Comparison of oropharyngeal leak pressure of air-Q™, i-gel™, and laryngeal mask airway supreme™ in adult patients during general anesthesia: A randomized controlled trial.

STUDY OBJECTIVE: Various randomized controlled trials and a meta-analysis have compared i-gel™ and laryngeal mask airway Supreme™ (LMA-S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air-Q™ with i-gel™ and LMA-S™ in adult patient. Hence, we designed this study to compare air-Q™ with LMA-S™ and i-gel™ in adult patients. MATERIALS AND METHODS: A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer-generated random number sequence: group air-Q™ (n = 25), group i-gel™ (n = 25), and group LMA-S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications. RESULTS: The mean ± standard deviation OLP of air-Q™, i-gel™, and LMA-S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H2O (P = 0.279). The first insertion success rate for air-Q™, i-gel™, and LMA-S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air-Q™, i-gel™, and LMA-S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air-Q™ insertion was significantly higher than time taken for i-gel™ (mean difference 5.8 s, P < 0.0001) and LMA-S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices. CONCLUSIONS: We concluded that air-Q™, i-gel™, and LMA-S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy.

Randomised controlled trial of central venous catheterisation through external jugular vein: A comparison of success with or without body manoeuvres.

BACKGROUND AND AIMS: The external jugular vein (EJV), often used for resuscitation, has been underutilised for central venous catheterisation (CVC) in view of an unpredictable success rate. There is an encouraging literature on the improved success rate of CVC through EJV with the inclusion of certain body manoeuvres. This prospective randomised controlled study was conducted with the aim of evaluating the efficacy of body manoeuvres in improving the success rate of CVC through EJV. METHODS: One hundred patients aged 18-50 years, scheduled for elective surgery requiring CVC, were randomly assigned to either undergo CVC using Seldinger technique with body manoeuvres or a control group undergoing CVC without body manoeuvres. The primary outcome was the success rate of CVC, as observed in the post-procedure chest radiograph. Secondary outcomes included quality of central venous pressure waveform, catheterisation attempts, total time for CVC, complications. RESULTS: CVC was achieved in 98% (49/50) of patients in study group and 80% (40/50) of patients in control group (P = 0.008). Mean catheterisation time was significantly lower in the study group (151.06 ± 40.50 s) compared to control group (173.50 ± 50.66 s) (P = 0.023). The incidence of catheter misplacement and failure to cannulate were lower in the study group (0%, 2% vs. 20%, 12.5%, respectively). Groups did not differ in a number of catheterisation attempts and incidence of haematoma. CONCLUSION: Inclusion of various body manoeuvres to Seldinger technique significantly improves the success rate of CVC through EJV.

Comparison of quality of the surgical field after controlled hypotension using esmolol and magnesium sulfate during endoscopic sinus surgery.

BACKGROUND AND AIMS: Most vital aspect of Endoscopic Sinus Surgery (ESS) is an optimal visibility in the surgical field. This invariably requires controlled hypotension to facilitate surgical dissection and to decrease operative time. We used esmolol and magnesium sulfate to achieve controlled hypotension and assessed the quality of the surgical field in ESS. MATERIAL AND METHODS: A total of 30 patients undergoing ESS, were enrolled in three parallel groups of 10 patients each in a prospective randomized double-blind study. "Magnesium Sulfate group" received magnesium sulfate 40 mg/kg intravenously (i.v.) as a bolus over 10 min before induction of anesthesia, followed by 15-30 mg/kg/h through infusion. "Esmolol group" received 0.5 mg/kg i.v. bolus over 10 min after induction followed by 150-300 µg/kg/min infusion and "control group" received normal saline in same volume schedule. The primary aim was to assess the quality of surgical field, using Fromme scale. Category Scale values of all the three groups were compared using Kruskal-Wallis analysis of variance (ANOVA) test. Hemodynamic data was compared using ANOVA test. RESULTS: Quality of the surgical field was better in both magnesium sulfate and esmolol groups as compared to the control group. Durations of anesthesia and surgery were significantly lower in esmolol group as compared to the control group. Blood loss was comparable in all the three groups. CONCLUSION: Quality of the surgical field was better in esmolol and magnesium sulfate groups as compared to control group. Duration of surgery was significantly less in esmolol group as compared to other two groups.

Partial airway obstruction following manufacturing defect in laryngeal mask airway (Laryngeal Mask Silken™).

Laryngeal mask (LM) airway is commonly used for securing airway in day-care surgeries. Various problems have been described while using LM airway. Out of those, mechanical obstruction causing airway compromise is most common. Here, we describe a case report of 4-year-old child who had partial upper airway obstruction due to LM manufacturer's defect. There was a silicon band in upper one-third of shaft of LM airway. This band was made up of the same material as that of LM airway so it was not identifiable on external inspection of transparent shaft. We suggest that such as non-transparent laryngeal mask, a transparent LM airway should also be inspected looking inside the lumen with naked eyes or by using a probe to rule out any manufacturing defect before its insertion.

Does the impact of elective temporary clipping on intraoperative rupture really influence neurological outcome after surgery for ruptured anterior circulation aneurysms?--A prospective multivariate study.

BACKGROUND: Elective temporary clipping (ETC) is increasingly used in surgery for aneurysms. This study was to assess whether the impact of ETC on intraoperative aneurysmal rupture (IAR) translates into neurological outcome. METHODS: Patients who underwent surgery for ruptured anterior circulation aneurysms were prospectively studied for various factors related to ETC, IAR and neurological outcome at 3 months. Univariate and multivariate analyses were performed using SPSS20. RESULTS: Of the total 273 ruptured aneurysm surgeries studied, IAR was observed in only six out of 132 aneurysms (4.5 %) who had ETC, compared with 78 out of 141 (55.3 %) without ETC (p < 0.001). Aneurysms complicated by IAR had significantly longer clipping time (8.3 min) compared with those without IAR (1.9 min) (p < 0.001). IAR had significant association with unfavorable outcome (38 % vs. 24 %) (p = 0.02). Patients with ETC had significantly shorter clipping time (2.9 min) compared with those without ETC (4.8 min) (p = 0.02). Unfavorable outcome was noted in 30 out of 132 with ETC (23 %), compared with 48 out of 141 without ETC (34 %) (p = 0.04). This beneficial effect was nonsignificantly greater in younger and good clinical grade patients. While episodes of ETC within clipping time of 20 min did not show significant difference in outcome, repeated rescue clipping (45 % unfavorable outcome, p = 0.048) and total clipping time of at least 20 min (75 % unfavorable outcome, p = 0.008) had significant impact on outcome. In multivariate analysis, the use of ETC (p = 0.027) and total temporary clipping less than 20 min (p = 0.049) were noted to result in significantly better outcome, independent of other factors. CONCLUSIONS: The use of ETC decreased the occurrence of IAR and the total clipping time, thereby leading to significantly better outcome, independent of other factors. While repeated elective clipping within total clipping time of 20 min did not influence outcome, repeated rescue clipping and total clipping time of at least 20 min had significant impact on outcome.

Eptifibatide: The evidence for its role in the management of acute coronary syndromes.

INTRODUCTION: Acute coronary syndromes and non-Q-wave myocardial infarction are often initiated by platelet activation. Eptifibatide is a cyclic heptapeptide and is the third inhibitor of glycoprotein (Gp) IIb/IIIa that has found broad acceptance after the specific antibody abciximab and the nonpeptide tirofiban entered the global market. Gp IIb/IIIa inhibitors act by inhibiting the final common pathway of platelet aggregation, and play an important role in the management of acute coronary syndromes. AIMS: This review assesses the evidence for therapeutic value of eptifibatide as a Gp IIb/IIIa inhibitor in patients with acute coronary syndromes. EVIDENCE REVIEW: Several large, randomized controlled trials show that eptifibatide as adjunctive therapy to standard care in patients with non-ST segment elevation acute coronary syndrome is associated with a significant reduction in the incidence of death or myocardial infarction. Data are limited regarding the use of eptifibatide in patients with ST segment elevation myocardial infarction. Cost-effectiveness analysis indicates that eptifibatide is associated with a favorable cost-effectiveness ratio relative to standard care. According to US cost-effectiveness analysis about 70% of the acquisition costs of eptifibatide are offset by the reduced medical resource consumption during the first year. Eptifibatide was well tolerated in most of the trials. Bleeding is the most commonly reported adverse event, with most major bleeding episodes occurring at the vascular access site. Major intracranial bleeds, stroke, or profound thrombocytopenia rarely occurred during eptifibatide treatment. PLACE IN THERAPY: Eptifibatide has gained widespread acceptance as an adjunct to standard anticoagulation therapy in patients with acute coronary syndromes, and may be particularly useful in the management of patients with elevated troponin or undergoing percutaneous coronary interventions.

The D-dimer assay: a possible tool in the evaluation of atrial thrombosis.

Atrial fibrillation (AF) is a common arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age. Peripheral thromboembolism contributes significantly to the observed morbidity and mortality. Symptomatic AF, before cardioversion to normal sinus rhythm, requires either exclusion of atrial thrombi using transesophageal echocardiography (TEE) or the conventional use of three weeks of adequate anticoagulation. The exclusion of atrial thrombi by TEE, a nontomographic technique but comparable with conventional treatment of AF in outcomes, has inherent limitations due to the complex three-dimensional multilobed anatomy of the left atrial appendage, where the majority of atrial thrombi arise. Also, the conventional treatment of three weeks of therapeutic anticoagulation before cardioversion reportedly does not always eliminate atrial thrombi. Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombosis and, hence, may improve the evaluation of a patient with AF before cardioversion in addition to a TEE. A case is presented in which a positive D-dimer resulted in performing TEE to document atrial thrombosis and the complications of previous bacterial endocarditis. In the present case, this involved aortic root abscess formation and acute aortic regurgitation because of flailing of the noncoronary cusp that resulted in recurrent pulmonary edema.

A new ostial stent positioning system (Ostial Pro) for the accurate placement of stents to treat aorto-ostial lesions.

BACKGROUND: The stenting of aorto-ostial lesions in the native coronary circulation, renal arteries, and saphenous vein grafts is technically challenging. METHODS: We report the first in the world use of the Ostial Protrade mark, a novel nitinol-based device, utilized in conjunction with standard stenting techniques to assist in the precise placement of stents for the treatment of aorto-ostial lesions. RESULTS: The Ostial Pro, is a relatively simple nitinol device that is positioned within the guiding catheter. It has distal, self-expanding legs that are advanced just distal to the tip of the guiding catheter after the ostial lesion has been crossed with the coronary guidewire and stent delivery system. The expanded nitinol legs prevent the entry of the guiding catheter into the target vessel, mark the plane of the aortic wall, and align the tip of the guide with the aorto-ostial plane. We report the successful and precise placement of stents in the aorto-ostial location in two patients with; (1) a saphenous vein graft ostial lesion and (2) a right coronary ostial lesion, using the new Ostial Pro stent positioning device. Excellent stent positioning, relative to the aorto-ostial plane, was confirmed by angiography and long axis intravascular ultrasound in both cases. CONCLUSIONS: (1) The Ostial Pro is a new, commercially available (FDA cleared), nitinol device that is simple to use and appears effective in allowing the precise placement of stent(s) at the aorto-ostial location. (2) This approach may provide a simple and effective means to assure accurate stent placement in these difficult to treat lesions.

A case of congenitally corrected transposition of the great arteries with rare but life-threatening ventricular tachycardia and a coincidental single coronary ostium.

Congenitally corrected transposition of the great vessels (CCTGA) is a rare congenital heart defect. Patients with CCTGA have the anatomical right ventricle as their systemic pumping chamber, with ventricular dysfunction and congestive heart failure (CHF) being relatively common in older adults. The most common presenting feature is bradycardia due to high-degree atrioventricular (AV) blocks. Patients with CCTGA are increasingly subject to CHF with advancing age; this complication is extremely common by the fourth decade. The majority of patients have an inverted coronary arterial pattern.1 We report a case of a patient with CCTGA who presented with rare but life-threatening ventricular tachycardia (VT) leading to syncope, with preserved systemic ventricular function. Coincidentally, the patient also had a single coronary ostium.

Incidence and types of arrhythmias after mediastinal manipulation during transhiatal esophagectomy.

BACKGROUND: Transhiatal esophagectomy (THE) is a common operative procedure for carcinoma esophagus. Complications of this procedure include arrhythmias and hypotension during blunt dissection of the esophagus from posterior mediastinum. In the literature, exact incidence and type of arrhythmias have not been reported. We employed Holter monitoring during mediastinal manipulation in patients undergoing THE, for this purpose. METHODS: This prospective study was carried out in 20 consecutive American Society of Anesthesiologists grade I-II patients undergoing THE. Anesthetic technique included induction with thiopentone and maintenance with morphine, vecuronium, and isoflurane. In addition to routine parameters, Holter monitoring was undertaken to record the exact incidence and types of arrhythmias. "Premanipulation" or control period included duration of 30 minutes preceding mediastinal manipulation, while "during manipulation" or study period included the duration of mediastinal manipulation. The incidence of arrhythmias was studied for 48 hours in the postoperative period. The Fisher exact test was applied to analyze incidence of arrhythmias and hypotension. RESULTS: Out of 20 patients, only 2 had arrhythmias in the premanipulation period, while 13 had arrhythmias during the manipulation period (p < 0.01). During the manipulation period, arrhythmias included supraventricular ectopics and ventricular ectopics in 2 patients each and a combination of both in 9 patients. Arrhythmias were transient and had no correlation with either duration or degree of hypotension in all the patients. However, there was a linear relationship between hypotension and duration of mediastinal manipulation. Two patients (10%) had atrial arrhythmias in the postoperative period. CONCLUSIONS: In transhiatal esophagectomy, there is a significant incidence of both arrhythmias and hypotension during mediastinal manipulation. The incidence of arrhythmias can be minimized by limiting the duration of the manipulation. The incidence of postoperative arrhythmias was not significant.

Effects of NOS3 Glu298Asp polymorphism on hemodynamic reactivity to stress: influences of ethnicity and obesity.

Studies on the associations between the nitric oxide synthase gene (NOS3) Glu298Asp polymorphism and hypertension status or blood pressure (BP) levels have had inconsistent results. Potential moderating influences of ethnicity, sex, and obesity on the effects of the NOS3 polymorphism have not been examined. We evaluated the influence of these factors on associations between the NOS3 polymorphism, nitric oxide metabolites (NOx), and hemodynamics at rest and during stress. Subjects were 235 African American (AA) and 262 European American (EA) young adults (18.5+/-2.6 years). Hemodynamic measurements and blood samples for NOx assays were taken before and after a competitive video game challenge. Glu298Asp polymorphism was detected by polymerase chain reaction-restriction enzyme digestion assay. A regression model was built using genotypes, ethnicity, sex, and obesity (body mass index >85th percentile) and their interactions controlling for age; 20.1% of AAs and 49.8% of EAs were carriers of the Asp allele. AAs, regardless of obesity status, exhibited high diastolic blood pressure (DBP) reactivity unless they were nonobese and noncarriers of the Asp allele. EAs exhibited lower DBP reactivity unless they were obese Asp allele carriers. AA nonobese carriers exhibited the greatest total peripheral resistance reactivity. Obese Asp allele carriers exhibited the greatest increases in cardiac output and the greatest decrease in NOx to the stressor. Results indicate the importance of examining impact of BP control-related genetic polymorphisms within the context of moderating factors such as adiposity and ethnicity.