Naveed Siddiqui

Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial.

Background: Misidentification of the cricothyroid membrane in a “cannot intubate-cannot oxygenate” situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy. Methods: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex® device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1—easy = visual landmarks; 2—moderate = requires light palpation of landmarks; 3—difficult = requires deep palpation of landmarks; and 4—impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time. Results: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult–impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001). Conclusion: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Experience is not enough: repeated breaches in epidural anesthesia aseptic technique by novice operators despite improved skill.

Background:Invasive procedures such as epidural anesthesia carry risks for complications such as erroneous placement arising from inadequate manual skills and infection secondary to breaches in aseptic technique. Although it is assumed that improvement in aseptic technique parallels improved dexterity, this assertion remains unproven. The aim of this study was to determine whether increased proficiency in the manual skills for epidural anesthesia is associated with improved aseptic technique. Methods:Second-year anesthesia residents were repeatedly videotaped performing epidural anesthesia over 6-month periods. Three independent examiners blinded to the level of training of the residents evaluated the procedures for manual skills and aseptic technique. Each procedure was graded using a manual skills checklist, a global rating scale, and an aseptic technique checklist. The main outcome measures were the scores for these three tools. Results:Thirty-five sessions were videotaped over 1 yr. Interrater reliability was nearly perfect. A strong positive association was found between increased experience and manual skills, as reflected by the scores achieved on both the manual skills checklist and the global rating scale. In contrast, a nonsignificant or very weak correlation was found between the aseptic technique checklist total scores and the number of epidurals performed. Conclusion:Manual skills for invasive procedures improved with increasing experience, but aseptic technique did not, despite formal teaching. These findings reflect major gaps in the understanding and teaching of the principles of aseptic technique, most likely due to lack of structured training. Educational initiatives are needed to correct these teaching gaps.

Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour.

Success of cricothyroidotomy depends on accurate identification of anatomical neck landmarks. Anaesthetists palpated the cricothyroid membrane of 28 obese and 28 non‐obese women in labour (cut‐off BMI 30 kg.m−2) and marked the entry point for device insertion with an ultraviolet invisible pen. Ultrasonography was used to mark the midpoint of the cricothyroid membrane and the distance between the two marks was measured. The median (IQR [range]) distance between the two marks was significantly greater in the obese than the non‐obese patients (5 (2–9.5 [0–34]) mm vs 1.8 (0.1–6 [0–15]) mm, respectively; p = 0.02). The cricothyroid membrane was accurately identified with digital palpation in only 39% (11/28) of obese compared with 71% (20/28) of non‐obese patients (p = 0.03). Increased neck circumference in obese patients was significantly associated with inaccuracy in locating the cricothyroid membrane. Percutaneous identification of the cricothyroid membrane in obese women in labour was poor. Pre‐procedural ultrasound may help improved the identification of neck landmarks for cricothyroidotomy.

Heart rate/blood pressure response and airway morbidity following tracheal intubation with direct laryngoscopy, GlideScope and Trachlight: a randomized control trial

Background and objective Haemodynamic response to tracheal intubation might be detrimental in high-risk patients. Minimizing oropharyngo-laryngeal stimulation or avoiding laryngoscopy may attenuate this response. We hypothesized that intubations performed with GlideScope or Trachlight would generate a lesser haemodynamic response than the conventional method of direct laryngoscopy. The objective of this study was to compare the haemodynamic response following tracheal intubation, using three different techniques of intubation. We also examined postoperative airway morbidities as our secondary outcome. Methods This was a prospective randomized control trial, conducted at Mount Sinai Hospital of Toronto. After Ethics Board approval, 60 adult ASA status I and II patients, scheduled for elective surgery requiring general anaesthesia with orotracheal intubation, were randomly allocated into three groups. Intubation was performed by a single experienced anaesthesiologist, using direct laryngoscopy, GlideScope or Trachlight. The haemodynamic variables were measured noninvasively at specific time intervals. We also recorded the number of attempts and total time for intubation. Postoperative airway symptoms following surgery were assessed using a questionnaire. Results There was no significant difference in blood pressure and heart rate between the groups. Direct laryngoscopy intubation times were significantly lower than those of the other techniques (both P < 0.0001). The occurrence of sore-throat symptoms in recovery was significantly higher in the Trachlight group (P = 0.0033). Conclusion There was no benefit of using any of the three intubation techniques for attenuation of haemodynamic changes. There was a higher incidence of airway symptoms associated with Trachlight intubation.

Bedside Gastric Ultrasonography in Term Pregnant Women Before Elective Cesarean Delivery: A Prospective Cohort Study.

BACKGROUND:Bedside gastric ultrasound can reliably assess gastric contents in the perioperative period. We aimed to describe the qualitative and quantitative ultrasound assessment of the gastric antrum in fasted pregnant women at term. METHODS:Pregnant women were examined after a minimum period of overnight fasting (solid food, 6 hours; clear liquids, 2 hours) before their scheduled cesarean delivery. A standardized ultrasound examination of the gastric antrum was performed. Based on the qualitative assessment in the supine and right lateral decubitus positions, women were classified using a 3-point grading system (grade 0, no fluid; grade 1, fluid seen in right lateral decubitus position only; and grade 2, fluid seen in the both supine and right lateral decubitus positions). A quantitative assessment of the antral cross-sectional area (CSA) was performed using still images in the right lateral decubitus position. RESULTS:One hundred three women were included in the study; 53 of 103 exhibited grade 0 and 49 of 103 exhibited grade 1 antrum. One woman presented a grade 2 antrum (1/103 = 0.97%; 95% confidence interval [CI], 0.05%–6.06%). Overall, 95% of fasting subjects presented with an antral CSA ⩽9.6 cm2 (95% CI, 8.6–10.3 cm2) in the right lateral decubitus position (median [interquartile range] = 4.5 [3.2] cm2), corresponding to an estimated gastric volume of ⩽117 mL (95% CI, 108–127 mL) or ⩽1.5 mL/kg (95% CI, 1.3–1.7 mL/kg). CONCLUSIONS:All women but one presented with antral CSA compatible with residual gastric fluid. The qualitative 3-point grading system may be used to assess individual risk of perioperative gastric content aspiration. Our results suggest that an antral CSA of 10.3 cm2 in the right lateral decubitus position more accurately describes the upper limit of normal findings in the fasted pregnant patient at term.

Effect of a Preoperative Gabapentin on Postoperative Analgesia in Patients with Inflammatory Bowel Disease Following Major Bowel Surgery: A Randomized, Placebo-Controlled Trial

Postoperative pain management for patients with inflammatory bowel disease (IBD) can be challenging. These patients have a high tolerance to pain medication, and relative contraindications to the use of epidural analgesia, limiting the pain management options. We evaluated the effect of a single preoperative gabapentin dose on opioid consumption for patients with IBD undergoing abdominal surgery. Secondary outcomes were postoperative pain scores, opioid‐related side effects, and patients length of hospital stay.

Diagnosis and treatment of obstructive sleep apnea during pregnancy.

Purpose of review This review aims to provide an update on recent advances in the diagnosis and treatment of obstructive sleep apnea (OSA) during pregnancy and its effect on maternal and fetal outcomes. Recent findings Current OSA screening tools may not perform well in this population. There are some pieces of evidence linking poorer maternal and neonatal outcome with pregnant patients having OSA. At present, there are inadequate data on which to base fetal or maternal parameters for treatment of OSA, and no evidence that treatment in the short-term impacts maternal or neonatal outcomes. Summary Further research is needed to help in the detection and treatment of OSA in pregnancy.

An estimation for an appropriate end time for an intraoperative intravenous lidocaine infusion in bowel surgery: a comparative meta-analysis

STUDY OBJECTIVE There exists no commonly accepted regimen for an intravenous lidocaine infusion (IVLI). This study aims to determine an appropriate end time for an IVLI during bowel surgery. DESIGN A systematic search for randomized controlled trials assessing IVLI for bowel surgery was conducted using Ovid MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, Google Scholar, hand-searching references, and grey literature. Data were pooled for studies that stopped IVLI ≤60 minutes (intraoperative IVLI) after skin closure and where IVLI continued >60 minutes after surgery (postoperative continued IVLI). Quantitative analysis was done using the random-effects model. MAIN RESULTS Seven studies (n = 362) were identified after the systematic search. Three studies (n = 160) and 4 studies (n = 202) used an intraoperative and postoperative continued IVLI, respectively. An intraoperative IVLI significantly reduced pain scores at rest for 48 hours (standardized mean difference on a 0-10 scale, -1.24; 95% confidence interval, -1.93 to -0.56) and 72 hours (standardized mean difference, -1.12; 95% confidence interval, -1.79 to -0.44) compared with postoperative IVLI (test for interaction: P < .001 and P = .003, respectively). Although intraoperative IVLI reduced 24-hour pain scores on movement, this was not statistically different than pain scores in the postoperative IVLI group (test of interaction: P = 0.68). There were no differences between intraoperative IVLI and postoperative IVLI for postoperative in-hospital nausea, vomiting, time to bowel movement, and length of hospital stay. CONCLUSION Continuing an IVLI beyond 60 minutes after surgery has no added analgesic or gastrointestinal benefit. Further research is needed to clarify an optimal IVLI regimen and end time.

A randomized double-blind comparison of a morphine-fentanyl combination vs. morphine alone for patient-controlled analgesia following bowel surgery

▪ Abstract:  An ideal patient‐controlled analgesia (PCA) opioid would have both a rapid onset and a long duration of action, attributes, which are not available in currently existing opioids including morphine, the most widely used agent. A mixture of rapid onset and long‐acting opioids may potentially achieve both these qualities. In a randomized, double‐blind study, we compared a fentanyl–morphine combination with morphine alone for PCA, in 54 patients undergoing bowel surgery. The combination solution was prepared according to a 1:75 fentanyl to morphine potency ratio. The mixture contained fentanyl 13.33 μg/mL and morphine 1 mg/mL. The morphine alone solution contained 2 mg/mL. Patients were randomly allocated to one of the regimens and were then evaluated 4 times during the first 48 hours following surgery. Time to effect, visual analog pain scores, opioid consumption, demands, deliveries, and side effects on an opioid‐related symptom distress scale were recorded. Groups were well matched for age, weight, and sex. There were no significant differences between groups in time to effect, PCA usage, pain scores or side effects other than the occurrence of nausea, which was lower for the combination group in 1 visit. Further studies are needed to explore the potential of different potency ratios and opioid combinations to achieve rapid and long‐lasting pain control. ▪

Intraperitoneal Instillation of Lidocaine Improves Postoperative Analgesia at Cesarean Delivery: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND: Cesarean delivery is a commonly performed procedure worldwide. Despite improvements in balanced multimodal analgesia, there remains a proportion of women for whom postoperative pain relief and patient satisfaction are still inadequate. Intraperitoneal instillation of local anesthetic has been shown to be effective in reducing postoperative pain after abdominal surgery. We sought to investigate the effect of intraperitoneal instillation of lidocaine on postcesarean delivery pain as part of a multimodal analgesia regimen. METHODS: We studied women scheduled for elective cesarean delivery under spinal anesthesia. Spinal anesthesia was performed with 0.75% hyperbaric bupivacaine, fentanyl, and morphine. At the end of the cesarean delivery, immediately before parietal peritoneum or fascia closure, patients were randomized to receive either lidocaine (20 mL 2% lidocaine with epinephrine) or placebo (20 mL normal saline) instilled into the peritoneal cavity. The primary outcome was pain score on movement at 24 hours. Secondary outcomes were pain score at rest and on movement at 2, 24, and 48 hours; maternal satisfaction score; analgesic consumption; incidence of nausea, vomiting, and itching; and return of bowel function. RESULTS: Two hundred four women were recruited. Baseline characteristics were similar between the lidocaine and placebo groups. Pain scores at 24 hours postcesarean delivery on movement (parameter estimate 0.02 [95% confidence interval {CI} −0.14 to 0.18]; P = .823) and at rest (parameter estimate 0.00 [95% CI −0.32 to 0.33]; P = .986) were similar in both groups. Pain scores at 2 hours postcesarean delivery on movement (parameter estimate −0.58 [95% CI −0.90 to −0.26]; P = .001) and at rest (parameter estimate −1.00 [95% CI −1.57 to −0.43]; P = .001) were lower in the lidocaine group. Subgroup analysis of patients with peritoneum closure revealed significantly lower pain scores at 24 hours on movement (parameter estimate −0.33 [95% CI −0.64 to −0.03]; P = .032) in the lidocaine group. The number of women requesting postoperative opioids for breakthrough pain was significantly lower in the lidocaine group compared with that of the placebo (40 [40%] vs 61 [65%], respectively, relative risk 0.59 [95% CI 0.43–0.81]; P = 0.001). CONCLUSIONS: The use of intraperitoneal instillation of lidocaine improves early postoperative pain management after cesarean delivery. Furthermore, it reduces the number of women requesting systemic opioids in the immediate postpartum period. Women undergoing peritoneal closure may particularly benefit from this intervention.