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.

Comparison of the Analgesic Efficacy of Ultrasound-Guided Superficial Serratus Anterior Plane Block With Deep Serratus Anterior Plane Block in Patients Undergoing Modified Radical Mastectomy: A Randomized Clinical Trial.

Background Acute postoperative pain after breast cancer surgery adversely affects recovery and is an independent predictor of chronic postsurgical pain in these patients. Serratus plane blocks have been found to provide analgesia to the anterior hemithorax. However, trials comparing superficial serratus plane block and deep serratus block in breast cancer surgery patients are sparse. Methodology A total of 74 female patients with American Society of Anesthesiologists physical status I and II scheduled for elective modified radical mastectomy for breast cancer were randomized into two groups. Group A patients received a superficial serratus plane block with 30 mL of 0.25% bupivacaine, and group B patients received a deep serratus plane block with 30 mL of 0.25% bupivacaine. Postoperatively, the Numerical Rating Scale (NRS) score was measured during the immediate postoperative period, after 30 minutes and at one, four, eight, 16, and 24 hours, as well as on the second and third day. After discharge, the NRS scores were recorded in the second and third weeks and then monthly once for three months. All patients received patient-controlled analgesia with intravenous (IV) morphine. The duration of analgesia, pain scores, and 24-hour morphine consumption were also noted. Results In group A, the mean duration of analgesia (hours) was 5.51 ± 1.42, whereas in group B the mean duration of analgesia (hours) was 6.69 ± 1.18 (p < 0.01). NRS scores for pain during rest at 12 and 16 hours and NRS scores for pain during cough at eight, 12, and 16 hours, as well as at the third month were significantly lower in group B. However, morphine consumption was comparable between the groups. Conclusions Deep serratus plane block was associated with better NRS scores for pain on rest and coughing and prolonged duration of analgesia after a modified radical mastectomy. We conclude that the deep serratus plane block provides superior and extended analgesia than the superficial serratus plane block after a modified radical mastectomy.

Comparing the efficacy of modified thenar eminence technique with conventional thenar eminence technique of mask ventilation during induction of general anaesthesia - A randomised crossover study.

Background and Aims: Mask ventilation is one of the important skills required for successful airway management. Following the induction of general anaesthesia, there could be airway obstruction due to fall back of the tongue or soft palate. This obstruction could be overcome by manoeuvring the mandible or inserting airways. The primary objective of the study was to compare the efficacy of modified thenar eminence technique of mask ventilation in improving expired tidal volume (VTE) over conventional thenar eminence technique and the secondary objective was to compare peak airway pressure (PMAX) and ease of mask ventilation between the two techniques. Methods: Seventy-six patients were randomised into group M and group C. In group M, the modified thenar eminence technique was performed for five consecutive breaths followed by conventional technique, and vice versa was followed in group C. In each breath, VTE, PMAX and end-tidal carbon dioxide were noted. Participants reported the ease of ventilation score using the Likert scale for each technique. Results: VTE was significantly more in modified thenar eminence technique than conventional technique [mean ± standard deviation, 370 ± 55 ml versus 313 ± 50 ml, P = 0.01]. Ease of ventilation score [median 1.70 (interquartile range (1-2)) versus 2.3 (2-3), P = 0.01] showed that modified technique was easier compared to conventional technique. Conclusion: Modified thenar eminence technique of mask ventilation is superior to the conventional technique in terms of VTE and ease of ventilation in the unanticipated difficult airway.

Comparison of clinical methods to diagnose pediatric endobronchial intubation-A randomized controlled trial.

BACKGROUND AND AIMS: Diagnosing accurate placement of the tip of the endotracheal tube is crucial in pediatric practice. This study was conducted to find out the efficacy of five clinical methods to ascertain the tube position by a resident anesthesiologist. MATERIAL AND METHODS: This was a randomized crossover study conducted in a research institute. Fifty pediatric patients were enrolled. All patients were randomly allocated to tracheal (group T) or bronchial group (group B). The five clinical methods which were evaluated include the auscultation, observation of chest movements, bag compliance, tube depth, and capnography. In group T, the tube was placed in the trachea and later positioned in bronchus (assisted by fiberoptic bronchoscopy). The vice versa was done in group B. In each position, a single test followed by all tests was performed and after the change of position, the same single test followed by all tests was performed. Correct and incorrect diagnoses by tests in detecting tube positions were made and their sensitivity and odds ratio were estimated. RESULTS: The tube depth and combination of all tests detected endobronchial intubation with a sensitivity of 88% and 97%, respectively, which is more than that of auscultation (70%) and observation (55%). Evaluation of the difference in agreement level of tube depth to detect tube-position showed the odds ratio of 2.28 (0.17-30.95) for detecting endobronchial intubation. CONCLUSION: We observed that the tube-depth was better than the other individual tests in diagnosing endobronchial intubation in pediatric patients. However, its efficacy is lesser than that of performing all clinical tests together.

Comparison of medication acceptance of intranasal midazolam administered by parents versus doctors in children - A randomized trial.

BACKGROUND: The positive effects of midazolam as a premedication in pediatric patients are well documented. Although there are many studies regarding the route and dosage of administration, literature does not have any evidence on the outcome of medication acceptance based on the person administering the drug. AIM: The aim of this study was to compare the medication acceptance and preoperative anxiolysis of intranasal midazolam administered by parents and anesthesiologists. MATERIALS AND METHODS: This prospective randomized study was conducted in sixty children belonging to the American Society of Anesthesiologists Class 1 or 2 belonging to either sex, aged between 1 and 9 years, undergoing elective surgeries. Group P received intranasal midazolam administered by parents, whereas Group D received intranasal midazolam administered by doctors. Various scores were assessed. RESULTS: Children were more sedated in Group P. Clinically, medication acceptance was better in Group P when compared with Group D, but a statistically significant difference in medication acceptance was seen only in patients who are >4 years of age. Parental separation, Ramsay Sedation Score, and mask acceptance were better in Group P than in Group D. CONCLUSION: Intranasal midazolam when given by parents produces better preoperative anxiolysis and easier parental separation as compared with administration by a medical staff.

Correlation between correctly sized uncuffed endotracheal tube and ultrasonographically determined subglottic diameter in paediatric population.

BACKGROUND AND AIMS: Conventional age-based formulae often fail to predict correct size of endotracheal tube (ETT). In this study, we evaluated usefulness of ultrasound in determining appropriate tube size and derived a formula which enables us to predict correct tube size. METHODS: A total of 41 American Society of Anesthesiologists' physical status 1 and 2 children in the age group of 2-6 years, undergoing elective surgery under general anaesthesia with uncuffed ETT were included in the study. Ultrasonography (US) was used to measure the subglottic diameter after induction of anaesthesia. The trachea was intubated with an ETT that allowed an audible leak between 15-30 mmHg. Pearson's correlation was used to assess the correlation between US measured subglottic diameter (US-SD) with diameter of ETT used. Linear regression was used to derive a formula for predicting ETT size. RESULTS: We found that US-SD and patient's age correlated well with actual ETT OD (r: 0.83 and 0.84, respectively). Age-based formula, ETT ID = (Age/3) +3.5 [r: 0.81] had better correlation with actual ETT OD than conventional age-based Cole's formula, i.e., ETT ID = Age/4 + 4 [r: 0.77]. Our results enabled us to derive a formula for selecting uncuffed ETT based on US-SD. CONCLUSION: Our study concludes that although US-SD correlates with actual tracheal tube used and may be useful in choosing appropriate size ETT, there was no difference in number of correct predictions of ETT size by US measurement, universal formula, and locally derived formula.

Psychomotor recovery of dexmedetomidine compared with propofol after sedation during spinal anesthesia: A randomized control trial.

BACKGROUND AND AIMS: Early psychomotor recovery is an essential part of day care surgery which depends on brain integration of motor and sensory co-ordination. Even though dexmedetomidine is commonly used for day care procedures, the recovery profile was not studied. Hence, this study was designed to evaluate the psychomotor recovery of sedation with dexmedetomidine during spinal anesthesia. MATERIAL AND METHODS: Sixty-six patients were included. Group D received dexmedetomidine 0.5 µg/kg (loading dose) followed by 0.2-1 µg/kg/hour. Group P received propofol infusion of 25-100 µg/kg/minute. Psychomotor recovery was assessed by finger-tapping, manual dexterity, visual spatial memory capacity, and pen and paper tests. Psychomotor tasks were given to the patients postoperatively at every 30 minutes for 2 hours followed by every hour up to 4 hours after surgery. Distribution of patients, age, weight, duration of surgery, and the level of sensory blockade was compared using independent t-test. Student's t-test has been used to find the significance of parameters such as heart rate, mean arterial pressure, oxygen saturation (SpO2), psychomotor recovery between two groups. P < 0.05 was considered as significant. RESULTS: The motor recovery using finger tapping test was faster in Group D than Group P (73.94 ± 42.13 vs 101.21 ± 37.98 minutes, P-value = 0.007). Motor recovery using peg board test was faster in Group P than Group D (82.12 ± 40.37 vs 99.39 ± 43.08 minutes, P-value = 0.098). Visual spatial capacity memory test and pen and paper test were unaffected. CONCLUSIONS: We conclude that patients who received dexmedetomidine showed earlier recovery with finger tapping test. Hence, we suggest to use dexmedetomidine for complete psychomotor recovery and fast-track discharging of the patient after spinal anesthesia.

Comparing slow and rapid bolus of ephedrine in pregnant patients undergoing planned cesarean section under spinal anesthesia.

BACKGROUND AND AIMS: While ephedrine was the preferred drug for treating spinal-induced hypotension in pregnancy, its use has declined because of resultant fetal acidosis. The objective of this randomized control trial was to compare the effects of a slow and rapid bolus of ephedrine on fetal acidosis, maternal blood pressure, and heart rate (HR) during cesarean section performed under spinal anesthesia. MATERIAL AND METHODS: Eighty full-term parturients scheduled for cesarean section under spinal anesthesia were randomly allocated into two groups. While both groups received 6 mg of ephedrine to treat hypotension, Group R (n = 40) received it as a rapid intravenous bolus and Group S (n = 40) received it slowly over 20 s with an infusion pump. The maternal vital parameters were recorded until delivery of the baby using a video camera. Umbilical cord blood was obtained using the three clamp method. Hemodynamic parameters, fetal acidosis, total number of ephedrine bolus used, peak HR after the ephedrine bolus, and occurrence of postoperative nausea and vomiting (PONV) were compared between the groups. RESULTS: Mean increase in HR and blood pressure were significantly higher in Group R than the Group S after the first ephedrine bolus. Umbilical artery pH was significantly lower in Group R than in Group S (7.2 [6.8-7.3] vs. 7.3 [7.3-7.4], P < 0.01). A total number of ephedrine boluses were comparable in the two groups. 35% of the patients had PONV in Group R, whereas none had it in Group S (P < 0.01). CONCLUSION: Slow bolus of ephedrine is better than rapid bolus to treat spinal-induced hypotension during cesarean section in view of less fetal acidosis.

Evaluation of simple pre-determined length insertion technique (SPLIT) with conventional method for oral fibreoptic intubation: A randomised cross-over study.

BACKGROUND AND AIMS: The difficulty during flexible fiber-optic bronchoscopy (FOB) guided tracheal intubation could be because of inability in visualising glottis, advancing and railroading of endotracheal tube. Several methods are available for visualising glottis, but none is ideal. Hence, this randomised controlled study was designed to evaluate the simple pre-determined length insertion technique (SPLIT) during oral FOB. METHODS: Fifty-eight patients were randomised into Group C and Group P. General anaesthesia was maintained with sevoflurane and oxygen in spontaneous respiration. In Group C, conventional flexible fiberoptic laryngoscopy was done followed by SPLIT and vice versa in Group P. The time to visualise the glottis (T1), from glottic visualisation to pass beyond glottis (T2) and from incisors to pass beyond the glottis (T3) were noted from the recorded video. The time interval was analysed using Wilcoxon matched pairs test and Mann-Whitney U-test. RESULTS: The T1 was significantly less in SPLIT as compared to conventional technique (13 [10, 20.25] vs. 33 [22, 48] s). The T3 was significantly less in SPLIT (24.5 [19.75, 30] vs. 44 [34, 61.25] s). The T1 by SPLIT was comparable between residents and consultants (P = 0.09), whereas it was significantly more among residents than the conventional technique. The SPLIT was preferred by 91.3% anaesthesiologists. CONCLUSION: The SPLIT significantly lessened the time to visualise the glottis than conventional technique for FOB. The SPLIT was the preferred technique. Hence, we suggest using the SPLIT to secure the airway at the earliest and also as an alternative to conventional technique.

Back to the drawing board-relearn the clinical skills: A root cause analysis of a missed case of bilateral vocal cord paralysis.

Bilateral vocal cord paralysis being misdiagnosed as bronchial asthma has been reported in the literature on several occasions. Diagnosing this condition needs precise clinical acumen which could lead us to make an integrated diagnostic and treatment plan. Here, we report another missed case of bilateral vocal cord paralysis and the root cause analysis of the incident. This report emphasises the need for appropriate clinical examinations and workup during the pre-operative assessment.

Diagnostic accuracy of bedside tests for predicting difficult intubation in Indian population: An observational study.

BACKGROUND: Unanticipated difficult intubation can be challenging to anesthesiologists, and various bedside tests have been tried to predict difficult intubation. AIMS: The aim of this study was to determine the incidence of difficult intubation in the Indian population and also to determine the diagnostic accuracy of bedside tests in predicting difficult intubation. SETTINGS AND DESIGN: In this study, 200 patients belonging to age group 18-60 years of American Society of Anesthesiologists I and II, scheduled for surgery under general anesthesia requiring endotracheal intubation were enrolled. Patients with upper airway pathology, neck mass, and cervical spine injury were excluded from the study. MATERIALS AND METHODS: An attending anesthesiologist conducted preoperative assessment and recorded parameters such as body mass index, modified Mallampati grading, inter-incisor distance, neck circumference, and thyromental distance (NC/TMD). After standard anesthetic induction, laryngoscopy was performed, and intubation difficulty assessed using intubation difficulty scale on the basis of seven variables. STATISTICAL ANALYSIS: The Chi-square test or student t-test was performed when appropriate. The binary multivariate logistic regression (forward-Wald) model was used to determine the independent risk factors. RESULTS: Among the 200 patients, 26 patients had difficult intubation with an incidence of 13%. Among different variables, the Mallampati score and NC/TMD were independently associated with difficult intubation. Receiver operating characteristic curve showed a cut-off point of 3 or 4 for Mallampati score and 5.62 for NC/TMD to predict difficult intubation. CONCLUSION: The diagnostic accuracy of NC/TM ratio and Mallampatti score were better compared to other bedside tests to predict difficult intubation in Indian population.

Comparison of different regimens of intravenous dexmedetomidine on duration of subarachnoid block.

BACKGROUND AND AIMS: Many studies have studied the effect of intravenous dexmedetomidine on the prolongation of the duration of the subarachnoid block (SAB). These studies had administered dexmedetomidine using different regimens. This study was designed to find out the suitable regimen with maximum advantages and minimum disadvantages. MATERIAL AND METHODS: Ninety-three ASA 1 and 2 patients scheduled to undergo surgeries under SAB were randomly allocated into three groups namely B, M, and BM. After SAB, Group B received 0.5 µg/kg of dexmedetomidine bolus over 15 min, Group M received 0.5 µg/kg/h of dexmedetomidine infusion until the end of surgery, Group BM received both bolus and infusion. RESULTS: The time to achieve T10 sensory level (SL) was significantly faster in the Groups B and BM than in the Group M. Maximum block height achieved was T4 and was same in all the groups. The Time to achieve maximum SL and Bromage 3 was comparable in all groups. The two-segment regression time and time to reach Bromage 0 was significantly higher in Groups M and BM than Group B. The time for a first request of analgesia was similar in Groups M and BM. The maximum sedation attained in all groups was Ramsay Sedation Score of 3. Side effects such as bradycardia, hypotension, and desaturation were comparable between the groups. CONCLUSION: We conclude that the continuous infusion of dexmedetomidine results in more advantages than just a bolus dose. Therefore, we suggest using only the maintenance dose of intravenous dexmedetomidine after subarachnoid blockade for prolonging the duration and achieving sedation.

ECG artefacts mimicking atrial flutter in posterior fossa surgery.

ECG artefacts are defined as abnormalities in the monitored ECG, which result from measurement of cardiac potentials on the body surface and are not related to the electrical activity of the heart. In the operation theatre, the use of various types of electrical equipment may interfere with ECG interpretation. We describe our experience with artefacts resembling atrial fibrillation when a nerve integrity monitoring device was used on a patient undergoing posterior fossa surgery for epidermoid tumour. These artefacts resemble serious arrhythmias and may result in unwanted interventions. To enable better identification of such artefacts, a 12-lead ECG should be considered as it will display rhythm in all the leads; while artefacts will present in only a few leads, true arrhythmia will be present in all the 12 leads. Our case report aims to increase awareness regarding ECG artefacts and to explain how to distinguish them from actual arrhythmias.

Comparison of i-gel supraglottic airway and LMA-ProSeal™ in pediatric patients under controlled ventilation.

BACKGROUND: i-gel™ and the ProSeal™ laryngeal mask airway (PLMA) are two supraglottic airway devices with gastric channel used for airway maintenance in anesthesia. This study was designed to evaluate the efficacy of i-gel compared with PLMA for airway maintenance in pediatric patients under general anesthesia with controlled ventilation. MATERIALS AND METHODS: A total of 60 American Society of Anesthesiologists physical status 1 and 2 patients were included in the study and randomized to either i-gel or PLMA group. After induction of anesthesia using a standardized protocol for all the patients, one of supraglottic airway devices was inserted. Insertion parameters, ease of gastric tube insertion and fiber-optic scoring of the glottis were noted. Airway parameters such as end-tidal carbon dioxide (EtCO2), peak airway pressures and leak airway pressures were noted. Patients were observed for any complications in the first 12 h of the post-operative period. RESULTS: Both groups were comparable in terms of ease of insertion, number of attempts and other insertion parameters. Ease of gastric tube insertion, EtCO2, airway pressures (peak and leak airway pressure) and fiber-optic view of the glottis were comparable in both groups. There were no clinically significant complications in the first 12 h of the post-operative period. CONCLUSION: i-gel is as effective as PLMA in pediatric patients under controlled ventilation.