Track your trach: Removal of a fractured tracheostomy tube using a flexible fibreoptic bronchoscope in a patient with severe head injury.

Tracheostomy is a common airway procedure for life support in critically ill patients with head injuries. This procedure is safe but also associated with early and late complications. Tube fracture and dislodgement into the tracheobronchial tree leading to airway obstruction is a rare but life-threatening complication after prolonged tracheostomy tube placement. There are very few published reports of tracheostomy tube fracture and dislodgement into tracheobronchial tree in a neurologically injured patient. We report a case of a fractured tracheostomy tube which got impacted in the left main bronchus, in a 41-year-old male patient who had been on prolonged tracheostomy tube after craniotomy and evacuation of subdural hematoma. The distal part of the tracheostomy tube fractured and impacted in the left main bronchus. Fibreoptic bronchoscopy was performed through the oral cavity to extract it, and the anaesthetic management during the period is discussed.

A Randomized Double-Blind Controlled Trial to Assess the Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Cardiac Surgery.

OBJECTIVE: Cardiac surgical pain is of moderate-to-severe intensity. Ineffective pain control may lead to increased cardiopulmonary complications and poor surgical outcomes. This study aimed to assess the efficacy of ultrasound-guided erector spinae plane block in providing analgesia in adult cardiac surgeries. DESIGN: Prospective, randomized, double-blinded clinical trial. SETTINGS: Single-center, tertiary care hospital with university affiliation. PARTICIPANTS: Thirty patients of either sex, aged 18-to-60 years, body mass index 19-to-30 kg/m2, undergoing elective on-pump single-vessel coronary artery bypass grafting or valve replacement under general anesthesia. INTERVENTIONS: Patients were randomly categorized into two groups of 15 patients each to receive bilateral erector spinae plane block with 20 mL per side of 0.25% levobupivacaine (group E) or sham block with 20 mL of normal saline (group C). MAIN RESULTS: Mean analgesic requirement in terms of fentanyl equivalents (µg) in the first 24 hours postoperatively was 225 ± 112 in group E and 635 ± 145 in group C (95% confidence interval, 313.10-506.90; p < 0.05). Mean time to first rescue analgesia was 356.9 ± 34.5 in group E and 123.9 ± 13.1 minutes in group C (p < 0.05). Cox proportional hazard ratio for rescue analgesic requirement in group E-to-group C was 5.0. Duration of mechanical ventilation was 88.4 ± 17 and 103.5 ± 18 minutes in groups E and C, respectively (p < 0.05). Ramsay sedation score at six hours postextubation was 1.45 ± 0.53 in group E and 3.19 ± 0.62 in group C (p < 0.05). Mean numerical rating score was 3.67 ± 1.41 in group E and 4.50 ± 1.00 in group C (p = 0.17). No significant differences were observed in the incidences of postoperative nausea vomiting, pruritus, and erector spinae plane block-related infection and pneumothorax. CONCLUSION: Single-shot erector spinae plane block provides superior analgesia as compared with sham block. It decreased the first 24-hour postoperative analgesic consumption by 64.5% and risk of pain by five times in the authors' population. It also reduced the sedation and duration of mechanical ventilation in postcardiac surgery patients.

A randomised controlled comparison of video versus instructor-based compression only life support training.

BACKGROUND AND AIMS: Sudden cardiac deaths remain a major health problem worldwide. Most of these cases generally involve out of hospital cardiac arrest, making the role of bystander resuscitation very crucial. In the developing countries, illiteracy and scarcity of health professionals is a great barrier to cardiopulmonary resuscitation (CPR) training. Video-based CPR training can offer an easily accessible modality in these situations. Hence, this study was conducted with an aim to assess the efficacy of video-based training in comparison to the traditional instructor-based CPR training in layman. METHODS: This prospective cross-over observational study included 109 undergraduate university students attending voluntary resuscitation training and were randomly divided into two groups of video-based demonstration (VBD) and instructor-based demonstration (IBD) of compression only life support (COLS). They were then assessed for psychomotor skill development (Laerdal Simpad Plus Q-CPR) and perception about the quality of training methodology as primary and secondary objectives, respectively. RESULTS: Population characteristics were similar in both the groups. In the VBD, scene safety was performed by 95.2% and call for help by 97.6%, and by 76.1% each in the IBD group (P < 0.05). Response to compression time (RCT) was significantly shorter in VBD (35 ± 9 sec) as compared to IBD (54 ± 14 sec) (P < 0.001). However, the proportion of participants performing response check, correct site identification, and other parameters were comparable. CONCLUSION: Video-based COLS training significantly decreased the RCT by 35% compared to traditional instructor-based training. However, other features of high-quality CPR remain comparable.

A Randomized Control Trial of Awake Oral to Submental Conversion versus Asleep Technique in Maxillofacial Trauma.

AIM: This study was designed to evaluate the efficacy of awake oral to submental conversion over asleep technique. MATERIALS AND METHODS: This randomized clinical study was conducted in maxillofacial department of a tertiary care hospital in patients who had panfacial or mandibular fractures requiring elective surgical correction. The patients were randomly divided into two groups of 12 patients each, asleep fiberoptic-assisted submental intubation (SMI) (Group G; n = 12) and awake fiberoptic-assisted SMI (Group A; n = 12). The primary predictor was mean conversion time of oral to SMI while other predictors were overall success rate, ease of conversion, and complications. Data are presented as mean (±standard deviation) and frequencies (%) as appropriate. Statistical analysis done using unpaired t-test or Chi-square test was performed and P < 0.05 was considered statistically significant. RESULTS: Twenty-four patients (19:5;Male:Female) aged 18-55 years (Group G = 35.96; Group A = 32.43 years) were included in the study. SMI was successful in all except two patients in group G. Overall success rate was similar in both groups. Time to convert orotracheal intubation to SMI was significantly less in group A (Group G = 9.55 ± 1.42, Group A = 5.67 ± 1.73; P < 0.001). Ease of SMI was found Grade I in 30% and 83% of the patients of group G and A, respectively. No serious complications were observed except 2 cases of bleeding, and 1 case of tube damage. CONCLUSION: Awake oral to submental conversion requires lesser time in comparison to asleep technique besides improving the ease (Δ = 53%) of the procedure.

Comparison of endotracheal intubation time in neutral position between C-Mac® and Airtraq® laryngoscopes: A prospective randomised study.

BACKGROUND AND AIMS: In the recent past, many novel devices such as AirTraq® and C-MAC® video laryngoscope (VL) have been introduced in an attempt to reduce anaesthetic morbidity and mortality associated with difficult intubation. In this study, we aimed to evaluate and compare C-MAC® VL with a standard Macintosh blade and the AirTraq® optical laryngoscope as a intubating devices with the patient's head in neutral position. METHODS: Sixty American Society of Anesthesiologist Physical Status I-II patients were randomly assigned to be intubated with C-MAC® VL (Group CM; n = 30) or AirTraq® (Group AT; n = 30) in the neutral position, with or without the application of optimization manoeuvres. The primary outcomes of this study were the success rate and the time taken to intubate. Glottic view, ease of tracheal intubation and haemodynamic responses were considered as secondary end points. RESULTS: The incidence of successful intubation was similar in both the groups (P = 1.00). However, the time for intubation was significantly less with C-MAC® VL (Group CM = 14.9 ± 12.89 s, Group AT = 26.3 ± 13.34 s; P = 0.0014). There was no significant difference between the two groups in terms of ease of intubation and glottic view. However, the haemodynamic perturbations were much less with C-MAC® VL. CONCLUSION: We conclude that both the devices were similar in visualising larynx in the neutral position with similar success rates of intubation. However, the C-MAC® VL was better with respect to intubation time and haemodynamic stability.

Levobupivacaína o ropivacaína: un ensayo aleatorio doble ciego controlado con dosis equipotentes en la anestesia espinal / Levobupivacaine or ropivacaine: A randomised double blind controlled trial using equipotent doses in spinal anaesthesia

Introduction: Levobupivacaine and ropivacaine are relatively new local anaesthetics developed in order to address the issue of bupivacaine toxicity Although certain differences do exist between their pharmacological profiles, its clinical relevance at equipotent doses is not evident so far Objective: To compare the efficacy and characteristics of equipotent doses of intrathecal levobupivacaine with ropivacaine Methodology: Sixty ASA grade I/II patients of 18-60 years, either sex posted for lower limb orthopaedic surgery under spinal anaesthesia were randomly given either 15 mg levobupivacaine or 22.5 mg ropivacaine. Sensory and motor block, haemodynamic characteristics, as well as any side effects, were recorded Results: Onset of sensory block to T10 was more rapid in group R than group L, p < 0.0001. The median (range) height achieved in group R was T7 (T5-T10) while in group L was T7 (T4-T10). Time to reach maximum height and time to modified Bromage grade 3 was shorter in group R as compared to group L, p < 0.0001. Levobupivacaine produced significantly longer (290.50 ± 34.67) duration of motor block compared to ropivacaine (222.50 ± 23.00). Duration of analgesia was significantly longer in group L (309.83 ± 36.45) than group R (249.50 ± 22.83). No serious adverse effects were recorded. Conclusion: Levobupivacaine produces significantly longer duration of analgesia than ropivacaine when used in a ratio of 0.6:1. Efficacy, toxicity and haemodynamic profile make ropivacaine suitable agent for surgeries with low threshold for hypotension.

Introducción: La levobupivacaína y la ropivacaína son anestésicos locales relativamente nuevos, desarrollados con el fin de abordar la cuestión de la toxicidad de la bupivacaína. Aunque existen ciertas diferencias entre sus perfiles farmacológicos, su relevancia clínica en dosis equipotentes no es evidente hasta ahora. Objetivo: Comparar la eficacia y las características de las dosis equipotentes de levobupiva-caína por vía intratecal con las de ropivacaína. Metodología: A Sesenta pacientes de grado ASA I/II de 18 a 60 años y de ambos sexos, programados para cirugía ortopédica del miembro inferior bajo anestesia espinal, se les dio al azar o bien 15 mg de levobupivacaína o 22,5 mg de ropivacaína. El bloqueo motor, el bloqueo sensorial, las características hemodinámicas y cualquier otro efecto secundario fueron registrados. Resultados: El inicio del bloqueo sensorial en T10 fue más rápido en el grupo R que en el grupo L, p < 0,0001. El nivel mediano (rango) alcanzado en el grupo R fue T7 (T5-T10), mientras en el grupo L fue T7 (T4-T10). El tiempo para alcanzar el nivel máximo y para alcanzar un grado 3 en la escala de Bromage fue más breve en el grupo R en comparación con el grupo L, p < 0,0001. La levobupivacaína produce una duración significativamente más larga (290.50 ± 34.67) del bloqueo motor que la ropivacaína (222.50 ± 23.00). La duración de la analgesia fue significativamente más larga en el grupo L (309.83 ± 36.45) que en el grupo R. No se registraron efectos adversos graves. Conclusión: La levobupivacaína produce una duración de la analgesia significativamente más larga que la ropivacaína cuando se utiliza en una proporción de 0,6:1. La eficacia, toxicidad y perfil hemodinámico hacen de la ropivacaína un agente adecuado para cirugías con un umbral bajo de hipotensión.

Correlation between central venous pressure and peripheral venous pressure with passive leg raise in patients on mechanical ventilation.

BACKGROUND: Central venous pressure (CVP) assesses the volume status of patients. However, this technique is not without complications. We, therefore, measured peripheral venous pressure (PVP) to see whether it can replace CVP. AIMS: To evaluate the correlation and agreement between CVP and PVP after passive leg raise (PLR) in critically ill patients on mechanical ventilation. SETTING AND DESIGN: Prospective observational study in Intensive Care Unit. METHODS: Fifty critically ill patients on mechanical ventilation were included in the study. CVP and PVP measurements were taken using a water column manometer. Measurements were taken in the supine position and subsequently after a PLR of 45°. STATISTICAL ANALYSIS: Pearson's correlation and Bland-Altman's analysis. RESULTS: This study showed a fair correlation between CVP and PVP after a PLR of 45° (correlation coefficient, r = 0.479; P = 0.0004) when the CVP was <10 cmH2O. However, the correlation was good when the CVP was >10 cmH2O. Bland-Altman analysis showed 95% limits of agreement to be -2.912-9.472. CONCLUSION: PVP can replace CVP for guiding fluid therapy in critically ill patients.