Recent advances in airway management

Airway management is a core skill essential for anaesthesiologists and health care providers involved in resuscitation and acute care of patients. Advancements in airway management are continuously evolving. This narrative review highlights the recent advancements with respect to innovations, tools, techniques, guidelines, and research in both technical and non-technical aspects of airway management. These include nasal endoscopy, virtual endoscopy, airway ultrasound, video endoscopes, supraglottic airways with enhanced protection against aspiration, hybrid devices, and the use of artificial intelligence and telemedicine, the utility of which has increased in recent times, thereby improving success with airway management and enhancing patient safety. There has been an increasing emphasis on peri-intubation oxygenation strategies to reduce complications in patients with a physiologically difficult airway. Recent guidelines for difficult airway management and preventing unrecognised oesophageal intubation are available. Large multicentre airway data collection helps us examine airway incidents, aetiology, and complications to expand our knowledge and give us insights for change in practice.

Simulation with a colour indicator to help reduce contamination during airway management in COVID-19 times: An experience from a tertiary centre in India

BACKGROUND AND AIMS

The coronavirus disease 2019 (COVID-19) pandemic has initiated modified protocols for aerosol-generating procedures. A simulation study using dye was conducted to highlight contamination at intubation and extubation and to encourage adherence to the new COVID-19 protocol among anaesthesia personnel in our institution.

METHODS

A video demonstrating the new COVID-19 protocols was circulated in the Department of Anaesthesiology a week prior to the study. Thirty teams, each comprising an anaesthesia resident and a staff technician, were enroled. Each team was asked to demonstrate the steps of preparation, intubation and extubation on a mannequin in a COVID-19 scenario. Checklists were used to assess points of contamination and adherence to the protocols. Following debriefing, a repeat simulation was conducted. The use of a dye highlighted the points of contamination. The study subjects provided feedback on the usefulness of the session and practical difficulties encountered in adapting to the new protocols.

RESULTS

The average contamination scores decreased by 3.4 (95% confidence interval (CI): 2.4-4.4, P < 0.001) in the post-debrief session. Adherence to the steps of the modified protocol improved by a score of 2.7 (CI: 3.6-1.83) among anaesthesiologists and by 4.3 (CI: 5.3-3.3) among technicians. Further, 93% felt that the use of the colour indicator reinforced awareness of the possible points of contamination.

CONCLUSION

Simulation with a low-fidelity mannequin by using colour indicator for secretions is an effective teaching tool to reduce health hazards during airway management in COVID-19 times.

Management of ruptured sinus of valsalva for device closure in a patient with haemophilia

The association of Hemophilia A and ruptured aneurysm of sinus of valsalva (RSOV) has never been reported to the best of our knowledge. We report the case of a 29-year-old male patient with Hemophilia type A who presented with a RSOV into right atrium (RA). The patient underwent device closure off the RSOV and received Factor VIII infusions to decrease blood loss. The peri-procedural management is being presented in this case report.

Modified Tricuspid Annular Plane Systolic Excursion for Assessment of Right Ventricular Systolic Function

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) has become a popular tool for assessing right ventricular (RV) systolic function because of its ease of application. TAPSE using transesophageal echocardiography (TEE) is limited by alignment with the lateral wall of the RV. Modified TAPSE (m-TAPSE) is a novel method for measuring TAPSE. m-TAPSE is the difference in the ‘apical to lateral tricuspid annulus distance’ during diastole and systole. The aim of the present study was to compare prospectively m-TAPSE with the most commonly used parameter TAPSE and near-gold standard 2D echocardiographic parameter RV fractional area change (RV FAC).

METHODS

We conducted a prospective observational study of 125 consecutive patients undergoing coronary artery bypass graft surgery in a single tertiary care center. Post-anesthetic induction TAPSE was recorded using transthoracic echocardiography (TTE). m-TAPSE was recorded using TEE in the mid-esophageal four-chamber view. RV FAC was also assessed using TEE. m-TAPSE < 16 mm, TAPSE < 16 mm and RV FAC < 35% were taken as cut-offs for RV systolic dysfunction. Correlations were assessed using the Pearson correlation coefficient. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using 2 × 2 cross table.

RESULTS

m-TAPSE was significantly correlated with TAPSE (r = 0.797, p < 0.001). Similarly, a significant correlation was observed between m-TAPSE and RV FAC (r = 0.602, p < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of m-TAPSE were 100%, 98.3%, 80%, 100% and 98.4%, respectively.

CONCLUSIONS

m-TAPSE correlated well with both RV FAC and TAPSE. Therefore, m-TAPSE can be considered an easily measurable alternative parameter for evaluating RV systolic function in a busy intraoperative setting.

Transthoracic echocardiography versus transesophageal echocardiography for rupture sinus of Valsalva aneurysm

We report a rare case of sinus of Valsalva aneurysm of both right and left coronary sinus (LCS), with perforation of the LCS opening into the left ventricle. The LCS aneurysm with its perforation was undiagnosed on transthoracic echocardiography emphasizing the role of transesophageal echocardiography in delineating the anatomy.

Is endothelin gene polymorphism associated with postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting?

BACKGROUND

The mechanism of development of atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) has not been clearly defined, and the involvement of multiple factors such as advanced age, withdrawal of β-blockers, inadequate atrial protection, and electrolyte imbalance, particularly hypomagnesemia has been documented by several authors. Despite all the available pharmacologic prophylaxis, incidence of AF still remains high in this group of patients. This unexplained cause could be genetic inheritance of endothelin-1 (ET-1) gene which is thought to have a pro-arrhythmogenic effect.

AIM

This study aims to investigate the relationship between plasma ET-1 concentrations, ET-1 gene polymorphisms in loci -1370 T/G, -134 (3A/4A) Ins/del, Lys198Asn (G/T), and occurrence of AF in patients undergoing CABG.

METHODOLOGY

Ninety-eight nonrelated, nondiabetic patients over a period of 4 years undergoing routine CABG were selected for the present study. All patients were genotyped for three single nucleotide polymorphisms (SNPs) in loci -1370 T/G, -134 (3A/4A) Ins/del, and Lys198Asn (G/T) in the ET-1 gene by gene sequencing. The plasma ET-1 concentrations were measured using an ET immunoassay.

RESULTS

Plasma ET-1 concentrations were higher in AF+ group (P = 0.001) as compared to AF- group. The allele frequencies between AF+ and AF- group were significantly different only with respect to the Lys198Asn (G/T) SNP of the ET-1 gene.

CONCLUSION

The study described the possible correlation of polymorphism of ET gene in CABG population from India. The ET-1 gene might play a disease-modifying role in atrial fibrillation.

Lactate, endothelin, and central venous oxygen saturation as predictors of mortality in patients with Tetralogy of Fallot

Background:

Lactate and central venous oxygen saturation (ScVO₂) are well known biomarkers for adequacy of tissue oxygenation. Endothelin, an inflammatory marker has been associated with patient's nutritional status and degree of cyanosis. The aim of this study was to explore the hypothesis that lactate, ScVO₂ and endothelin before induction may be predictive of mortality in pediatric cardiac surgery.

Methods:

We conducted a prospective observational study of 150 pediatric (6 months to 12 years) patients who were posted for intracardiac repair for tetralogy of fallot and measured lactate, ScVO₂ and endothelin before induction (T₁), 20 minutes after protamine administration (T₂) and 24 hours after admission to ICU (T₃).

Results:

Preinduction lactate and endothelin levels were found to predict mortality in patients of tetralogy of fallot with an odds ratio of 6.020 (95% CI 2.111-17.168) and 1.292(95% CI 1.091-1.531) respectively. In the ROC curve analysis for lactate at T₁, the AUC was 0.713 (95% CI 0.526–0.899 P = 0.019). At the cutoff value of 1.750mmol/lt, the sensitivity and specificity for the prediction of mortality was 63.6% and 65.5%, respectively. For endothelin at T₁, the AUC was 0.699 (95% CI 0.516–0.883, P = 0.028) and the cutoff value was ≤2.50 (sensitivity, 63.6%; specificity, 58.3 %). ScVO₂ (odds ratio 0.85) at all three time intervals, suggested that improving ScVO₂ can lead to 15% reduction in mortality.

Conclusions:

Lactate, ScVO₂ and endothelin all showed association with mortality with lactate having the maximum prediction. Lactate was found to be an independent, reliable and cost-effective measure of prediction of mortality in patients with tetralogy of fallot.

Medication errors in anesthesia: unacceptable or unavoidable?

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Literature search for research planning and identification of research problem

Literature search is a key step in performing good authentic research. It helps in formulating a research question and planning the study. The available published data are enormous; therefore, choosing the appropriate articles relevant to your study in question is an art. It can be time-consuming, tiring and can lead to disinterest or even abandonment of search in between if not carried out in a step-wise manner. Various databases are available for performing literature search. This article primarily stresses on how to formulate a research question, the various types and sources for literature search, which will help make your search specific and time-saving.

Dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block

Context:

Dexmedetomidine as an adjuvant to local anesthetics in peripheral nerve blocks has been used in only a few studies.

Aims:

We aimed at assessing the effect of dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block.

Settings and Design:

Random, controlled, and triple blind.

Materials and Methods:

Sixty American Society of Anesthesiologist grade I and II patients of either sex scheduled for elective upper limb surgery under supraclavicular brachial plexus block were divided into three equal groups in a prospective randomized double-blind controlled manner. For block patients in Group C received 0.5% ropivacaine (30cc), 0.5% ropivacaine with 50 μg dexmedetomidine (30cc) in Group D and 0.5% ropivacaine (30cc) in Group D-IV along with intravenous infusion of 50 μg dexmedetomidine in normal saline.

Statistical Analysis Used:

IBM-SPSS software version 17, Chi-square test, Mann-Whitney U-test.

Results:

Demographic profile and surgical characteristics were similar in all the three groups. Sensory block and motor block onset was earlier in group D than in group D-IV and group C. The sensory block and motor block duration was also prolonged in group D when compared with group D-IV and group C. The duration of analgesia was significantly longer in group D and D-IV when compared to group C.

Conclusions:

Dexmedetomidine as an adjuvant to 0.5%ropivacaine in ultrasound guided brachial plexus block shortens the sensory as well as motor block onset time, prolongs sensory and motor block duration and also increases the duration of analgesia. The action of dexmedetomidine most probably is local rather than centrally mediated.

A comparative study evaluating the prophylactic efficacy of oral clonidine and tramadol for perioperative shivering in geriatric patients undergoing transurethral resection of prostate

Background and Aims:

Perioperative shivering, in geriatric patients undergoing urological surgery under central neuraxial blockade is a common complication. Prophylactic measures to reduce shivering are quintessential to decrease the morbidity and mortality. Believing that oral formulation will bring down the cost of treatment, we decided to compare the efficacy of oral clonidine and tramadol, as premedication, in prevention of shivering in patients undergoing transurethral resection of prostate (TURP) under spinal anesthesia in a prospective and double-blind manner.

Materials and Methods:

The patients were randomly allocated into three groups (40 patients each). Group I received oral clonidine 150 μg, Group II received oral tramadol 50 mg, while Group III received a placebo. Number of patients having shivering, their grades and duration, hemodynamic changes, and side-effects in the form of sedation were recorded. Data were analyzed using analysis of variance, Student's t-test, Z test as and when appropriate.

Results:

In group I and II, 38 patients (95%) and 37 patients (92.5%) did not shiver, respectively. Although in the group III, 24 patients (60%) exhibited no grade of shivering, the shivering was of significantly severe intensity and lasted for a longer duration. No, clinically significant collateral effects were observed in patients who were administered clonidine or tramadol.

Conclusions:

Oral clonidine and tramadol were comparable in respect to their effect in decreasing the incidence, intensity, and duration of shivering when used prophylactically in patients who underwent TURP under subarachnoid blockade.

Use of oral tramadol to prevent perianesthetic shivering in patients undergoing transurethral resection of prostate under subarachnoid blockade

Context:

Under regional anesthesia, geriatric patients are prone to shivering induced perioperative complications that Anesthesiologists should prevent rather than treat.

Aim:

We investigated the prophylactic efficacy of oral tramadol 50 mg to prevent the perioperative shivering after transurethral resection of prostate (TURP) surgery under subarachnoid blockade (SAB). Shivering is usually overlooked in patients undergoing urological surgery under spinal anesthesia and may result in morbidity, prolonged hospital stay and increased financial burden. Use of prophylactic measures to reduce shivering in geriatric patients who undergo urological procedures could circumvent this. Oral formulation of tramadol is a universally available cost-effective drug with the minimal side-effects.

Settings and Design:

Prospective, randomized, double-blinded, placebo-controlled study.

Patients and Methods:

A total of 80 patients who were scheduled for TURP surgery under subarachnoid block were randomly selected. Group I and II (n = 40 each) received oral tramadol 50 mg and placebo tablet respectively. After achieving subarachnoid block, the shivering, body temperature (tympanic membrane, axillary and forehead), hemodynamic parameters and arterial saturation were recorded at regular intervals.

Statistical Analysis Used:

T-test, analysis of variance test, Z-test and Fisher exact test were utilized while Statistical Product and Service Solutions, IBM, Chicago (SPSS statistics (version 16.0)), software was used for analysis.

Results:

Incidence of shivering was significantly less in patients who received tramadol (7.5% vs. 40%; P < 0.01). The use of tramadol was associated with clinically inconsequential side-effects.

Conclusion:

We conclude that the use of oral tramadol 50 mg is effective as a prophylactic agent to reduce the incidence, severity and duration of perioperative shivering in patients undergoing TURP surgery under SAB.