding to the radio-opaque marker was determined by palpation technique by one anesthetist. Two other anesthetists (A and B) blinded to the result of manual palpation, independently used USG to determine the level of intervertebral space. A consultant radiologist assessed the radiographs to determine the correct position of the marker, which was judged to be the accurate space. Results: We recruited a total of 71 patients, of which 64 patients were included in the final analysis. Accurate identification by manual method was 31/64 (48%), by US A was 27/64 (42%) and by US B was 22/64 (34%). The difference in accuracy between manual palpation and US imaging was not statistically significant (P = 0.71). Conclusion: US imaging may not be superior to manual palpation for identifying intervertebral level.

Comparison of actual and ideal body weight for selection of appropriate size of ProSeal™ laryngeal mask airway in overweight and obese patients: A prospective, randomised study

Background and Aims: The ProSeal™ laryngeal mask airway (PLMA) has advantages of providing better cuff seal and the presence of a gastric drain tube. The manufacturer recommends actual body weight (ABW) for size selection. Pharyngeal area reduces with increase in body mass index (BMI); hence, in overweight patients, PLMA selected on ABW may not fit well. We hypothesised that the ideal body weight (IBW) would be more appropriate in size selection of PLMA. Methods: This randomised, single-blind study included 124 patients of 20–60 years and American Society of Anesthesiologists Class I–II, with BMI >25. Patients were randomly divided into two groups. In Group ABW, PLMA was selected based on ABW (62 patients) and in Group IBW, PLMA was selected based on IBW (62 patients). The primary outcome was the first-attempt insertion success rate. Oropharyngeal air leaks, gastric air leaks, drain tube air leaks, insertion difficulty scores and postoperative complications were assessed. Fibre-optic view (Grade I–IV) was assessed for proper placement by a blinded assessor. Statistical analyses were performed using Chi-square test or Fishers exact test. Results: First-attempt insertion success rate and overall insertion success rates were similar in both the groups. Group IBW patients had significantly less resistance during insertion, lower peak airway pressures, successful nasogastric tube insertions, better fibre-optic views and less post-operative complications. Oropharyngeal leak pressure and instrumentation used for insertion were comparable. Conclusion: IBW is preferable for the size selection of the PLMA in overweight and obese patients compared to the ABW.

Nasal septal perforation diagnosed intraoperatively by course of nasotracheal tube from left nostril to right nostril

A 28-year-old man was posted for right medial maxillectomy under general anaesthesia following recurrence of poorly differentiated neuroendocrine carcinoma of the right ethmoidal sinus. Three months before, he had undergone complete excision of the tumour and had received three cycles of etoposide and carboplatin after surgery. Physical examination did not reveal any gross abnormality in the upper airway.