nan Yunus

Pondering for the frequency of routine single-lumen tracheostomy tube change for ongoing airway management in adult intensive care unit

Background: Tube blockage in the Intensive Care Unit (ICU) leads to preventable deaths. Routine change of tube for ongoing airway management is one of the indications for tracheostomy tube (TT) changes. However, there are limited data or evidence to recommend the frequency of such change. Aim: The study aims to determine the frequency of routine TT change in adult ICU patients. Subjects and Methods: A retrospective evaluation of ICU records of the patients who had been on TT for >5 days from July 2013 to April 2015 was performed. Data with regard to age, sex, diagnosis, and on tube days (TDs) before the TT was changed with either confirmed/suspicion of blockage and nonblockage were collected. Patients who had blockage and nonblockage were analyzed as individual groups as well as compared using INSTAT software to find the statistical estimates. Results: A total of 62 patients (72.58% males; mean ± standard deviation age: 50.62 ± 18.47 years; mean intubated days of 11.42) with a total of 1022 TT days were evaluated. Fifty-six episodes of tube blockage and 57 episodes (each >5 TT days) of nonblockage were analyzed and compared. The 95% confidence interval (CI) for mean of on TDs for nonblockage and blockage was 7.16–8.27 and 8.08–9.84 days, respectively, in the study population (P = 0.0171). Conclusion: The frequency for routine change of single-lumen TT for ongoing airway management in ICU patient should be 7–10 days taking the lowest 95% CI for nonblockage as the earliest point and the highest 95% CI for blockage as the late point.

Airway management in maxillofacial injuries: Identifying clinical determinants requiring non-conventional strategies

Aim: Airway management in maxillofacial injuries is challenging. Conventionally, the method of securing the airway is using Macintosh laryngoscope to intubate the patients. Knowing the clinical variables associated with the need for nonconventional (nonMacintosh) laryngoscopy will aid in better airway management. The present analysis was aimed to identifying the clinical variables associated with nonconventional tracheal intubation in patients with maxillofacial injury. Materials and Methods: Medical records of maxillofacial injury patients with at least one facial bone fracture who needed tracheal intubation from January 2009 to June 2016 in a teaching institute were screened for data collection. The clinicodemographic parameters, techniques, and instruments used for tracheal intubation were noted. The INSTAT software was used for statistical analysis, and P < 0.05 was considered significant. Results: Seventy-three patients (mean age 27.47 ± 9.92 years; 94.52% male) were analyzed. A total of 61.64% of tracheal intubations required nonconventional techniques [i.e. video laryngoscope (27.4%), fiberoptic bronchoscope (26.03%), tracheostomy (6.85%), and 1.37% retrograde intubation]. Video laryngoscopy was preferred over Macintosh in patients with confirmed/suspected C-spine injury. Mouth opening <2 cm [odds ratio (OR): 7.33], multiple facial bone fracture (OR: 4.80), and concomitant mandible and maxilla fractures (OR: 6.50) were associated with tracheal intubation by nonconventional laryngoscopy (P = 0.01). Conclusion: Multiple facial bone fractures, concomitant mandible and maxilla fracture, and mouth opening <2 cm need tracheal intubation using a technique other than Macintosh laryngoscopy.

Dexmedetomidine in Attenuation of Haemodynamic Response and Dose Sparing Effect on Opioid and Anaesthetic Agents in Patients undergoing Laparoscopic Cholecystectomy- A Randomized Study

INTRODUCTION Perioperative procedures are stressful and lead to haemodynamic instability with potentially devastating consequences. Dexmedetomidine is found to have many of the desired characteristics that are required in perioperative period. AIM To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc-Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant. RESULTS Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The Minimum Alveolar Concentration (MAC) requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective. CONCLUSION Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.

An observational cohort study on pre-operative investigations and referrals: How far are we following recommendations?

Background and Aims: Pre-operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence-based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre-operative investigations and referral practices and compare it with the standard guidelines. Methods: The present observational study was carried out during 2014-2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre-anaesthetic check-up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA). Results: Seventy-five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist-ordered testing was more focused than surgeons. Conclusion: More than two-third of pre-operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre-operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.