Multimodal blood loss prevention bundle for endoscopic resection of juvenile nasopharyngeal angiofibroma: A case series

Surgery for excision of juvenile nasopharyngeal angiofibroma (JNA) carries the possibility of massive life-threatening haemorrhage. Anaesthetic management aims to maintain haemodynamic stability and reduce blood loss. This case series describes the application of the bundled approach as a multimodal blood loss prevention bundle (MBLPB). Twenty patients underwent 23 surgeries with MBLPB. The blood loss and the number of units of blood transfused were recorded. The surgeon satisfaction score was assessed. The median [interquartile range (IQR)] estimated blood loss was 1300 (650-2350) ml. Patients with tumours in stages I and II had a median (IQR) blood loss of 550 (270-750) ml compared to patients with higher grades of tumours (stages III, IV) with a median (IQR) blood loss of 2100 (1300-2500) ml. Median (IQR) units of packed red cells transfused was 1 (0-3). The surgeon's satisfaction score was high when MBLPB was applied for JNA. However, it does not appear to reduce blood loss markedly.

Current practice patterns of supraglottic airway device usage in paediatric patients amongst anaesthesiologists: A nationwide survey

Background and Aims:

Supraglottic airway devices (SGADs) are increasingly being used for airway management in paediatric patients undergoing general anaesthesia. This survey was designed to assess the nationwide practice patterns of SGAD usage in paediatric patients.

Methods:

A questionnaire of 28 questions was circulated amongst 16,532 members of the Indian Society of Anaesthesiologists through online survey engine Google Forms^® and served manually to 500 delegates attending the Asian Society of Paediatric Anaesthesiologists conference 2017. Percentage, mean and standard deviation were calculated using Microsoft Excel 2016 (Redmond, WA, USA).

Results:

Four hundred and five (2.3%) valid responses were obtained. The most commonly used device was i-gel^© (60.74%). Three hundred and four (75.06%) respondents had access to second-generation SGADs. Second-generation devices (60.74%) were more commonly used than first-generation devices (39.26%). Anaesthesiologists utilised SGADs in various challenging scenarios such as in the difficult airway (53.33%), remote locations (55.47%), ophthalmologic (38.77%) and long-duration surgeries (17.53%). Sixty per cent respondents did not use SGADs in laparoscopic surgery. Disposable SGADs were reused by 77.28% respondents. Oropharyngeal seal and intracuff pressures were not measured by 86.91% and 56.92% respondents, respectively. Difficulty in size selection (84.19%), securing position (82.22%) and maintaining unobstructed ventilation (78.76%) were common problems encountered while using SGADs.

Conclusion:

Although there is a widespread use of second-generation SGADs in Indian paediatric anaesthesia, safe practices such as using capnography, measurement of oropharyngeal seal pressure, cuff pressure and appropriate disinfection are lacking.

A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery

Background

We investigated whether the intraoperative administration of dexmedetomidine would attenuate the profound sympathoadrenal response associated with cleft palate (CP) surgery.

Methods

Sixty children aged 6 months to 12 years undergoing CP surgery under general anesthesia were randomly assigned to the control (C) or dexmedetomidine (D) groups. Group C received benzodiazepine (0.05 mg/kg midazolam followed by infusion of normal saline) fentanyl isoflurane anesthesia, and Group D received dexmedetomidine (loading 1 µg/kg followed by infusion of 0.5 µg/kg/h) fentanyl isoflurane anesthesia. Heart rate (HR), mean blood pressure (MBP), intraoperative fentanyl and isoflurane requirements, recovery scores, emergence agitation, pain scores, time and requirement of rescue analgesic, and surgeon satisfaction were noted.

Results

Intraoperative HR and MBP in Group D were significantly lower than the corresponding values in Group C (P < 0.001). HR decreased up to 16% in Group D. By contrast, HR increased up to 20% in Group C. Group D had comparable MBP to its baseline, whereas Group C had higher MBP until extubation (P = 0.015). Two children in Group D developed bradycardia and hypotension, which was successfully treated. The fentanyl and isoflurane requirements decreased by 43% and 30%, respectively, in Group D patients compared to those in Group C (P < 0.001). Group D had lower pain scores and less emergence agitation (P < 0.001). Time until requirement of first rescue analgesic was longer in Group D than that in Group C (P < 0.001). Surgeon satisfaction was higher in Group D than that in Group C.

Conclusions

Intravenous dexmedetomidine during CP surgery attenuated hemodynamic responses with excellent surgeon satisfaction. Close monitoring of hemodynamics is recommended.

A cohort evaluation of clinical use and performance characteristics of Ambu® AuraGain™: A prospective observational study

BACKGROUND AND AIMS

Ambu^® AuraGain™ (AG) (Ambu, Ballerup, Denmark) is a supraglottic device which has a design facilitating its use as a conduit for intubation. We designed this prospective observational study to assess the ease of AG placement in paralysed patients, determine its position and alignment to the glottis and assess its utility as a conduit for intubation.

METHODS

One hundred patients, aged 18-60 years, American Society of Anesthesiologists physical status I-II, undergoing elective surgery under general anaesthesia were included in the study. The ease and number of attempts for successful insertion, ease of gastric tube insertion, leak pressures, fibre-optic grade of view, number of attempts and time for tracheal intubation, time for AG removal and complications were recorded. The mean, standard deviation (SD), interquartile range (IQR) and range were calculated. The upper limit of confidence interval for overall failure rate was calculated using Wilson's score method.

RESULTS

AG was successfully inserted in all patients. The mean (SD) time taken for insertion was 17.32 (8.48) s. The median [IQR] leak pressures were 24 [20-28] cm of H₂O. Optimal laryngeal view for intubation was obtained in 68 patients. Eighty-eight patients could be intubated in the first attempt. Five patients could not be intubated. The overall failure rate of device was 9%.

CONCLUSION

AMBU^® AuraGain™ serves as an effective ventilating aid, but caution is suggested before using it as a conduit for endotracheal intubation.

Is segmental epidural anaesthesia an optimal technique for patients undergoing percutaneous nephrolithotomy?

Background and Aims:

Neuraxial anaesthesia has recently become popular for percutaneous nephrolithotomy (PCNL). We conducted a study comparing general anaesthesia (GA) with segmental (T₆–T₁₂) epidural anaesthesia (SEA) for PCNL with respect to anaesthesia and surgical characteristics.

Methods:

Ninety American Society of Anesthesiologists Physical Status-I and II patients undergoing PCNL randomly received either GA or SEA. Overall patient satisfaction was the primary end point. Intraoperative haemodynamics, epidural block characteristics, post-operative pain, time to rescue analgesic, total analgesic consumption, discharge times from post-anaesthesia care unit, surgeon satisfaction scores and stone clearance were secondary end points. Parametric data were analysed by Student's t-test while non-parametric data were compared with Mann–Whitney U-test.

Results:

Group SEA reported better patient satisfaction (P = 0.005). Patients in group GA had significantly higher heart rates (P = 0.0001) and comparable mean arterial pressures (P = 0.24). Postoperatively, time to first rescue analgesic and total tramadol consumption was higher in Group GA (P = 0.001). Group SEA had lower pain scores (P = 0.001). Time to reach Aldrete's score of 9 was shorter in group SEA (P = 0.0001). The incidence of nausea was higher in group GA (P = 0.001); vomiting rates were comparable (P = 0.15). One patient in group SEA developed bradycardia which was successfully treated. Eight patients (18%) had hypertensive episodes in group GA versus none in group SEA (P = 0.0001). One patient in GA group had pleural injury and was managed with intercostal drain. Stone clearance and post-operative haemoglobin levels were comparable in both groups.

Conclusion:

PCNL under SEA has a role in selected patients, for short duration surgery and in expert hands.

A prospective randomized double-blind study comparing dexmedetomidine vs. combination of midazolam-fentanyl for tympanoplasty surgery under monitored anesthesia care

Background:

Analgesia and sedation are usually required for the comfort of the patient and surgeon during tympanoplasty surgery done under local anesthesia. In this study, satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine were compared with a combination of midazolam-fentanyl.

Materials and Methods:

Ninety patients undergoing tympanoplasty under local anesthesia randomly received either IV dexmedetomidine 1 μg kg^-1 over 10 min followed by 0.2 μg kg^-1h^-1 infusion (Group D) or IV midazolam 0.06 mg kg^-1 plus IV fentanyl 1 μg kg^-1 over 10 min (Group MF) followed by normal saline infusion at 0.2 ml kg^-1h^-1. Sedation was titrated to Ramsay sedation score (RSS) of three. Vital parameters, rescue analgesics (fentanyl 1 μg kg^-1) and sedatives (midazolam 0.01 mg kg^-1), patient and surgeon satisfaction scores were recorded.

Results:

Patient and surgeon satisfaction score was better in Group D than Group MF (median interquartile range (IQR) 9 (8-10) vs. 8 (6.5-9.5) and 9 (8.5-9.5) vs. 8 (6.75-9.25), P = 0.0001 for both). Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group MF (P < 0.05). Percentage of patients requiring rescue fentanyl was higher in Group MF than Group D (40% vs. 11.1%, P = 0.01). One patient in Group D while four in Group MF (8.8%) required rescue sedation with midazolam (P > 0.17). Seven patients in Group D had dry mouth vs. none in Group MF (P = 0.006). One patient in Group D had bradycardia with hypotension which was effectively treated.

Conclusion:

Dexmedetomidine is comparable to midazolam-fentanyl for sedation and analgesia in tympanoplasty with better surgeon and patient satisfaction. Hemodynamics need to be closely monitored.

Clinical and mycological spectrum of cutaneous candidiasis in Bombay

A total of 150 patients with cutaneous candidiasis were studied. A detailed clinical history was taken. Scrapings were examined in 10% KOH, and the material cultured on Sabouraud's agar. Species were identified by the serum germ tube test, sugar fermentation and sugar assimilation tests. Of 150 patients 79 were females. The commonest presentation was intertrigo (75), vulvovaginitis (19) and paronychia (17). A history of chronic exposure to water was obtained in 94 cases, all had erosio interdigitalis blastomycetica and/or paronychia. Diabetes melltius as a predisposing factor was observed in 22 patients. The 10 cases of balanoposthitis had associated diabetes mellitus. Smear and culture were positive in all the patients. C. albicans was isolated in 136 cases, C. tropicalis in 12, and C. guillermondi in 2. The cultures of C. albicans had positive serum germ tube test. The 6 patients in the paediatric age group having perianal/genital involvement had a stools culture positive for C. albicans.

Penile and scrotal lesions in leprosy: case reports

Six leprosy patients in the Ridley-Jopling spectrum of BT-BL showing lesions on penis and scrotum are presented, as we believe that this common enough clinical feature is not well documented in the literature.

Pachyonychia Congenita

Pachyonychia congenital is an infrequent genodermatosis, characterized by nail dystrophy, hyperkeratosis of the palms and soles, follicular keratosis and leukoplakia. It was seen in two male patients aged 12 and 35 years respectively. The younger patient had nail changes, palmo-planter keratoderma, eye changes, hypotrichosis and mental retardation, while the elder one had minimal nail changes, keratoderma and leukoplakia.

Clinical, Bacteriological and Immunological Profile of 20 Patients with Dermatitis Cruris Pustulosa Et Atrophicans

This study was carried out to determine whether an abnormality in polymorphonuclear leucocyte (PMN) function and/or a deficiency in immunoglobulins (IgG and IgM) and complement (C4 and C3) could be the underlying cause of chronicity in DCPA. Twenty adult males were studied. Penicillin resistant coagulase positive S. Aureus was isolated from the pus samples of all the patients. AU the strains were susceptible to chloramphenicol, cotrimoxazole anderythromycin. Patch and usage tests done with coconut and mustard oil were negative. The total and differential leucocyte counts in all the patients were within normal limits. In vitro PMN functions were estimated by measuring percentage phagocytosis and intra cellular killing capacity (ICK) using S. aureus as the test organism. Both these parameters were significantly raised before treatment (p.001) and returned to normal after treatment. Immunolobulin levels did not rise above normal which may suggest a depressed response to bacterial infection. Complement (C3) levels were significantly lower (p) than the controls.

Thalidomide in leprosy--study of 94 cases

Thalidomide has a beneficial effect on type II Lepra reaction especially chronic and recurrent reaction. It helps to minimise steroid dependency. Thalidomide was given to 94 cases of type II lepra reaction, who had not responded to steroids or had repeated reactions. This clinical data was analysed regarding clinical improvement, relapse of reaction, side effects of the drug, etc. The analysis showed that all the patients improved remarkably and steroids could be withdrawn. If the competence of staff using this drug is enhanced, morbidity due to leprosy can considerably be reduced.