Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia.

Background: Classically subclavian vein catheterization is done in neutral arm position; recently, it has been done in different arm positions to compare success rate and catheter misplacement. There is a paucity of literature for comparing abducted and neutral arm position for right infraclavicular subclavian vein cannulation. Aim: Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia. Design: Randomized comparative study. Materials and Methods: After approval from Institutional Review Board and Ethical Committee, 100 patients of 18-70 years of age, of either sex, posted for elective neurosurgery under general anesthesia, requiring right subclavian vein cannulation were included in our study. They were randomly divided into two groups: abducted arm position (group 1-AG) and neutral arm position (group 2-NG) using sealed envelope technique. Results: First attempt success rate was higher in AG group compared to NG group (P value- 0.741). Times taken (seconds) for cannulation in NG and AG group, catheter misplacement and hematoma (P value- 0.37, P value- 0.37, P value- 1, respectively) were lesser in AG Group. Conclusion: For USG-guided infraclavicular subclavian vein cannulation, abducted arm position, and neutral arm position in terms of first attempt success rate, number of attempts and associated complications has comparable results; however, further studies with larger group of patients are required to assess the overall advantage of abducted arm position over neutral arm position.

Comparison of Ultrasound Examination and Fiberoptic Laryngoscopy for Confirmation of Laryngeal Mask Airway Placement.

OBJECTIVES: 1) To compare ultrasound (US) examination and fiberoptic laryngoscopy (FOL) for confirmation of laryngeal mask airway (LMA) placement. 2) To evaluate the necessity for reinsertion of LMA based on FOL. METHODS: This prospective observational study included 100 adult patients of American Society of Anesthesiologists (ASA) Grade I and II, undergoing elective surgery under General Anesthesia requiring Proseal LMA™ placement as an airway device. LMA placement was first confirmed by clinical tests. Clinically acceptable patients were further assessed by US and categorized as acceptable (US-A) or unacceptable (US-U) and again by FOL as (FOL-A and FOL-U). Categorical variables presented in number, percentage (%), and continuous variables presented as mean ± SD and median. Inter-rater kappa agreement was used to find out the strength of agreement of acceptability between FOL and US. RESULTS: The LMA placement was clinically acceptable in 82% of patients on first attempt. FOL had 63% (FOL-A) acceptable LMA placement as compared with US examination which had 56% (US-A). In 85% of patients, US and FOL findings were in good agreement with each other for LMA placement (κ = 0.690 and P < .05). In all patients of FOL of unacceptable (FOL-U) category (37%), LMA was replaced with endotracheal tube. CONCLUSION: US provides a safe, non-invasive, and real-time dynamic assessment with 85% diagnostic accuracy for confirmation of LMA placement as compared with FOL.

Comparison of Proseal Laryngeal Mask Airway with the I-Gel Supraglottic Airway During the Bailey Manoeuvre in Adult Patients Undergoing Elective Surgery.

OBJECTIVE: Since the inception of Bailey manoeuvre, various authors have advocated for the substitution of endotracheal tube (ETT) with a supraglottic airway device (SAD) before the emergence from anaesthesia. There is scant information about the ideal supraglottic device in the literature. The present study compared the Proseal laryngeal mask airway (LMA) with the I-gel SAD during the Bailey manoeuvre. The primary objective was to compare these for ease of insertion and adequate placement of supraglottic airway, whereas the secondary objective was comparison of haemodynamics following the Bailey manoeuvre. METHODS: A total of 100 patients aged 18-60 years who were scheduled for elective surgery under general anaesthesia were randomised into 2 groups: group I (Bailey manoeuvre using Proseal LMA) and group II (Bailey manoeuvre using I-gel). The Bailey manoeuvre was performed 15 min before the end of surgery using the chosen supraglottic airway as per randomisation. We measured the ease of insertion (number of attempts required for insertion) and adequate placement (Brimacombe scoring) of SADs (fibre-optic bronchoscopy). Haemodynamic parameters were recorded until 10 min after the Bailey manoeuvre. RESULTS: The groups were comparable in terms of demographic parameters. Both the devices were comparable in terms of ease of insertion (p>0.05). Significantly higher (p<0.05) Brimacombe scores were seen with the I-gel. Significant (p<0.05) rise in systolic blood pressure, diastolic blood pressure, and mean arterial pressure was observed at the insertion of SAD, removal of ETT, and at 1 min after the Bailey manoeuvre in Proseal LMA in contrast to the I-gel. CONCLUSION: This study showed that the I-gel provides a better glottic visualisation and haemodynamically superior profile compared with the Proseal LMA during the Bailey manoeuvre.

Comparison of Blind Endotracheal Aspiration and Bronchoscopic Brush Biopsy Sampling Methods for Bacteriological Diagnosis of Ventilator-Associated Pneumonia in Intensive Care Unit.

BACKGROUND: The diagnosis of ventilator-associated pneumonia (VAP) is a challenge because the clinical signs and symptoms lack both sensitivity and specificity. Further confirmation of the diagnosis of VAP can be done by other diagnostic procedures such as bronchoscopic and blind endotracheal aspiration, but the selection of either diagnostic procedure is debatable. AIMS: The aim is to study and compare the role of bronchoscopic protected specimen brush biopsy (PSBB) and blind endotracheal aspiration for diagnosis of VAP. SETTINGS AND DESIGN: This prospective comparative study was conducted in multidisciplinary Intensive Care Unit of a tertiary care hospital. MATERIALS AND METHODS: Thirty patients clinically diagnosed to have VAP were further evaluated by bronchoscopic and blind endotracheal aspiration. The P value of PSBB and blind aspiration techniques was calculated, taking clinical pulmonary infection score of ≥6 as reference standard. STATISTICAL ANALYSIS USED: Statistical analysis was done using Chi-square and t-test. RESULTS AND CONCLUSIONS: Our study shows that for the diagnosis of VAP, PSBB and blind aspiration had Chi-square value of 0.83 with degree of freedom 1 which showed P = 0.3623 which is not significant. t-test value is 0.402 with degree of freedom 1 and P = 0.7567 which is still not significant. There was a good microbiologic concordance among bronchoscopic and nonbronchoscopic distal airway sampling techniques. Blind endotracheal aspiration is a comparable technique for bacteriological diagnosis of VAP.

Achieving Early Mother-baby Skin-to-skin Contact in Caesarean Section: A Quality Improvement Initiative.

OBJECTIVE: To improve rate of skin-to-skin contact for early initiation of breastfeeding at birth on operation table among healthy term and late pretem babies born by caesarean sections from 0% to 80% in eight weeks. METHODS: A quality improvement initiative was undertaken at maternity-newborn care unit of a tertiary-care hospital. A team involving Neonatologists/Pediatricians, Obstetricians, Anaesthesiologists, and Nurses in concerned areas identified problem areas using Fish bone analysis. Situational analysis was done through process flow mapping. Three Plan-do-study-act cyles were undertaken. Firstly, sensitization of personnel was done and a written policy was made. Secondly, maternal counselling and procedural modifications were done. Lastly, efforts were made to improve duration of contact. RESULTS: Rate of early skin-to-skin contact after Plan-do-study-act cycle 1, 2 and 3, respectively was 87.5%, 90% and 83.3%. It was 100% after sustainability phase after four months. CONCLUSION: Early skin-to-skin contact was achievable through sensitization of all persons involved and simple procedural changes. Prolonging duration of contact remained a challenge.

Comparison of Awareness of Patient Parameters between Two Groups of Caregivers in Intensive Care Unit.

AIM OF THE STUDY: The overlap in the scope of duties performed by two core groups of Intensive Care Unit caregivers, the doctors and nurses may lead to gaps in awareness of patient-related parameters among them. Our study tested the hypothesis that there is no difference in the awareness of patient-related parameters between the two study groups (doctors and nurses). MATERIALS AND METHODS: A questionnaire-based study, incorporating various aspects of a patient's medical care was designed. Pro forma for 100 patients was filled by doctors and nurses divided into two groups of 100 each (50 junior residents [JRs] and 50 senior residents [SRs] in the doctors' group). Statistical analysis of categorical data was done by Chi-squared test and interval data by t-test. A subgroup analysis was done for comparison between nurses SRs and JRs as independent groups. P < 0.05 was considered statistically significant. RESULTS: There was no statistically significant difference between the two groups (doctors and nurses) in terms of percentage of correct responses in the questionnaire (P = 0.655). A highly significant difference between the knowledge of SRs and nurses was found with a P = 0.0001. P < 0.0001 was calculated for the SRs versus JRs which was highly significant. CONCLUSIONS: As a group, doctors (SRs and JRs) did not reflect any difference in awareness of patient-related parameters when compared to nurses. However, SRs were more knowledgeable about the patient-related parameters when compared independently with the JRs and the nurses.

Comparative assessment of ProSeal™ laryngeal mask airway intervention versus standard technique of endotracheal extubation for attenuation of pressor response in controlled hypertensive patients.

BACKGROUND AND AIMS: Swapping of the endotracheal tube with laryngeal mask airway (LMA) before emergence from anaesthesia is one of the methods employed for attenuation of pressor response at extubation. We decided to compare the placement of ProSeal™ LMA (PLMA) before endotracheal extubation versus conventional endotracheal extubation in controlled hypertensive patients scheduled for elective surgeries under general anaesthesia. METHODS: Sixty consenting adult patients were randomly allocated to two groups of thirty each; Group E in whom extubation was performed using standard technique and Group P in whom PLMA was inserted before endotracheal extubation (Bailey manoeuvre). The primary outcome parameter was heart rate (HR). The secondary outcomes were systolic, diastolic and mean blood pressure (MBP), electrocardiogram, oxygen saturation and end-tidal carbon dioxide. Two-tailed paired Student's t-test was used for comparison between the two study groups. The value of P < 0.05 was considered as statistically significant. RESULTS: The patient characteristics, demographic data and surgical procedures were comparable in the two groups. A statistically significant decrease was observed in HR in Group P as compared to Group E. Secondary outcomes such as systolic, diastolic and MBP depicted a statistically insignificant difference. CONCLUSION: Bailey manoeuvre was not effective method to be completely relied upon during extubation when compared to standard extubation.

An account of the anesthetist's vigilance and prevention of adversity during donor nephrectomy.

Here, we present the case of a 42 year old female patient, ASA1 and donor for renal transplant surgery of her husband. The pre-anesthesia visit did not reveal any co-morbidity on history and the physical examination was also within normal limits. The patient was taken to the operating room and routine monitoring in the form of non-invasive blood pressure (NIBP), SpO2 probe and five lead electrocardiogram were applied. Anesthesia was induced with midazolam 1mg intravenous (i/v), fentanyl 100 µg i.v, propofol 100mg i/v and vecuronium bromide 5 mg. i/v. At the end of surgery, anesthesia was reversed and breathing attempts were observed. Suddenly the monitor displayed a drop in the ETCO2 to 5-6 mmHg. Immediately the ventilator circuit was checked which was found to be in place and on chest auscultation, bilateral equal air entry was heard. Sudden bradycardia with heart beat dropping to 32 beats per minute and a blood pressure reading of 90/50 mmHg was displayed on the monitor. Surgeons were informed about the possibility of an intra-abdominal bleed. On surgical exploration, the renal artery pedicle ligature was found to have slipped away resulting in torrential amount of bleeding. The bleeder having been identified was secured and a complete inspection of other possible bleeding sites was done. Post operatively, the patient was shifted to the intensive care unit with inotropic support. It was decided to keep the patient mechanically ventilated on volume control mode of ventilation. The patient remained stable on post-operative day 5, the patient was shifted to the ward.

Inadvertent high spinal anesthesia as sequelae to epidural injection of normal saline.

Here we present a case of high spinal blockade in a patient belonging to ASA Grade I which lead to need for endotracheal intubation. A 35 year old healthy male, weighing 59 kg, of height 165 cms presented with a post traumatic raw area over the left lower limb. A reverse sural graft along with skin grafting (from the thigh) was planned. In OR, the patient was placed in sitting position and the extradural space was identified by 'loss of resistance to air' technique at the L2-L3 intervertebral space. The catheter could not be threaded into the extradural space, hence 5ml of 0.9% saline was injected. However, still the catheter could not be negotiated. Further attempts to identify the extradural space at the L1-L2 and L3-L4 interspace levels were made. During these attempts a total of 18 ml of 0.9% saline was injected into the extradural space. Within 2 minutes blood pressure fell to 90/60 mmHg. Injection mephenteramine (3 mg) was given intravenously and a slight head up tilt was applied. After 2 more minutes the patient started complaining of tingling in his hands and difficulty in breathing. Oxygen 100% was administered via a face mask attached to the anesthesia circle system. In view of onset of respiratory failure, general anesthesia was induced. Thiopentone (200 mg) and Suxamethonium (75 mg) were given intravenously, the patient's trachea was intubated and his lungs ventilated with 40% oxygen, 60% nitrous oxide and 0.2-0.4% Isoflurane, without additional neuromuscular blockade. The arterial saturation promptly returned to 97% and, immediately after intubation, the heart rate was found to be 103 beats/min and the arterial BP 162/102 mmHg. At the end of surgery, spontaneous ventilation returned and the patient was allowed to breathe 100% oxygen via the tracheal tube until he awoke, when his trachea was extubated.

Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding - continuous vs. intermittent in head-injured critically ill patients.

INTRODUCTION: Measurement of respiratory quotient (RQ) and resting energy expenditure (REE) has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE. METHODS: After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds (30 kcal/kg/day) were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds (30 kcal/kg/day) were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. RESULTS: Demographic profile and SOFA score were comparable in the two groups. Base line RQ (0.8 vs. 0.86) and REE (1527 vs. 1599 kcal/day) were comparable in both the groups (P>0.05). RQ was comparable in both groups during the study period at any time of the day (P>0.05). Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups (P>0.05). REE was comparable in both the groups throughout the study period (P>0.5). Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups (P>0.05). CONCLUSION: We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup.

Critical events in intensive care unit.

This prospective study was designed to have an insight into critical events occurring in the 13-bedded multidisciplinary intensive care unit (ICU) of our hospital and to report the critical events to evaluate the avoidable/iatrogenic problems so as to improve patient outcome and keep a self-check in the ICU. The errors reported were due to wrong mechanical or human performance. Repeated performance errors of the same kind pointed to the problem area, to which was paid proper attention in the required manner. Some malfunctioning equipments were abandoned and the need for adequate availability of staff was emphasized. Reporting of critical events was done keeping the patients' and doctor's identities anonymous through a proforma designed to report the event.