Sumalatha Radhakrishna Shetty

The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit.

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in Paediatrics.

The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus). Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA). Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H 2 O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD) or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO 2 should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.

Paraplegia following caudal block in a child with Burkitt's lymphoma.

A juvenile form of glycerol kinase deficiency with episodic vomiting, acidemia, and stupor. J Pediatr 1984; 104: 736–739. 4 Mak TWL, Wong LM, Wong SN et al. Glycerol kinase deficiency presenting with hypodipsia, osmotic diuresis and severe hypernatremia. J Inherit Metab Dis 2005; 28: 1159–1161. 5 McCabe ER, Fennessey PV, Guggenheim MA et al. Human glycerol kinase deficiency with hyperglycerolemia and glyceroluria. Biochem Biophys Res Commun 1977; 78: 1327– 1333. 6 Krane EJ, Rhodes ET, Neely EK et al. Essentials of endocrinology: perioperative management of adrenal insufficiency. In: Cote CJ, Lerman J, Todres ID, eds. A Practice of Anesthesia for Infants and Children, 4th edn. Philadelphia: Saunders Elsevier, 2009: 535–556.

Evaluation of the Truview™ EVO2 laryngoscope for nasotracheal intubation

Background: The Truview™ EVO2 laryngoscope, with its unique optical lens system and blade tip angulation, has proved its usefulness in providing adequate laryngeal exposure and intubation via the oral route. However, the same has not been evaluated for nasotracheal intubation. Aim: We evaluated the suitability of the Truview™ EVO2 laryngoscope for nasotracheal intubation. Methods: Fifty ASA grade I and II elective surgical patients were studied. Patients aged below 15 years or having difficult airway were excluded. Under standard anesthesia protocol, nasotracheal intubation was performed using a Truview™ EVO2 laryngoscope and, in cases of inability to complete intubation in three attempts, the Macintosh laryngoscope was used. Time taken for intubation, use of Magills forceps and need for optimization maneuvers were noted. The primary outcome was percentage of successful intubation, while hemodynamic changes and duration of intubation were taken as secondary outcomes. Results: Majority (94%) could be intubated successfully with the Truview™ EVO2 laryngoscope. Average time taken for intubation was 50.1 s. The hemodynamic changes were not clinically significant. Regression analysis revealed lack of association between duration of intubation and hemodynamic changes. There were no serious complications. Conclusion: The Truview™ EVO2 laryngoscope is a useful tool in performing nasotracheal intubation, ensuring a high level of success rate among patients with normal airway anatomy.

Republication: All India difficult airway association 2016 guidelines for tracheal intubation in the intensive care unit

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often lifesaving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with under evaluation of the airway and suboptimal response to preoxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; Wherever, robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the (AIDAA) and Indian Society of Anaesthesiologists. Noninvasive positive pressure ventilation for preoxygenation provides adequate oxygen stores during TI for patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnea before hypoxemia sets in. High flow nasal cannula oxygenation at 60–70 L/min may also increase safety during intubation of critically ill patients. Stable hemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

Comparison between two doses of dexmedetomidine added to bupivacaine for caudal analgesia in paediatric infraumbilical surgeries

Background and Aims: Caudal block (CB) with adjuvants is routinely used in children for anaesthesia. We evaluated the efficacy of the α2 adrenergic agonist, dexmedetomidine at two different doses as an adjuvant to bupivacaine in CB. Methods: This study was conducted on ninety children. Control group BD0 received 0.25% bupivacaine 1 ml/kg, whereas, the study groups BD1 and BD2 received 1 μg/kg and 2 μg/kg dexmedetomidine, respectively, with 0.25% bupivacaine 1 ml/kg as a single shot CB. Adequacy of the block, haemodynamic changes, duration of analgesia and side effects were compared. Analysis of Variance was used for between-group comparisons of numerical variables. Students t-test and Mann–Whitney U-test were used for quantitative data. Results: The demography was comparable. Anal sphincter 5 min after administration of the CB was relaxed in 89.3%, 82.1% and 75% of cases in BD0, BD1 and BD2 groups, respectively. The sphincter was relaxed at the end of surgery in all the cases. Comparable haemodynamics was noted with significantly prolonged duration of analgesia in the groups BD1 (964.2 ± 309 min) and BD2 (1152.6 ± 380.4 min) compared to control (444.6 ± 179.4 min). While no complications were encountered in groups BD0 and BD1, bradycardia was observed in four cases of BD2 group with accompanied hypotension in one of them. Conclusion: Dexmedetomidine as an adjuvant to bupivacaine improves the quality of CB, provides good operating conditions and increases the duration of post-operative analgesia. We conclude that 1 μg/kg is as effective as 2 μg/kg of dexmedetomidine and with a better safety profile.

All India Difficult Airway Association 2016 guidelines for the management of anticipated difficult extubation

Extubation has an important role in optimal patient recovery in the perioperative period. The All India Difficult Airway Association (AIDAA) reiterates that extubation is as important as intubation and requires proper planning. AIDAA has formulated an algorithm based on the current evidence, member survey and expert opinion to incorporate all patients of difficult extubation for a successful extubation. The algorithm is not designed for a routine extubation in a normal airway without any associated comorbidity. Extubation remains an elective procedure, and hence, patient assessment including concerns related to airway needs to be done and an extubation strategy must be planned before extubation. Extubation planning would broadly be dependent on preventing reflex responses (haemodynamic and cardiovascular), presence of difficult airway at initial airway management, delayed recovery after the surgical intervention or airway difficulty due to pre-existing diseases. At times, maintaining a patent airway may become difficult either due to direct handling during initial airway management or due to surgical intervention. This also mandates a careful planning before extubation to avoid extubation failure. Certain long-standing diseases such as goitre or presence of obesity and obstructive sleep apnoea may have increased chances of airway collapse. These patients require planned extubation strategies for extubation. This would avoid airway collapse leading to airway obstruction and its sequelae. AIDAA suggests that the extubation plan would be based on assessment of the airway. Patients requiring suppression of haemodynamic responses would require awake extubation with pharmacological attenuation or extubation under deep anaesthesia using supraglottic devices as bridge. Patients with difficult airway (before surgery or after surgical intervention) or delayed recovery or difficulty due to pre-existing diseases would require step-wise approach. Oxygen supplementation should continue throughout the extubation procedure. A systematic approach as briefed in the algorithm needs to be complemented with good clinical judgement for an uneventful extubation.

Post-operative pulmonary embolism: Transthoracic echocardiography as a diagnostic tool

Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014 362 Peri-operative Anaesthetic management of patients with hypertrophic cardiomyopathy for noncardiac surgery: A case series. Ann Card Anaesth 2010;13:253-6. 2. Ahmed A, Zaidi RA, Hoda MQ, Ullah H. Anaesthetic management of a patient with hypertrophic obstructive cardiomyopathy undergoing modified radical mastectomy. Middle East J Anaesthesiol 2010;20:739-42. 3. Al-Mustafa MM, Abu-Halaweh SA, Aloweidi AS, Murshidi MM, Ammari BA, Awwad ZM, et al. Effect of dexmedetomidine added to spinal bupivacaine for urological procedures. Saudi Med J 2009;30:365-70. 4. Kanazi GE, Aouad MT, Jabbour-Khoury SI, Al Jazzar MD, Alameddine MM, Al-Yaman R, et al. Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block. Acta Anaesthesiol Scand 2006;50:222-7. 5. Noguchi T, Yosuke S. Spinal Anaesthesia with small dose of 0.5% isobaric bupivacaine for two patients with hypertrophic obstructive cardiomyopathy (HOCM). J Clin Anesth 2001;25:37-9.

Confluence of central venous catheters showing radiological relationship with carina

I read with great interest the article by Umesh et al. [1] on utilizing carina as a radiological landmark for detection of accidental arterial placement of a central venous catheter (CVC). Although ultrasound guided vascular access is desirable and is quoted as gold standard for central venous access, not all hospitals, intensive care units and departments are equipped with the device. Therefore, clinicians will have to rely on other ways of confirming the correct placement of CVC. Among the existing methods for identifying the arterial placement of a central venous catheter, the radiological method described by Umesh et al. seems to be the simple, convenient and reliable technique. I wish to report one incident that happened in our intensive care unit. A middle aged patient had a CVC secured through right subclavian vein in place for parenteral nutrition. However, as we suspected possibility of infection in the CVC, a decision was taken to replace the Shetty SR. Confluence of central venous catheters showing radiological relationship with carina. J Clin Monit Comput 2011; 25:147–148