Predicting Difficult Intubation by using Modified Mallampati (MMT) with or without Thyromental Height Test (TMHT)

Failed Tracheal Intubation with Subsequent inability to maintain an open airway and adequate oxygenation is the most frequent cause of brain damage or death during anesthesia. Recognizing before anesthesia the potential for difficult intubation allows time for optimal preparation. Proper Selection of equipment and techniques is needed to avoid unwanted situation. To find out difficulties associated with endotracheal intubation using Modified Mallampati Test (MMT) combined with Thyromental Height Test (TMHT) and MMT without TMHT. This prospective observational study was conducted at the Department of Anesthesia in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from April 2018 to September 2018. Two hundred two patients with different surgical procedures under general anaesthesia in different operation theaters of BSMMU, Dhaka were selected as study population. After taking written consents from each patient or his/her attendant elaborate history of illness, meticulous clinical examinations were performed and relevant laboratory investigations were done. All information was recorded in a preformed data sheet and statistical analysis was done by SPSS-22.0. Mean age ±SD of the study subjects was 42.49±14.29 years in MMT with TMHT group and 43.40±15.39 years in MMT without TMHT group. Females were enrolled more than males in both the groups. BMI was 28.75±3.59kg/m² in MMT with TMHT group and 29.44±8.64kg/m² in MMT without TMHT group. There were no significant differences in age, gender and BMI between the groups. Sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 96.0%, 96.2%, 100.0% and 98.0% respectively of MMT with TMHT in predicting intubation difficulty. Sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 96.0%, 96.2%, 100.0% and 98.0% respectively of MMT only in predicting intubation difficulty. MMT combined with TMHT is a better predictor of intubation difficulty than MMT alone.

Impact of Prehospital Pain Management on Emergency Department Management of Injured Children

OBJECTIVE

Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS.

METHODS

This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions.

RESULTS

We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care.

CONCLUSIONS

We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

A Systematic Review of a Long-forgotten Cause of Atrial Fibrillation and Stroke: Cor Triatriatum

Cor triatriatum is a rare congenital cardiac condition characterized by the division of one atrium into two chambers by a fibromuscular membrane, resulting in three atrial chambers. The goal of this study was to determine the associations of cor triatriatum with cyanosis, atrial fibrillation (AF), and stroke.

MEDLINE (PubMed, Ovid), Embase, and Cochrane databases were searched on April 25, 2019, for relevant articles on cor triatriatum. After initial screening and removal of duplicates, 235 articles were selected. Data were extracted from these articles, including types, presentations, diagnostic findings, management, and outcomes of patients with cor triatriatum.

Approximately 83% of patients with cor triatriatum had cor triatriatum sinistrum (CTS) and 17% had cor triatriatum dextrum (CTD). The mean age of all patients was 29±23 years. Mean ages at diagnosis differed significantly in patients with CTS and CTD (31±23 years vs. 21±20 years, p=0.02). CTS showed a significantly greater association with AF (14.65% vs. 12.5%, p=0.036) and had a substantially higher risk of stroke (7.9% vs. 5.0%, p=0.04) than CTD. CTS also had a numerically higher association with atrial septal defects (15.13% vs. 15.6%), but this difference was not statistically significant (p=0.89). In contrast, cyanosis at presentation was significantly more frequent in patients with CTD than CTS (5.5% vs. 5.3%, p=0.05). Management did not differ significantly between these groups (p=0.29). The overall mortality rate was 16%, with no significant difference between patients with CTS and CTD (p=0.33).

The higher likelihood of AF and stroke in CTS than in CTD patients warrants treatment of the former with anticoagulation agents, irrespective of their CHA₂DS₂-VASc scores (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex category). Patients with CTS usually present at an older age due to their lower risk of cyanosis and asymptomatic AF.

Primary glaucoma triple procedure with or without adjunctive mitomycin. Prognostic factors for filtration failure

PURPOSE

The prerequisite for selective use of adjunctive mitomycin C (MMC) in primary glaucoma triple procedure (PGTP) is a better understanding of the prognostic factors. Therefore, the authors carried out the current study on the outcome of PGTP with and without adjunctive MMC to determine the prognostic factors for filtration failure of PGTP.

METHODS

The study patients consisted of 174 consecutive primary open-angle glaucoma (POAG) patients undergoing PGTP. They were assigned randomly to either no adjunctive MMC (93 eyes of 93 patients) or adjunctive subconjunctival MMC (81 eyes of 81 patients) during the PGTP. After surgery, the patients were examined at regular intervals for visual acuity, intraocular pressure (IOP) control, medical therapy requirements, and complications. Filtration failure was determined according to two different criteria: (1) a less stringent set of criteria (criterion I) and (2) a more stringent set of criteria (criterion II).

RESULTS

There were no statistically significant differences between the groups with and without adjunctive MMC with respect to postoperative IOP, number of medications, and visual acuity outcome during mean follow-up (+/- standard deviation) of 25.1 +/- 5.5 months (P > 0.05 for each). However, there were prognostic factors for filtration failure in the control group but not in the MMC group. Black race, diabetes mellitus, preoperative IOP greater than or equal to 20 mmHg, and number of preoperative medications greater than two were found to be significant prognostic factors for filtration failure by criterion I. Black race, preoperative IOP greater than or equal to 20 mmHg and number of preoperative medications greater than 1 were significant prognostic factors for filtration failure by criterion II.

CONCLUSION

There was no statistically significant difference in the overall outcome of PGTP between control and MMC groups of nonselected patients with primary open-angle glaucoma. Black race, diabetes mellitus (by criterion I only), preoperative IOP greater than or equal to 20 mmHg, and number of preoperative medications greater than 2 (by criterion I) or greater than 1 (by criterion II) were found to be significant independent prognostic factors for filtration failure of PGTP without adjunctive MMC but no with adjunctive MMC. The use of adjunctive subconjunctival MMC in PGTP may have to be selective, primarily in those patients with primary open-angle glaucoma with one or more of the prognostic factors for filtration failure.