Rohit Varshney

Comparison of three supraglottic devices in anesthetised paralyzed children undergoing elective surgery

Context: The newest variation of the i-gel supraglottic airway is a pediatric version. Aims: This study was designed to investigate the usefulness of the size 2 i-gel compared with the ProSeal laryngeal mask airway (PLMA) and classic laryngeal mask airway (cLMA) of the same size in anesthetized, paralyzed children. Settings and design: A prospective, randomized, single-blinded study was conducted in a tertiary care teaching hospital. Methods: Ninety ASA grade I–II patients undergoing lower abdominal, inguinal and orthopedic surgery were included in this prospective study. The patients were randomly assigned to the i-gel, PLMA and cLMA groups (30 patients in each group). Size 2 supraglottic airway was inserted according to the assigned group. We assessed ease of insertion, hemodynamic data, oropharyngeal sealing pressure and postoperative complications. Results: There were no differences in the demographic and hemodynamic data among the three groups. The airway leak pressure of the i-gel group (27.1±2.6 cmH2O) was significantly higher than that of the PLMA group (22.73±1.2 cmH2O) and the cLMA group (23.63±2.3 cmH2O). The success rates for first attempt of insertion were similar among the three devices. There were no differences in the incidence of postoperative airway trauma, sore throat or hoarse cry in the three groups. Conclusions: Hemodynamic parameters, ease of insertion and postoperative complications were comparable among the i-gel, PLMA and cLMA groups, but airway sealing pressure was significantly higher in the i-gel group.

A prospective, randomized, Single-blinded, comparative study of Classic Laryngeal Mask Airway and ProSeal Laryngeal Mask Airway in pediatric patients.

Context: ProSeal Laryngeal Mask Airway (PLMA) is extensively being used in pediatric anesthesia. Aims: To evaluate the efficacy of PLMA as compared to Classic Laryngeal Mask Airway (CLMA) for airway maintenance in pediatric patients. Settings and Design: A prospective, randomized, Single-blinded study was conducted in a tertiary care teaching hospital. Materials and Methods: Sixty ASA I and II children were included. Patients were randomized to either size 2 PLMA or size 2 CLMA groups. Parameters noted were time for insertion, number of attempts, airway sealing pressure, blood pressures (systolic, diastolic, and mean), pulse rate, end-tidal carbon dioxide (EtCO2), peripheral oxygen saturation (SpO2), and postoperative change in abdominal circumference, and airway trauma. Statistical analysis used: Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the chi-square (χ2) test. Unless otherwise stated, data are presented as mean (SD). Significance was taken as P < 0.05. Results: There was no statistical difference between the two groups for the success rates at the first attempt of insertion, airway sealing pressure, hemodynamic responses, SpO2, EtCO2 and postoperative changes in abdominal circumference. Patients in the PLMA group had longer time of insertion and higher incidence of airway trauma. Conclusions: The PLMA and the CLMA were comparable for hemodynamic and ventilatory parameters and change in abdominal circumference; however, the time taken for insertion and airway trauma was more with PLMA.

Anaesthetic challenges in a patient presenting with huge neck teratoma

Paediatric airway management is a great challenge even for an experienced anaesthesiologist. Difficult airway in huge cervical teratoma further exaggerates the complexity. This case report is intended at describing the intubation difficulties that were confronted during the airway management of a three year old girl presenting with huge neck teratoma and respiratory distress. This patient was successfully intubated with uncuffed endotracheal tubes in second attempt under inhalational anaesthesia with halothane and spontaneous ventilation. This case exemplifies the importance of careful preoperative workup of an anticipated difficult airway in paediatric patients with neck swelling to minimize any perioperative complications.

Supraorbital Foramen - Morphometric Study and Clinical Implications in Adult Indian Skulls.

Introduction: Supraorbital foramen is an important site for various surgical and anesthetic procedures. Accurate localization of the foramen holds the key to success, although racial variations exist in various population groups. The study included the morphometry of supraorbital foramen and its location with respect to nearby anatomical landmarks. Methods: A total of 100 dry skulls (60 male and 40 female) were collected and observed for the study. Various parameters in the sagittal and transverse planes were noted from supraorbital foramen on both sides, together with its vertical and horizontal dimensions. In addition, the location of supraorbital foramen with respect to midline and frontozygomatic suture were noted. Results: The study of 100 adult skulls revealed that the SON (71% on right and 70% on left) was found more frequently than the SOF (29% on right and 30% on left).The distance between centre of SOF/SON and midline was found to be statistically signifIcant on right and left sides. Conclusion: This study makes possible the identifi cation of exact position of supraorbital foramen and also discuss its racial variation.

Morphometry of stylomastoid foramen and its clinical application in facial nerve block

Background: Stylomastoid foramen is an important site for Nadbath facial nerve block. Exact localization of foramen holds the key to success, thus decreasing the complications. Wide racial variation exists in position of stylomastoid foramen in different population groups. Aim: The aim was to study the morphometry of stylomastoid foramen and its location with respect to nearby anatomical landmarks. Materials and Methods: A total of 100 dry skulls (60 male and 40 female) were studied to locate the position of center of stylomastoid foramen (CSMF) with respect to tip and anterior border of the mastoid process and jugular foramen (JF). Along with this angle between antero-posterior line passing through the tip of the mastoid process and line joining the tip with stylomastoid foramen was also measured. Result: In 83.51% sides of skulls, the most common position of foramen was found to be anterior to the line passing through anterior border of the mastoid process. The mean distance of center of foramen from the tip of the mastoid process was 15.26 ± 1.4 mm on right and 14.32 ± 1.8 on the left side (P < 0.001) and from JF was 12.28 ± 1.9 mm and 12.96 ± 2.1 mm on the right and left sides, respectively (P < 0.01). The position of CSMF was found at an angle of 66.57° ± 2.6° and 65.96° ± 1.8° on the right and left sides, respectively from the tip of the mastoid process. Conclusion: This study makes possible the identification of the exact position of stylomastoid foramen and its application in facial nerve block.

A cadaveric study comparing the three approaches for ulnar nerve block at wrist.

Background: Ulnar nerve blockade as a component of wrist block is a promising technique for adequate anesthesia and analgesia for different surgeries of the hand. Due to anatomical variations in the location of ulnar nerve under the flexor carpi ulnaris (FCU) a technique with good results and minimal complications are required. Aim: The aim of the following study is to compare the three techniques (volar, transtendinous volar [TTV] and ulnar) for ulnar nerve block at the wrist in human cadaveric wrists. Materials and Methods: Our study was conducted using 40 cadaver wrists. After inserting standard hypodermic needles by three techniques for ulnar nerve blockade at the wrist, a detailed dissection of FCU was done. The mean distance from the tip of the needle to ulnar artery/nerve and number of instances in which the ulnar artery/nerve pierced were observed. Results: Inter-group statistical significance was observed in measurement of the mean distance (mm) from the tip of the needle to the ulnar artery (volar [0.92 ± 0.11], TTV [3.96 ± 0.14] and ulnar [7.14 ± 0.08] approaches) and ulnar nerve (volar/TTV/ulnar approaches were 0.71 ± 0.12/3.61 ± 0.10/6.31 ± 0.49, respectively) (P = 0.001). Inadvertent intra-arterial/intraneural injections was seen with volar approach in 14 (35%) and 16 (40%) of the cadaveric wrists respectively, statistically significant with transtendinous and ulnar techniques of ulnar nerve block. Conclusion: TTV approach could be a better technique of choice for ulnar nerve blockade at the wrist because of its ease to practice, safer profile and minimum chances of inadvertent intra-arterial/intraneural injection with adequate anesthesia/analgesia.

Unsafe abortion: Addressing the anaesthetic confronts

Unsafe abortion has a global incidence of about 20 million cases annually, out of which 97% cases are reported from developing nations. There are many reports showing the occurrence of bowel or uterine perforation in such instances, but most of them have concentrated upon surgical or obstetric complications. We report a case of unsafe abortion with ruptured uterus, intra-abdominal foetus, and bowel infarction that developed intraoperative cardiac arrest during the emergency laparotomy. This case highlights anaesthetic challenges in managing such critically ill-patients.