Comparative evaluation of nebulized versus intravenous dexmedetomidine on intubating conditions during awake fiberoptic nasotracheal intubation

BACKGROUND

There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring.

METHODS

In this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1μg.kg-1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1μg.kg-1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects.

RESULTS

The cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group.

CONCLUSIONS

Nebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation.

Audit on Practices of Endotracheal Suctioning in Intensive Care Unit Patients among Health Care Workers (HCWs)

Background

Endotracheal suctioning (ETS) is one of the most frequently performed invasive procedures in intensive care units (ICUs). This audit was aimed at studying current practices and knowledge regarding ETS in the Indian critical care setup, with the background aim of raising awareness regarding correct practices as per current recommendations in critically ill patients.

Materials and methods

After registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 20 questions pertaining to ETS was distributed through electronic media among resident doctors working in the ICUs across India. Responses received were statistically analyzed.

Results

The questionnaire was sent to 530 clinicians, of which only 200 (37.73%) responded. The audit revealed that only 22% respondents set the maximum negative pressure every time before suctioning, on the suction apparatus and only 32% said they would choose a catheter size of less than half the internal diameter of the endotracheal tube (ETT). About 90% of the respondents did not routinely do any form of documentation of the ETS. Almost 72% of the responders opined that closed suction systems reduce the chances of developing ventilator-associated pneumonia (VAP). Only 46% of respondents thought that no solution should be routinely instilled in ETT during ETS.

Conclusion

There is lack of awareness regarding frequency and technique of ETS, infection control and monitoring required during ETS. Institutional protocols should be in place to follow correct guidelines for performing ETS.

How to cite this article

Singh R, Bhalotra AR, Sharma S. Audit on Practices of Endotracheal Suctioning in Intensive Care Unit Patients among Health Care Workers (HCWs). Indian J Crit Care Med 2024;28(1):58-65.

Changes in Lung Function Parameters after Total Intravenous Anaesthesia and Balanced Anaesthesia with Desflurane: A Prospective Randomised Study

Objective

Following anaesthesia, there is a decrease in pulmonary function. Unlike volatile anaesthetics, propofol decreases the upper airway tone, and total intravenous anaesthesia (TIVA) with propofol may decrease coughing on emergence. Coughing may reduce postoperative atelectasis. Thus, TIVA may lead to greater decreases in lung function postoperatively as compared to balanced anaesthesia with desflurane.

Methods

Sixty patients of either sex, aged 18-60 years and American Society of Anaesthesiologists (ASA) status I/II, who were to undergo mastoid surgery, were randomly allocated to Group B and Group T. Anaesthesia was maintained with desflurane, nitrous oxide and oxygen in Group B, and with TIVA in Group T. Pulmonary function tests (PFT) were done preoperatively, and 1, 3 and 24 hours postoperatively.

Results

Demographic data and preoperative PFT were comparable in both groups. One hour after surgery, there was a greater decrease in FEV1 and peak expiratory flow rate (PEFR) in Group T (p=0.044 and 0.042, respectively). Three hours postoperatively, the decrease in MEFR and PEFR was again greater in Group T (p=0.005 and 0.008, respectively), while the MEFR recovered to preoperative values in Group B. By 24 hours, the forced vital capacity (FVC), MEFR and PEFR recovered to preoperative values in Group T, while FVC remained reduced in Group B (p=0.006).

Conclusion

Both anaesthetic techniques cause a postoperative impairment in the lung function, but while TIVA causes a greater reduction in PFT in the early postoperative period, recovery is also earlier. On the other hand, balanced anaesthesia with desflurane was associated with a greater reduction in PFT at 24 hours.

Giant Hydatid Cyst within a Congenital Cystic Adenomatoid Malformation of the Lung

A case of hydatid cyst within a congenital cystic adenomatoid malformation (CCAM) of the right lower lobe of lung in an 8-year-old girl is reported. Presence of CCAM was confirmed on histopathology of the lung tissue attached to the specimen.

Evaluation of diclofenac sodium as a perioperative analgesic

1. This study was undertaken to assess whether the analgesia conferred by Diclofenac sodium in the post operative period following general surgery is enhanced by preoperative administration of the drug. 2. Two groups of patients were studied. Group I patients received narcotic premedication and Group II patients received Diclofenac sodium as premedication. Post operatively both groups were administered intramuscular Diclofenac sodium 8 hourly for 48 hours. 3. Pain scoring using visual analogue scale indicated a better pain relief in Group II patients. In Group I, 75% patients had a pain score less than 3 whereas 85% in Group II had a pain score less than 3 (Figure 1). 4. Pulmonary function tests were done 24 hours after surgery and revealed improved values of all parameters in Group II patients. This indicates a greater degree of analgesia in Group II patients. 5. Preoperative administration of the drug reduces the initiation of pain in the periphery and decreases the inflammatory response after surgery. 6. NSAIDS do not have any central effect or any respiratory depression. Patients in our study were found to be awake, cooperative and pain free. The additional analgesia conferred by preoperative administration in conjunction with adequate postoperative therapy allows us to recommend Diclofenac sodium as a sole analgesic for perioperative pain relief except in those patients with a bleeding diathesis.