Rakhee Goyal

Comparison of size 2 i‐gel supraglottic airway with LMA‐ProSeal™ and LMA‐Classic™ in spontaneously breathing children undergoing elective surgery

Background:  We compared size 2 i‐gel® (Intersurgical Inc.), a relatively new supraglottic airway device for use in spontaneously breathing anesthesized children with two different types of laryngeal mask airway‐ProSeal™ laryngeal mask airway (PLMA) and Classic™ laryngeal mask airway (cLMA) for the ease of insertion, oropharyngeal sealing pressures (OSPs), and air leak. The hemodynamic effects on insertion of device and postoperative adverse effects were also noted.

An evaluation of brachial plexus block using a nerve stimulator versus ultrasound guidance: A randomized controlled trial

Background and Aims: This study was carried out to evaluate the difference in efficacy, safety, and complications of performing brachial plexus nerve blocks by using a nerve locator when compared to ultrasound (US) guidance. Material and Methods: A total of 102 patients undergoing upper limb surgery under supraclavicular brachial plexus blocks were randomly divided into two groups, one with US and the other with nerve stimulator (NS). In Group US, “Titan” Portable US Machine, Sonosite, Inc. Kensington, UK with a 9.0 MHz probe was used to visualize the brachial plexus and 40 ml of 0.25% bupivacaine solution was deposited around the brachial plexus in a graded manner. In Group (NS), the needle was inserted 1-1.5 cm above mid-point of clavicle. Once hand or wrist motion was detected at a current intensity of less than 0.4 mA 40 ml of 0.25% bupivacaine was administered. Onset of sensory and motor block of radial, ulnar and median nerves was recorded at 5-min intervals for 30-min. Block execution time, duration of block (time to first analgesic), inadvertent vascular puncture, and neurological complications were taken as the secondary outcome variables. Results: About 90% patients in US group and 73.1% in NS group, had successful blocks P = 0.028. The onset of block was faster in the Group US as compared to Group NS and this difference was significant (P 0.007) only in the radial nerve territory. The mean duration of the block was longer in Group US, 286.22 ± 42.339 compared to 204.37 ± 28.54-min in Group NS (P < 0.05). Accidental vascular punctures occurred in 7 patients in the NS group and only 1 patient in the US group. Conclusion: Ultrasound guidance for supraclavicular brachial plexus blockade provides a block that is faster in onset, has a better quality and lasts longer when compared with an equal dose delivered by conventional means.

Small is the new big: An overview of newer supraglottic airways for children.

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

Management of a case of ankylosing spondylitis for total hip replacement surgery with the use of ultrasound-assisted central neuraxial blockade.

Management of a case of ankylosing spondylitis can be very challenging when the airway and the central neuraxial blockade, both are difficult. Ultrasound-assisted central neuraxial blockade may lead to predictable success in the field of regional anaesthesia. We present a young patient with severe ankylosing spondylitis where conventional techniques failed and ultrasound helped in successful combined spinal–epidural technique for total hip replacement surgery.

Total intravenous anesthesia with dexmedetomidine and ketamine in children

1 Spencer R, Chang P, Guimaraes A et al. The use of Google Glass for airway assessment and management. Pediatr Anesth 2014; 24: 1009–1011. 2 Muensterer OJ, Lacher M, Zoeller C et al. Google Glass in pediatric surgery: an exploratory study. Int J Surg 2014; 12: 281–289. 3 Albrecht U-V, von Jan U, Kuebler J et al. Google Glass for documentation of medical findings: evaluation in forensic medicine. J Med Internet Res 2014; 16: e53.

Case series: Dexmedetomidine and ketamine for anesthesia in patients with uncorrected congenital cyanotic heart disease presenting for non-cardiac surgery

The number of patients with uncorrected congenital cyanotic heart disease is less but at times some may present for non-cardiac surgery with a high anesthetic risk. Some of these may even be adults with compromised cardiopulmonary physiology posing greater challenges to the anesthesiologist. The authors have used a combination of dexmedetomidine and ketamine for anesthesia for non cardiac surgery in five patients with cyanotic heart disease and right to left shunt (3-Eisenmengers syndrome, 2-Tetralogy of Fallot). The sympathoinhibitory effects of dexmedetomidine were balanced with the cardiostimulatory effects of ketamine, thereby maintaining good cardiovascular stability. The analgesia was good and there was no postoperative agitation. This drug combination was effective and safe for patients with cyanotic heart disease for non cardiac surgeries.

Endotracheal tube cuff leak: Minor product defect or lack of cuff pressure monitoring?

Sir, We report a leak in the pilot inflation line of an endotracheal tube (ETT) resulting in partial loss of tidal volume and increased risk of pulmonary aspiration. It also brings out the significance of intra-operative cuff pressure monitoring. A 60-year-old man, body mass index 30 kg/m2, a case of acute subdural hematoma and subarachnoid hemorrhage with increased intracranial pressure and deteriorating sensorium (Glasgow Coma Scale 6) was admitted to the intensive care unit. The history of preoperative fasting and other co-morbidities was unreliable. After a quick routine pre check for cuff patency of the ETT by inflation and cuff inspection followed by rapid deflation, the patient was intubated with a size 8.0 mm ID ETT (Ruschelit® Safety Clear Plus, Teleflex Medical Sdn Bhd, Kamunting, Malaysia) and the cuff was inflated with air and manually palpated to assess adequacy of its pressure. He was mechanically ventilated and other measures to control intracranial pressure were initiated. The patient was shifted to the operation theatre for an emergency craniotomy. Nitrous oxide and oxygen 60:40 sub-minimum alveolar concentration isoflurane and propofol infusion 50–100 μg/kg/min were used for maintenance. During the period of approximately 45 min from the time of intubation to the beginning of surgery, a loss of tidal volume was noticed. A check laryngoscopy ruled out tube migration. The cuff appeared lax and was re-inflated but the events repeated in the same manner again. The ETT was changed with another one and examined for obvious leaks. This ETT was then immersed in a bowl of water and the cuff inflated with an aneroid manometer (Mallinckrodt Medical Athlone, Ireland). Multiple air bubbles were noticed to appear at higher cuff pressures (>100 cm H2O), but as the pressure was reduced gradually, their size, number and speed lowered, and the bubbling stopped at the cuff pressure below 40 cm H2O. The leak was detected from the point where the transparent pilot inflation line entered the blue stem of the pilot cuff [shown by the arrow in [Figure 1]. The product defect was communicated to the manufacturers. Figure 1 Arrow showing air bubbles in water at higher cuff pressure; inset showing pilot inflation line entering the pilot cuff with the arrow showing the probable leak site A leak from any part of the ETT assembly can be alarming, more so in cases of difficult airway or in surgeries involving limited access to airway (non-supine position and head and neck surgery) where a change of tube may not be possible intra-operatively.[1] It may cause increased risk of pulmonary aspiration and inadequate ventilation (inadequate depth of anesthesia, intra-operative awareness, and hemodynamic instability). The leaks in the cuffs and the various ways to tackle them are well known but a defect in the pilot inflation line has been sparsely reported in the literature.[2] Various methods using continuous inflation with air, saline or lignocaine jelly or use of three-way stopcock to maintain cuff pressure are documented, though most of them are no more than a rescue measure.[1] This report alarms the caregiver to be vigilant at all times as even minor leaks from unusual sites may have clinically significant and long-standing consequences. Besides, it also reinforces the need for objective monitoring of the ETT cuff pressure, especially in the presence of nitrous oxide (which readily diffuses into the cuff and increases its pressure). Manual assessment of cuff pressure may be grossly incorrect and may underestimate pressures.[3] The pressure can be high as to manifest minor leaks (even when high volume low-pressure cuffs are used), as seen in the case reported. The effects of the leak due to the minor product defect could have been avoided if the cuff pressure was measured and maintained within the safe range of 20–30 cm of H2O.[4]

Adductor canal block for post-operative analgesia after simultaneous bilateral total knee replacement: A randomised controlled trial to study the effect of addition of dexmedetomidine to ropivacaine

Background and Aims: Knee replacement surgery causes tremendous post-operative pain and adductor canal block (ACB) is used for post-operative analgesia. This is a randomised, controlled, three-arm parallel group study using different doses of dexmedetomidine added to ropiavcaine for ACB. Methods: A total of 150 patients aged 18–75 years, scheduled for simultaneous bilateral total knee replacement, received ultrasound-guided ACB. They were randomised into three groups -Group A received ACB with plain ropivacaine; Groups B and C received ACB with ropivacaine and addition of dexmedetomidine 0.25 μg/kg and 0.50 μg/kg, respectively, on each side of ACB. The primary outcome was the duration of analgesia. Total opioid consumption, success of early ambulation, and level of patient satisfaction were also assessed. Results: The patient characteristics and block success rates were comparable in all groups. Group C patients had longer duration of analgesia (Group C 18.4 h ± 7.4; Group B 14.6 ± 7.1; Group A 10.8 ± 7; P < 0.001); lesser tramadol consumption (Group C 43.8 mg ± 53.2; Group B 76.4 ± 49.6; Group A 93.9 mg ± 58.3; P < 0.001) and lesser pain on movement (P < 0.001). The patients in Group B and C walked more steps than in Group A (P < 0.002). The level of patient satisfaction was highest in Group C (P < 0.001). Conclusions: The addition of dexmedetomidine to ropivacaine resulted in longer duration of analgesia after adductor canal block for simultaneous bilateral total knee replacement surgery.

Pulse contour analysis guided management of a case of puerperal uterine inversion and hemorrhagic shock – ‘Giving what it takes’

Acute uterine inversion is difficult to diagnose and is associated with significant blood loss and shock out of proportion to the blood loss. Pulse contour analysis guided (Flotrac™/Vigileo™-system Edwards Lifesciences, Irvine, CA, USA) monitoring is a new tool which provides a precise and invaluable insight into the hemodynamics of such delicately poised patients.

Dexmedetomidine and ketamine combination for a patient with xeroderma pigmentosa

Patients of xeroderma pigmentosa (XP) have increased sensitivity to ultraviolet light and a defective nucleotide excision repair (NER) mechanism in their DNA. Several types of neurological, dermatological, and ophthalmological complications are common in these patients. There is increasing evidence of delayed recovery and worsening of neurological status following general anesthesia in such patients. Some reports have shown uneventful conduct of total intravenous anesthesia in patients of XP. The authors report a case of XP in a young girl for surgery, previously anesthetized with delayed recovery, managed successfully with a combination of intravenous dexmedetomidine and ketamine.