Parul Mullick

Comparison of ‘whoosh’ and modified ‘swoosh’ test for identification of the caudal epidural space in children

Background : Caudal analgesia is widely used in pediatric anesthesia practice. The ‘whoosh’ test which uses air to identify the epidural space, has been recommended as a guide for successful needle placement. However, the use of air may be associated with an incidence of neurological complications. The ‘swoosh’ test avoids the injection of air and was originally performed using injection of a local anesthetic solution. A comparison was made between the ‘whoosh’ test and a modified ‘swoosh’ test using saline to identify the caudal epidural space in children.

Difficult laryngoscopy and intubation in the Indian population: An assessment of anatomical and clinical risk factors

Background and Aim: Differences in patient characteristics due to race or ethnicity may influence the incidence of difficult airway. Our purpose was to determine the incidence of difficult laryngoscopy and intubation, as well as the anatomical features and clinical risk factors that influence them, in the Indian population. Methods: In 330 adult patients receiving general anaesthesia with tracheal intubation, airway characteristics and clinical factors were determined and their association with difficult laryngoscopy (Cormack and Lehane grade 3 and 4) was analysed. Intubation Difficulty Scale score was used to identify degree of difficult laryngoscopy. Results: The incidence of difficult laryngoscopy and intubation was 9.7% and 4.5%, respectively. Univariate analysis showed that increasing age and weight, male gender, modified Mallampati class (MMC) 3 and 4 in sitting and supine positions, inter-incisor distance (IID) ≤3.5 cm, thyromental (TMD) and sternomental distance, ratio of height and TMD, short neck, limited mandibular protrusion, decreased range of neck movement, history of snoring, receding mandible and cervical spondylosis were associated with difficult laryngoscopy. Multivariate analysis identified four variables that were independently associated with difficult laryngoscopy: MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring. Conclusions: We found an incidence of 9.7% and 4.5% for difficult laryngoscopy and difficult intubation, respectively, in Indian patients with apparently normal airways. MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring were independently related to difficult laryngoscopy. There was a high incidence (48.5%) of minor difficulty in intubation.

Sternomental distance and sternomental displacement as predictors of difficult laryngoscopy and intubation in adult patients

Background: Several morphometric airway measurements have been used to predict difficult laryngoscopy (DL). This study evaluated sternomental distance (SMD) and sternomental displacement (SMDD, difference between SMD measured in neutral and extended head position), as predictors of DL and difficult intubation (DI). Materials and Methods: We studied 610 adult patients scheduled to receive general anesthesia with tracheal intubation. SMD, SMDD, physical, and airway characteristics were measured. DL (Cormack-Lehane grade 3/4) and DI (assessed by Intubation Difficulty Scale) were evaluated. The optimal cut-off points for SMD and SMDD were identified by using receiver operating characteristic (ROC) analysis. Multivariate logistic regression was used to predict DL and ROC curve was used to assess accuracy on developed regression model. Results: The incidence of DL and DI was 15.4% and 8.3%, respectively. The cut-off values for SMD and SMDD were ≤14.75 cm (sensitivity 66%, specificity 60%) and ≤5.25 cm (sensitivity 70%, specificity 53%), respectively, for predicting DL. The area under the curve (AUC) with 95% confidence interval (CI) for SMD was 0.66 (0.60–0.72) and that for SMDD was 0.687 (0.63–0.74). Multivariate analysis with logistic regression identified inter-incisor distance, neck movement <80°, SMD, SMDD, short neck and history of snoring as predictors and the predictive model so obtained exhibited a higher diagnostic accuracy (AUC: 0.82; 95% CI 0.77–0.86). SMDD, but not SMD, correlated with DI. Conclusions: Both SMD and SMDD provide a rapid, simple, objective test that may help identifying patients at risk of DL. Their predictive value improves considerably when combined with the other predictors identified by logistic regression.

Airway management in patients with burn contractures of the neck

Airway management of patients with burn contracture of the neck (PBC neck) is a challenge to the anesthesiologist. Patient evaluation includes history, physical and airway examination. A safe approach in the airway management of a patient with moderate to severe PBC neck is to secure the airway with the patient awake. The anesthesiologist should have a pre-planned strategy for intubation of the difficult airway. The choices advocated for airway management of such patients include awake fiberoptic-guided intubation, use of intubating laryngeal mask airway, intubation without neuromuscular blocking agents, intubation with neuromuscular blocking agents after testing the ability to ventilate by mask, pre-induction neck scar release under local anesthesia and ketamine or sedation followed by direct laryngoscopy and intubation and video-laryngoscope guided intubation, amongst others. Preparation of the patient includes an explanation of the proposed procedure, sedation, administration of antisialogogues and regional anesthesia of the airway. The various options for intubation of patients with PBC neck, intraoperative concerns and safe extubation are described. Back-up plans, airway rescue strategies and a review of literature on this subject are presented.

A prospective observational study of skin to subarachnoid space depth in the Indian population.

Background and Aims: A pre-puncture estimate of skin to subarachnoid space depth (SSD) may guide spinal needle placement and reduce complications associated with lumbar puncture. Our aim was to determine (1) The SSD in Indian males, females, parturients and the overall population; (2) To derive formulae for predicting SSD and (3) To determine which previously suggested formula best suited our population. Methods: In this prospective, observational study, 800 adult Indian patients undergoing surgery under spinal anaesthesia were divided into three groups: Males (Group M), females (Group F) and parturients (Group PF). SSD was measured after lumbar puncture. The relationship between SSD and patient characteristics was studied and statistical models were used to derive formula for predicting SSD. Statistical analysis included One-way ANOVA with post hoc analysis, forward stepwise multivariate regression analysis and paired t-tests. Results: Mean SSD was 4.71 ± 0.70 cm in the overall population. SSD in adult males (4.81 ± 0.68 cm) was significantly longer than that observed in females (4.55 ± 0.66 cm) but was comparable with SSD in parturients (4.73 ± 0.73 cm). Formula for predicting SSD in the overall population was 2.71 + 0.09 × Body Mass Index (BMI). Stocker′s formula when applied correlated best with the observed SSD. Formulae were derived for the three groups. Conclusions: We found gender-based differences in SSD, with SSD in males being significantly greater than that observed in the female population. SSD correlated with BMI in the parturient and the overall population. Amongst the previously proposed formulae, Stocker′s formula was most accurate in predicting SSD in our population.

Comparison of priming versus slow injection for reducing etomidate-induced myoclonus: a randomized controlled study

Background Etomidate injection is often associated with myoclonus. Etomidate injection technique influences the incidence of myoclonus. This study was designed to clarify which of the two injection techniques—slow injection or priming with etomidate—is more effective in reducing myoclonus. Methods This prospective randomized controlled study was conducted on 189 surgical patients allocated to three study groups. Control group (Group C, n = 63) received 0.3 mg/kg etomidate (induction dose) over 20 s. Priming group (Group P, n = 63) received pretreatment with 0.03 mg/kg etomidate, followed after 1 min by an etomidate induction dose over 20 s. Slow injection group (Group S, n = 63) received etomidate (2 mg/ml) induction dose over 2 min. The patients were observed for occurrence and severity of myoclonus for 3 min from the start of injection of the induction dose. Results The incidence of myoclonus in Group P (38/63 [60.3%], 95% CI: 48.0–71.5) was significantly lower than in Group C (53/63 [84.1%], 95% CI: 72.9–91.3, P = 0.003) and Group S (49/63 [77.8%], 95% CI: 66.0–86.4, P = 0.034). Myoclonus of moderate or severe grade occurred in significantly more patients in Group C (68.3%) than in Group P (36.5%, P < 0.001) and Group S (50.8%, P = 0.046), but the difference between Groups P and S was not significant (P = 0.106). Conclusions Priming is more effective than slow injection in reducing the incidence of myoclonus, but their effects on the severity of myoclonus are comparable.

Green urine: A cause for concern?

128 Journal of Anaesthesiology Clinical Pharmacology | Volume 33 | Issue 1 | January-March 2017 with objects such as oral preoperative medication, prefilled epinephrine syringe, plastic wrapping from a filter, a heat and moisture exchanger, mucus, and an inferior turbinate, or herniation of the cuff have occurred but are all rare events.[5] This is an unusual case of ETT obstruction by tubercular granulation tissue, either an endobronchial focus or a tubercular lymph node eroding through the bronchus. However, in either case, this was asymptomatic and could not be picked up during preanesthetic evaluation. Lin et al. reported a case of acute ETT obstruction caused by unexpected hemoptysis in a patient undergoing surgery for Pott’s spine in prone position, which was relieved just by placing the patient supine (as happened in our case as well).[6] Further, FOB not only has a role in diagnosis of an adverse respiratory event in an intubated patient but also is a useful therapeutic tool as well.[5] An algorithm for the management of airway obstruction is to exclude ventilator, circuit, and ETT as causes step by step followed by considering and treating patient sources of resistance.[7]

Is a minimum dose of atropine in children justified

1. Suleman A, Ikramullah Q, Ahmed F, Khan MY. Indications and complications of bronchoscopy: An experience of 100 patients in a tertiary care hospital. J Postgrad Med Inst 2008;22:210‐4. 2. B o k e r A M . B i l a t e r a l t e n s i o n p n e u m o t h o r a x a n d pneumoperitonium during laser pediatric bronchoscopy — Case report and literature review. Middle East J Anaesthesiol 2008;19:1069‐78. 3. Hussain S, Khan RA, Iqbal M. Tension pneumothorax caused by ventilating rigid bronchoscopy for removal of foreign body. Anaesth Pain Intensive Care 2011;15:57‐9. 4. Levy H, Kallenbach JM, Feldman C, Pincus P, Hurwitz M. Delayed pneumothorax after transbronchial lung biopsy. Thorax 1986;41:647‐8. 5. Du Rand IA, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: Accredited by NICE. Thorax 2013;68 Suppl 1:i1‐44. Access this article online

Consent and the Indian medical practitioner.

Consent is a legal requirement of medical practice and not a procedural formality. Getting a mere signature on a form is no consent. If a patient is rushed into signing consent, without giving sufficient information, the consent may be invalid, despite the signature. Often medical professionals either ignore or are ignorant of the requirements of a valid consent and its legal implications. Instances where either consent was not taken or when an invalid consent was obtained have been a subject matter of judicial scrutiny in several medical malpractice cases. This article highlights the essential principles of consent and the Indian law related to it along with some citations, so that medical practitioners are not only able to safeguard themselves against litigations and unnecessary harassment but can act rightfully.

Alcohol increases bonding between the tracheal tube and the tracheal tube connector.

The tracheal tube (TT) connector needs to be firmly seated in both the TT and the breathing circuit to prevent disconnection during use. However, at times, the connector may loosen from its connection into the TT, increasing the likelihood of disconnection. We report a very simple yet useful technique to circumvent this problem.