Vanlal Darlong

Comparison of performance and efficacy of air-Q intubating laryngeal airway and flexible laryngeal mask airway in anesthetized and paralyzed infants and children.

Flexible laryngeal mask airway is a commonly used supraglotic airway device (SAD) during ophthalmic surgeries. Air‐Q intubating laryngeal airway (ILA) is a newer SAD used as primary airway device and as a conduit for intubation as well. Available literature shows that air‐Q performs equal or better than other SADs in children and adults. However, limited data is available using air‐Q in infants and small children <10 kg. So, our aim was ‘To compare the performance and efficacy of these two devices in infants and small children’. Our hypothesis is that air‐Q due to its improved cuff design will yield better airway seal pressures and improved laryngeal alignment as compared to flexible laryngeal mask airway.

Internal jugular vein cannulation: A comparison of three techniques

Context: Ultrasound-guided internal jugular vein (IJV) cannulation is known for increasing success rate and decreasing rate of complications. The ultrasound image can be used as a real time image during cannulation or to prelocate the IJV before attempting cannulation. Aims: This study compares both the ultrasound-guided technique with the classical anatomical landmark technique (central approach) for right IJV cannulation in terms of success rate, complications, and time for cannulation. Settings and Design: A prospective, randomized, observational study was conducted at a tertiary care hospital. Material and Methods: One hundred twenty patients requiring IJV cannulation were included in this study and were randomly allocated in three groups. Number of attempts, success rate, venous access time, catheterization time, and complications were observed in each group. Statistical Analysis Used: Statistical analysis was performed using STATA-9 software. Demographic data were compared using one-way analysis of variance (ANOVA). Nonparametric data were compared using the Kruskall–Wallis test, and multiple comparisons were done applying The Mann–Whitney test for individual pairs of groups. Nominal data were compared by applying the Chi-square test and Fisher exact test. Results: Successful cannulation (≤3 attempt) was achieved in 90.83% of patients without any statistical significant difference between the groups. Venous access time and catheterization time was found to be significantly less in both the ultrasound groups than the anatomical land mark group. Number of attempts and success in first attempt was similar between the groups. Conclusions: Both the ultrasound techniques are found to be better than the anatomical landmark technique. Further, ultrasound-guided prelocation was found to be as effective as ultrasound guided real-time imaging technique for right IJV cannulation.

Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns.

Background Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy. Patients and methods The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry. In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered. Results Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 ± 2 to 28 ± 2.7 cmH2O and central venous pressure increased from 12.9 ± 1 to 19.2 ± 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice. Summary Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.

Perioperative management of patient with alkaptonuria and associated multiple comorbidities

Alkaptonuria is a rare inherited genetic disorder of tyrosine metabolism characterized by a triad of homogentisic aciduria, ochronosis, and arthritis. The most common clinical manifestations of ochronosis involve the musculoskeletal, respiratory, airway, cardiovascular, genitourinary, cutaneous, and ocular systems. We report the perioperative anesthetic management of a 56-year-old alkaptonuric patient, with multiple comorbidities scheduled, for revision total hip replacement. A review of her medical history revealed alkaptonuria, hypothyroidism, rheumatoid arthritis, hypertension, diabetes mellitus, and Potts spine with disc prolapse. We want to highlight the need of thorough preoperative evaluation in patients of alkaptonuria, as it is associated with multiple comorbidities. The systemic involvement should determine the anesthetic plan. Caution should be exercised during positioning to prevent injury to the joints and the spine.

Comparative efficacy and safety of the Ambu® AuraOnce™ laryngeal mask airway during general anaesthesia in adults: a systematic review and meta‐analysis

Previous comparisons between the Ambu® AuraOnce™ and other laryngeal mask airways have revealed different results across various clinical studies. We aimed to perform a systematic review with meta‐analysis on the efficacy and safety of the AuraOnce compared with other laryngeal mask airways for airway maintenance in adults undergoing general anaesthesia. Our search of PubMed, PubMed Central, Scopus and the Central Register of Clinical Trials of the Cochrane Collaboration yielded nine randomised controlled trials eligible for inclusion. Comparator laryngeal mask airways were the LMA Unique™ (four trials), the LMA Classic® (five trials) and the Portex® Soft Seal® (three trials). The AuraOnce provided an oropharyngeal leak pressure higher than the LMA Unique (304 participants, mean (95% CI) difference 3.1 (1.6–4.7) cmH2O, p < 0.0001) and equivalent to the LMA Classic. The Soft Seal provided a higher leak pressure than the AuraOnce (229 participants, mean (95% CI) difference 3.5 (0.4–6.7) cmH2O, p = 0.03). Insertion was significantly faster with the AuraOnce than the LMA Unique (304 participants, mean (95% CI) difference 5.4 (2.1–8.71) s, p = 0.001) and Soft Seal (229 participants, mean (95% CI) difference 9.5 (3.0–15.9) s, p = 0.004), but similar to the LMA Classic. The first‐insertion success rate of the AuraOnce was equivalent to the LMA Unique, LMA Classic and Soft Seal. We found a higher likelihood of bloodstaining on the cuff with the Soft Seal and a higher incidence of sore throat with the LMA Classic. We conclude that the AuraOnce is an effective alternative to the LMA Classic and LMA Unique, and easier to insert than all three other devices studied.

Fiberoptic-Guided Fogarty Catheter Placement Using the Same Diaphragm of an Adapter Within the Single-Lumen Tube in Children

IMPLICATIONS We describe successful placement of a Fogarty catheter for one-lung ventilation through a single-lumen tube using a single diaphragm of an adapter for both the fiberoptic bronchoscope and the Fogarty catheter.

Lowe's syndrome with Fanconi syndrome for ocular surgery: perioperative anesthetic considerations.

Lowes syndrome is a rare inherited metabolic disorder characterized by mental retardation, kidney malfunction, and abnormalities of the eyes and bones. A 4 month-old child with Lowes and Fanconis syndrome, undergoing bilateral congenital cataract surgery, is presented. Preoperative electrolyte imbalance was corrected by potassium, calcium, magnesium, phosphate, and bicarbonate supplementation. Anesthesia was administered uneventfully using appropriate anesthetic agents and monitoring. Adequate preoperative evaluation and optimization, along with selection of anesthetic agents and fluid and electrolyte management with appropriate perioperative monitoring, is key to a successful outcome.

Congenital erythropoietic porphyria: anesthetic implications

Congenital erythropoietic porphyria is a rare error of heme metabolism. Derangement of heme metabolism leads to disfiguration, phototoxicity, and the precipitation of porphyric crises. This case report discusses the myriad perioperative considerations in a patient with congenital erythropoietic porphyria.

Perioperative management of a patient of Rubinstein-Taybi syndrome with ovarian cyst for laparotomy.

Rubinstein-Taybi syndrome (RTS) is a multisystem involvement disease. These children may present for various surgeries of different systems. Due to multisystem involvement, perioperative management of such patients poses peculiar challenges for the anesthesiologists. We report the successful anesthetic management of a patient with RTS with tonsillar hypertrophy grade III scheduled for ovarian cystectomy.

Comparison of subarachnoid block with bupivacaine and bupivacaine with fentanyl on entropy and sedation: A prospective randomized double-blind study.

Background and Aims: We studied the state entropy to monitor the sedative effect of subarachnoid block (SAB) using bupivacaine alone or combination of bupivacaine and fentanyl. The effect of use of fentanyl via the subarachnoid route on the sedation level was also studied using the entropy scores and the decrease in the requirement of propofol used as an adjuvant sedative drug. Materials and Methods: In this prospective randomized double-blind study, 30 patients of age 18-70 years requiring SAB were enrolled for the study. Patients with any known allergy to study drugs, contraindication for SAB, obesity, neurological or psychiatric disease on concurrent medication and refusal were excluded from the study. Patients were randomly allocated into two groups: Group C: SAB was administered with 2.5 mL (12.5 mg) of 0.5% hyperbaric bupivacaine; Group D: SAB was administered with 2.5 mL of 2 mL (10 mg) of 0.5% hyperbaric bupivacaine and 0.5 mL (25 μg) fentanyl. Propofol infusion was started if the state entropy (SE) value was ≥75, at the rate of 100 μg/kg/min till the SE value reaches in the range of 60-75 (recorded as onset time). Thereafter the infusion rate was titrated to maintain SE value between 60 and 75. The level of sedation was measured with SE and Ramsay sedation (RS) scale. Results: The demographic profile and baseline parameters, were comparable in two groups (P > 0.05). After SAB, decrease in SE and response entropy was noted in both the groups and fall was significant in Group D (P < 0.0001). The total propfol required in thew two groups were comparable being 3.97 ± 2.14 mg/kg in Group C and 3.41 ± 2.34 mg/kg in Group D (P = 0.342). The change in the mean RS values was from 1.17 ± 0.38 to 1.69 ± 0.47 in Group D (P = 0.06), whereas in Group C it was from 1.03 ± 0.18 to 1.43 ± 0.50 (P = 0.041) within 20 min of SAB. Conclusion: Subarachnoid block causes sedation per se, but the level of sedation is not clinically significant and the sedation caused is not enough to avoid sedative agents for allaying anxiety in patients intraoperatively. The sedative effect of SAB was enhanced by adding intrathecal fentanyl probably because of better quality of SAB. SE showed good correlation with RS scaling system. Therefore, SE may be used as reliable tool to titrate sedation in patients undergoing surgery under SAB.