The Preoperative Fasting Conundrum: An Audit of Practice in a Tertiary Care Children's Hospital.

OBJECTIVE: This article aimed to study preoperative fasting times in children undergoing elective surgery and to analyze the effect of active interventions conducted to promote compliance with current fasting guidelines. METHODS: An initial audit was performed in which 85 children up to 15 years of age posted for elective surgeries were surveyed. A question- naire was circulated among nurses, resident medical officers, and surgeons to assess their knowledge regarding recent fasting guidelines and its importance. The mean preoperative fasting times were found to be much longer than the recommended guidelines. Interventions were carried out to spread awareness about recent preoperative fasting guidelines. A re-audit was done 4 months after the initial audit. RESULTS: The initial audit revealed a mean preoperative fasting time for solids and water to be 9.43 hours and 6.64 hours, respectively. About 43.6% of hospital staff believed "fasting from midnight" regimen is the best method to prevent pulmonary aspiration. Incorrect orders by doctors (47%) and ward nurses (38%) were found to be important causes of non-adherence. After the intervention, mean preoperative fasting times for solids and water decreased to 7.7 hours and 2.6 hours, respectively. CONCLUSION: Adopting simple measures such as education and multidisciplinary teamwork can optimize fasting duration and children's experi- ences preoperatively.

Comparative Study of Three Methods for Depth of Central Venous Catheter Placement in Children: An Observational Pilot Study.

OBJECTIVE: Central venous cannulation of the internal jugular vein is difficult in paediatric patients because of the small size of the vein and anatomic variations. Many studies have shown the accuracy of various formulae for calculating the depth of placement. The aim of this study was to assess the most reliable method for central venous catheter (CVC) tip placement in paediatric patients. METHODS: Sixty-nine patients in the age groups from 0 to 12 years were divided in three groups for three published techniques for catheter tip placement. In Group E, catheter tip was placed at the distance measured from entry point to sternal angle. In Groups P and H, Peres and trans-oesophageal echocardiography (TEE)-derived formulae, respectively, were used for catheter placement. Post-procedure chest radiograph was performed for all patients, and tip position was recorded. Appropriate catheter tip position was considered just above or at the level of carina. The number of attempts and complications were recorded. Chi-square test was used for statistical analysis. RESULTS: Of 69 patients, 65% of patients in Group P, 52% in group H and 91% in group E had appropriate CVC tip placement. The chi-square test showed that the difference in the number of patients with appropriately positioned CVC tip among the three groups was statistically significant (p=0.0134), with intergroup analysis showing Group E to be superior. One patient had an episode of arrhythmia during guide wire insertion and was resuscitated successfully. CONCLUSION: Catheter tip placement by external distance or landmark technique is a more accurate method for catheter placement than the Peres and TEE-based formulae. It does not require measurement of patients' height and reduces the chances of repositioning of catheter.

Comparison of analgesic efficacy and safety of continuous epidural infusion versus local infiltration and systemic opioids in video-assisted thoracoscopic surgery decortication in pediatric empyema patients.

INTRODUCTION: The stripping of the densely innervated and inflamed parietal pleura in empyema during video-assisted thoracoscopic surgery (VATS) decortication can lead to significant pain and major postoperative respiratory compromise. Hence, we compared the analgesic efficacy of continuous epidural infusion versus local infiltration and systemic opioids in children undergoing VATS decortications. METHODOLOGY: Following ethics approval and informed consent, forty patients from 1 to 12 years of age were randomized into two groups, Group E (epidural) and Group L (local infiltration) after induction of anesthesia. In Group E, a thoracic epidural catheter was inserted between T4 and T8. A bolus dose of 0.5 ml/kg of 0.25% injection bupivacaine was given epidurally before incision. Postoperatively, the patients received epidural infusion with bupivacaine and fentanyl up to 48 h using an elastomeric balloon pump. In Group L, patients received local infiltration of bupivacaine (2 mg/kg) and lignocaine (5 mg/kg) at the port sites before incision and at the end of surgery. They also received injection tramadol 1 mg/kg intravenously TDS with thrice daily postoperatively. The pain scores (Face, Legs, Activity, Cry, Consolability/ Wong-Baker FACES scale) were assessed every 4 h on the 1st day and 6 h on the 2nd day. Injection diclofenac 1 mg/kg intravenous was used as a rescue analgesic for pain scores more than 4. Side effects such as nausea, vomiting, constipation, and motor blockade were noted. Quantitative and categorical data were assessed using t-test and Chi-square test, respectively. RESULTS: The pain scores were lower in the epidural group than in the local infiltration group at 0, 4, and 20 h postoperatively (P = 0.001, 0.01, and 0.038, respectively). Seventeen out of nineteen patients required rescue analgesia in the local infiltration group in the postoperative period as compared to five patients in the epidural group with a P value of 0.000081. CONCLUSION: Epidural analgesia can be considered as an effective modality of reducing pain in patients undergoing VATS decortication for empyema in pediatric patients.

Unanticipated Difficult Airway in a Neonate: Are we Prepared for this CHAOS?

Unanticipated difficult airway in a neonate is a challenging situation with many difficulties because of inherent anatomical variations. To complicate the situation there is a lack of appropriate equipment, expertise and established guidelines on the management of difficult airway in neonates and infants. There are few published reports regarding the use of available devices for emergency front-of-neck access. We report the case of airway management of a neonate with an unanticipated finding of subglottic stenosis. Subglottic stenosis is one of the aetiologies of congenital high airway obstruction syndrome, which may be diagnosed antenatally based on ultrasonography findings.

Comparison of efficacy and cost-effectiveness of 0.55% ortho-phthalaldehyde and 2% glutaraldehyde for disinfection of laryngoscopes: A prospective pilot study.

BACKGROUND AND AIMS: The laryngoscope is a potential source of cross-infection as it involves contact with the mucous membrane, saliva and occasionally blood. This study compared efficacy and cost-effectiveness of two Centre for Disease Control approved agents for disinfection of laryngoscope blades. METHODS: One hundred and sixty patients requiring laryngoscopy and intubation for general anaesthesia were randomly allocated into two groups. After tracheal intubation, used laryngoscope blades were cleaned with tap water. The blades were then immersed in either 2% w/v glutaraldehyde for a contact time of 20 min or 0.55% w/v ortho-phthalaldehyde (OPA) for 10 min. The handles were wiped with 0.5% w/v chlorhexidine wipes. Samples were collected using sterile cotton swabs from the tip, flange and light bulb area of the laryngoscope blade and one from the handle. They were cultured aerobically on blood and McConkey agar. RESULTS: In 2% glutaraldehyde group, of 240 samples sent from the blades, 2 (0.8%) showed the growth of methicillin-resistant coagulase-negative staphylococci (MRCONS) and Enterobacter. In OPA group, of 240 samples, 2 (0.8%) showed growth of MRCONS. Thus, 2% glutaraldehyde and 0.55% OPA were comparable in terms of efficacy of disinfection. Growth was seen on 4 out of 160 handles. CONCLUSIONS: We suggest OPA for high-level disinfection of laryngoscope blades as it is equally efficacious as compared to glutaraldehyde, with a shorter contact time and available as a ready to use formulation.