M Ravishankar

Manual displacement of the uterus during Caesarean section

Ninety ASA 1 and 2 pregnant women with term singleton pregnancies and no maternal and fetal complications, scheduled for elective or emergency Caesarean section, were randomly allocated to group LT (15° left lateral table tilt, n = 45) and group MD (leftward manual displacement, n = 45). Subarachnoid block was established with a 25‐gauge spinal needle at the L3‐L4 interspace using 1.5 ml of 0.5% hyperbaric bupivacaine. A median sensory level of T6 was observed in both groups but the incidence of hypotension was markedly lower in group MD when compared to group LT (4.4% vs 40%; p < 0.001) with a significant reduction in mean (SD) ephedrine requirement (6 (0) vs 11.3 (4.9) mg; p < 0.001). The mean (SD) fall in systolic blood pressure was 28.8 (7.3) mmHg in group LT and 20 (12.7) mmHg in group MD. The time to maximum fall in systolic blood pressure was similar in both groups (4.5 min). We conclude that manual displacement of the uterus effectively reduces the incidence of hypotension and ephedrine requirements when compared to 15° left lateral table tilt in parturients undergoing Caesarean section.

Local anaesthesia for awake fibreoptic nasotracheal intubation

Background: Awake fibreoptic nasotracheal intubation (FNI) is performed in potentially difficult airways under local anaesthesia. This observer‐blinded study was designed to evaluate the efficacy of upper airway anaesthesia produced by nebulized lignocaine against combined regional block (CRB) for awake FNI.

Preemptive caudal bupivacaine and morphine for postoperative analgesia in children

We designed this double-blind study to evaluate the efficacy of preemptive epidural bupivacaine and small-dose morphine for postoperative analgesia in children after herniorraphy. Sixty children, ASA physical status I or II, who were undergoing elective hernia repair under general anesthesia were randomly allocated into two groups. Group I (preemptive group) received 0.66 mL/kg 0.25% bupivacaine with morphine 0.02 mg/kg caudally after the induction of anesthesia but 15 min before surgery. Group II (postincisional group) received the same drug mixture after surgery. Pain was assessed using an objective pain scale (OPS). Time to first postoperative analgesics (TFA), the number of supplementary analgesic used, and the amount of morphine consumed over the ensuing 24-h period were noted. The OPS score was significantly less in Group I at 0.5, 4, and 8 h (P < 0.05) than in Group II after surgery. The median OPS score recorded over 24 h was 0 for Group I and 2 for Group II, which was significantly different (P < 0.05). The TFA in Group I (12.55 +/- 3.06 h) was significantly (P < 0.05) prolonged compared with Group II (10.62 +/- 3.18 h). The total postoperative morphine consumption in Group I (2.24 +/- 1.4 mg) was significantly (P < 0.05) less than that in Group II (3.34 +/- 2.29 mg). Nevertheless, the incidence of nausea and vomiting was not significantly different between the groups. In this study, we demonstrated that preemptive epidural bupivacaine and small-dose morphine administration is superior to the same mixture given at the conclusion of surgery for pain relief. Implications: This study was performed on two groups of 30 children undergoing hernia repair. Group I received a bupivacaine-morphine mixture caudally before surgery, and Group II received the same drugs caudally at the completion of surgery. Postoperative assessment demonstrated longer and better pain relief in Group I. (Anesth Analg 1998;87:52-6)

Laryngeal mask insertion in children: a rational approach

Background: Various techniques of laryngeal mask airway (LMATM) insertion have been described in adults but only limited clinical trials have been conducted in children despite a varying range in success rate by the recommended method.

Conventional tracheal tubes for intubation through the intubating laryngeal mask airway.

The laryngeal mask airway (LMA)-Fastrach™ silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n = 50), prewarmed PVCT (n = 50), and LAT (n = 50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P < 0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P < 0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P < 0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.

Video assisted fiberoptic intubation for temporomandibular ankylosis

In the era of fiberoptics, securing of the airway under general anesthesia in small children with temporomandibular joint ankylosis without a flexible pediatric fiberoptic endoscope requires considerable skill. We describe the use of an adult flexible fiberoptic laryngoscope with a video camera system to visualize the glottis from one nostril while the tracheal tube was passed from the other nostril.

Effect of needle insertion site on ilioinguinal‐iliohypogastric nerve block in children

Background:  Three different sites of needle insertion have been proposed for ilioinguinal‐iliohypogastric (ILIH) nerve block. This double‐blind study was designed to assess the quality of analgesia produced from these different sites.

Unusual foreign body airway obstruction after laryngeal mask airway insertion.

Airway obstruction during general anesthesia is fairly common. Foreign body causing obstruction of the laryngeal mask airway is uncommon but can confuse the anesthesiologist trying to troubleshoot the cause of inability to ventilate. We present a case of complete airway obstruction with a nematode caught in the vertical bars of the laryngeal mask airway after its insertion.

Flexible Laryngeal Mask Airway for Cleft Palate Surgery in Children: A Randomized Clinical Trial on Efficacy and Safety

Objective: To evaluate the efficacy of a flexible laryngeal mask airway in children undergoing palatoplasty. Design: Prospective, randomized, single-center study. Setting: Jawaharlal Institute of Postgraduate Medical Education and Research. Patients: Sixty-six children (American Society of Anesthesiologists physical status 1 and 2) scheduled to undergo palatoplasty were assigned randomly to an endotracheal intubation group (RAE group, n  =  33) and a flexible laryngeal mask airway group (FLMA group, n  =  33). Main Outcome Measures: Peak airway pressure, inspired and expired tidal volume, end-tidal carbon dioxide, lung compliance, and airway resistance were continuously measured after placement of the assigned airway. The percentage leak around the airway was quantified as the leak fraction. Parametric data between groups were analyzed using an unpaired Students t test and within groups using a one-way analysis of variance. Nonparametric variables were analyzed using the Fisher exact test. Results: In two children, the flexible laryngeal mask airway was displaced from its original position; whereas, one endotrachial tube advanced endobronchially. The leak fraction was significantly higher in the RAE group when compared with that in FLMA group (13.34% ± 13.74% versus 5.96% ± 3.78%, p < .05) until the throat pack was applied. Peak airway pressure and resistance were significantly higher in the RAE group compared with the FLMA group at all time intervals, p < .05. During emergence, frequency of coughing, desaturation, and laryngospasm were increased in the RAE group. Conclusion: A flexible laryngeal airway mask is suitable for maintaining the airway and helps in smooth emergence in children undergoing palatoplasty.

Cardiorespiratory effects of balancing PEEP with intra-abdominal pressures during laparoscopic cholecystectomy.

Background: Applying appropriate positive end-expiratory pressure (PEEP) to corresponding intra-abdominal pressure (IAP) can improve gas exchange during capnoperitoneum without any hemodynamic effects. Materials and Methods: A total of 75 patients were randomly allocated to group 0PEEP (n=25), group 5PEEP (n=25), and group 10PEEP (n=25) according to the level of PEEP, in whom capnoperitoneum was created with IAP of 14, 8, and 14 mm Hg, respectively. Hemodynamic and respiratory parameters were recorded up to 30 minutes after capnoperitoneum. Results: In 0PEEP group, mean end-tidal carbon dioxide demonstrated significant rise 2 minutes after capnoperitoneum and plateaued at about 15 minutes but remained at high level for up to 30 minutes when compared with the 5PEEP and 10PEEP groups (P<0.05). Correspondingly, the mean PaCO2 (48.0±4.1 mm Hg) for the 0PEEP group was higher at 30 minutes when compared with 5PEEP (37.8±2.7 mm Hg) and 10PEEP (37.2±3.9 mm Hg) groups. The oxygenation was better preserved in 5PEEP and 10PEEP groups with significantly higher PaO2/Fio2 ratio. Heart rate, mean arterial pressure, and cardiac output remained stable throughout the study in all the 3 groups. Conclusions: Application of appropriate PEEP corresponding to the IAP helped maintain CO2 elimination and improved oxygenation without any hemodynamic disturbance in patients undergoing laparoscopic cholecystectomy.