Tanvir Samra

Comparison of supraglottic devices i-gel ® and LMA Fastrach ® as conduit for endotracheal intubation

Background and Aims: i-gel®, a recently introduced supraglottic airway device (SAD) has been claimed to be an efficient supraglottic airway. It can also be used as a conduit for endotracheal intubation. However, LMA Fastrach® frequently used for this purpose; hence in this randomized study, success rate of blind tracheal intubation through two different SADs i-gel® and LMA Fastrach® was evaluated. The complications if any were also studied. Methods: A total of 100 patients undergoing elective surgery under general anaesthesia were randomised in two groups comprising of 50 patients each to tracheal intubation using either i-gel (I group) or LMA Fastrach (F group). After induction of anaesthesia SAD was inserted and on achieving adequate ventilation with the device, blind tracheal intubation was attempted through the SAD. Success at first-attempt and overall tracheal intubation success rates were evaluated, and tracheal intubation time was measured. Data were analysed using IBM SPSS Statistics 20.0 software (Statistical Package for Social Sciences by International Business Machines Corporation). P < 0.05 was considered as statistically significant. Results: There was no difference in the incidence of adequate ventilation with either of the SAD. The success rate of tracheal intubation in first attempt was 66% in Group I and 74% in Group F, while overall success rate of tracheal intubation was 82% in Group I when compared to 96% in Group F. Time taken for successful tracheal intubation through LMA Fastrach was lesser (20.96 s) when compared to i-gel (24.04 s). Complication rates were statistically similar in both the groups. Conclusion: i-gel® is a better device for rescue ventilation due to its quick insertion but an inferior intubating device in comparison to LMA Fastrach®.

Peri-operative concerns in a patient with thyroid storm secondary to molar pregnancy

Awareness of the presence of thyroid function abnormalities in patients with molar pregnancy is important for its prompt diagnosis and management. We report the development of thyroid storm in the immediate post-operative period in a 25-year-old female who underwent evacuation of her molar pregnancy under saddle spinal block after being controlled for her thyrotoxicosis with a combination of antithyroid drugs, iodine, steroids and adrenergic blocking agents. We advocate the use of esmolol infusions up to a maximum dose of 200 μg/kg/min for immediate haemodynamic management of the patient. Optimum time needed for stabilisation of the hyper metabolic state after initiation of antithyroid drugs is still not known and evacuation of molar pregnancy remains the only definitive management of the thyrotoxic state.

Comparison of oropharyngeal leak pressure of air-Q™,i-gel™, and laryngeal mask airway supreme™ in adult patients during general anesthesia: A randomized controlled trial

Study Objective: Various randomized controlled trials and a meta-analysis have compared i-gel™ and laryngeal mask airway Supreme™ (LMA-S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air-Q™ with i-gel™ and LMA-S™ in adult patient. Hence, we designed this study to compare air-Q™ with LMA-S™ and i-gel™ in adult patients. Materials and Methods: A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer-generated random number sequence: group air-Q™ (n = 25), group i-gel™ (n = 25), and group LMA-S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications. Results: The mean ± standard deviation OLP of air-Q™, i-gel™, and LMA-S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H2O (P = 0.279). The first insertion success rate for air-Q™, i-gel™, and LMA-S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air-Q™, i-gel™, and LMA-S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air-Q™ insertion was significantly higher than time taken for i-gel™ (mean difference 5.8 s, P < 0.0001) and LMA-S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices. Conclusions: We concluded that air-Q™, i-gel™, and LMA-S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy.

ASSIST - Patient satisfaction survey in postoperative pain management from Indian subcontinent

Introduction: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. Settings and Design: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. Material and Methods: Pain scores, patients and caregivers satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. Statistical Analysis: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. Results: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1–10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). Conclusion: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.

Comparison of serum triglyceride levels with propofol in long chain triglyceride and propofol in medium and long chain triglyceride after short term anesthesia in pediatric patients.

Background: Significant increase in serum triglyceride (ST) concentration have been described in adult population after prolonged administration of propofol formulation containing long chain triglyceride (LCT). Though, medium chain triglyceride-LCT (MCT-LCT) propofol when compared with LCT propofol for long-term sedation in adults resulted in identical triglyceride levels, the elimination of triglyceride was faster in patients administered MCT-LCT propofol. Materials and Methods: A total of 40 children were randomized into two groups of 20 each; Group I were induced with 1% LCT propofol (3 mg/kg) and Group II with 1% medium and LCT propofol and maintained with descalating dose of 20.15 and 10 mg/kg/h at 10 min intervals. Blood samples for ST concentration were obtained before induction of anesthesia, at the end of propofol infusion and 4 h after terminating propofol infusion. Results: ST levels were raised significantly above the basal values in both the groups but the rise was significantly higher in Group I (P < 0.05). Four hours after stopping propofol infusion the triglyceride levels were similar to the basal values in Group II, whereas in Group I the values were significantly greater than the baseline (P < 0.05) as well as those of Group II (P < 0.05). No clinically significant adverse effect of hypertriglyceridemia was observed. Conclusion: Even short term anesthesia with LCT and MCT-LCT propofol (1%) leads to elevated ST levels. The increase in ST levels is less with MCT-LCT propofol and elimination of triglyceride is also rapid after terminating MCT-LCT propofol infusion.

Assessment of procedural skills in residents working in a research and training institute: An effort to ensure patient safety and quality control

Background: To ensure patient safety, it is important to regularly assess the knowledge and practical skills of anesthesia trainees. This study was conducted to evaluate the competency of the residents and the impact of various corrective measures in the form of didactic lectures and clinical skill demonstrations on the conduct of various procedural skills by the residents. Materials and Methods: Ninety-five junior residents were enrolled in this study. Assessment of competency of 1st, 2nd, and 3rd year residents in performing various procedure skills of anesthesia was done in two stages using procedure specific checklist (PSC) and Global Rating Scales (GRSs). Preliminary results of the first assessment (Score 1) were discussed with the residents; deficiencies were identified and corrective measures suggested by didactic lectures and clinical skill demonstrations which were followed by a subsequent assessment after 3 months (Score 2). Results: There was a statistically significant improvement in the PSC and GRS scores after corrective measures for all the procedural interventions studied. Percentage increase in scores was maximum in 1st year (42.98 ± 6.62) followed by 2nd year (34.62 ± 5.49) and minimum in 3rd year residents (18.06 ± 3.69). The percentage increase of scores was almost similar for all subset of procedural skills; low, intermediate, and high skill anesthetic procedures. Conclusion: For assessment of procedural skills of residents, use of PSC and GRS scores should be incorporated and the same should be used to monitor the impact of various corrective measures (didactic lectures and clinical skill demonstrations) on the conduct of various procedural skills by the resident.

Broken Epidural Catheter: An Anesthesiologist’s Dilemma

Epidural anesthesia is a safe procedure and is routinely performed by the anesthesiologists. Breakage of an epidural catheter is a rare, but a worrisome complication. However, if this happens, the presence of retained epidural catheter fragment should be properly documented and should also be informed to the surgical team and the patient. Here, we present two cases of such an event and also highlighting the common reasons that could have precipitated that event.

Perioperative use of transthoracic echocardiography in a patient with congenitally corrected transposition of great arteries, atrial septal defect and severe pulmonary stenosis for lower segment cesarean section

A 25-year-old female with congenitally corrected transposition of great arteries (CCTGAs), atrial septal defect, and severe pulmonary stenosis underwent lower segment cesarean section at 34 weeks of gestation using combined spinal epidural anesthesia (CSEA). We used transthoracic echocardiography (TTE) for intraoperative monitoring of the cardiovascular system because these patients are reported to have a high prevalence of myocardial perfusion defects, regional wall motion abnormalities, and impaired ventricular contractility. Scanning was done at four different time intervals; preoperatively, after initiation of CSEA, after delivery of child and postoperatively (6 and 24 h postdelivery) to detect regional wall motion and valvular abnormalities, calculate ejection fractions and optimize fluid administration. In this case report, we thus discuss the anatomical defects of CCTGA, physiologic concerns and emphasize on the use of TTE for perioperative management of such cases.

Post-intubation tension pneumothorax and pneumoperitoneum in a low birth weight neonate with giant epulis

Congenital epulis is a benign soft‐tissue lesion of the alveolar mucosa. It may be sessile or pedunculated and vary in size from several millimetres to a few centimetres.[1,2] Surgical excision is the treatment of choice. The most important aspect of pre‐anaesthetic evaluation is assessment for difficult airway. Literature on the anaesthetic management of neonates with congenital epulis is limited to a few isolated case reports.[3,4] We discuss the development of post‐intubation tension pneumothorax and pneumoperitoneum in a neonate with an anticipated difficult airway due to an intra‐oral giant epulis.

An aberrantly positioned central venous catheter: A presage of an underlying anatomical anomaly.

Sir, The left subclavian vein was cannulated uneventfully using bony landmark technique in a 52-year-old male for hyperalimentation and administration of inotropes and intravascular fluids in Intensive Care Unit (ICU). He was a postoperative case of cancer of the sigmoid colon and had undergone a hemicolectomy. He was admitted in view of massive intraoperative blood loss leading to hemodynamic instability and long duration of surgery. His stay was further complicated by development of septic shock. Postinsertion chest radiograph revealed the position of the catheter in the left para mediastinal location [Figure 1]. This raised suspicion of a left-sided superior vena cava (SVC). Cross-sectional imaging with computed tomography (CT), magnetic resonance, or a saline contrast echocardiography was the options available to confirm the diagnosis. A bedside CT (contrast-enhanced) of the thorax is not available in our ICU and decision to shift the patient to radiology was deferred in view of hemodynamic instability of the patient and requirement of high dose of inotropes. Bedside transthoracic echocardiography was performed which showed a structurally normal heart with a dilated coronary sinus. The tip of the central venous catheter, however, could not be observed with confidence. Agitated saline was infused via the central venous catheter and this was followed by opacification of the coronary sinus and the right atrium. Persistent left-sided SVC (PLSVC) draining to right atrium via coronary sinus was confirmed. Malpositioning into tributaries of left brachiocephalic vein (left internal thoracic vein, left superior intercostal vein) and left pericardiophrenic vein was unlikely as the pressure tracing was consistent with central venous placement (a, c, x, v, y waves could be identified). Placement in left subclavian artery and descending thoracic aorta was ruled out as pressures ranged from 5-8cm of H20 and results of blood gas analysis were consistent with venous placement. Figure 1 Chest X-ray suggestive of persistent left-sided superior vena cava; widening of the aortic shadow, a paramedian bulge along the left heart border. An electrocardiography lead and a surgical drain can also be visualized The incidence of PLSVC is 0.3–0.5% in healthy individuals and 1.3–4.5% in patients with coexisting cardiac defects.[1,2] About 82% of PLSVC coexist with a right SVC and so this anomaly is often missed when central venous catheters are inserted on the right side. Venous drainage of PLSVC is into right atrium in majority of cases but could be in the left atrium also [Table 1]. Table 1 Venous drainage of persistent left-sided superior vena cava Left-sided jugular venous distention and an abnormal and exaggerated jugular venous waveform on left-sided catheterizations due to direct transmission of left atrial pressures raise suspicion of this anomaly. Anesthetist and intensivist need to be aware of this anomaly as it may cause the following complications:[3,4,5] Difficulty in insertion of left-sided pulmonary artery catheters or pacing wire Systemic embolization of air or thrombus in patients with PLSVC draining into the left atria Right-to-left shunting and unexplained cyanosis and clubbing in the patient (PLSVC draining into left atria) Arrythmias, cardiac arrest, and coronary sinus thrombosis Causes distention of the right heart during cardiac surgeries if not ligated or separately cannulated. It is a contraindication to retrograde cardioplegia. Left para mediastinal location of central venous catheter led to diagnostic dilemma in our patient, but a methodological assessment of all the differential diagnosis using simple bedside tests enabled us to make a diagnosis of PLSVC draining into right atria. It is the most common congenital venous anomaly in the chest and it is thus important for the clinicians to be aware of this. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.