Comparison of Tracheal Intubation Using the Storz's C-Mac D-blade(TM) Video-Laryngoscope Aided by Truflex(TM) Articulating Stylet and the Portex(TM) Intubating Stylet.

BACKGROUND: Tracheal intubation using Storz's C-Mac D-blade(TM) videolaryngoscope is associated with difficult negotiation of the tracheal tube into the glottis due to steep angulation of its blade. OBJECTIVES: In this study, we hypothesized that Truflex(TM) articulating stylet with its ability to dynamically tailor the ETT shape to patients' oropharyngeal anatomy would be better suited to the D-blade angulation and ease tracheal intubation compared to Portex(TM) intubation stylet. PATIENTS AND METHODS: Following approval by the Ethical Issues Committee and informed consent, 218 ASA I and II patients of either sex were enrolled in this interventional, single-blind, randomized controlled trial. Tracheal intubation was performed following a uniform general anesthetic technique using the Storz's C-Mac D-blade(TM) videolaryngoscope aided by either Truflex(TM) articulating stylet or the Portex(TM) intubation stylet by an experienced anesthesiologist. The outcome measures included success or failure to intubate in the first attempt, total intubation time, hemodynamic disturbances, trauma if any and user satisfaction. RESULTS: The number of patients in whom intubation was successful in the first attempt was significantly higher by using Truflex™ articulating stylet (99.1%) compared to Portex(TM) intubation stylet (90.0%; P-Value = 0.003). User satisfaction grade was significantly better while using Truflex(TM) articulating stylet (8.5 ± 0.88) compared to the Portex(TM) intubation stylet (8.23 ± 0.99; P-Value = 0.035). We did not observe any significant difference in total intubation time, hemodynamic disturbances or trauma. CONCLUSIONS: Storz's C-Mac D-blade(TM) videolaryngoscope provides grade I Cormack and Lehane's glottic view in 99.1% patients. First attempt successful tracheal intubation and user satisfaction significantly improved by Truflex(TM) articulating stylet compared to the Portex(TM) intubation stylet.

Neurocysticercosis presenting as focal hydrocephalus.

A 40-year-old man presented with a 2-month history of headache, nausea and vomiting, with generalised seizures for the past 15 days. On examination he had bilateral papilloedema, visual acuity was 6/6 in both eyes but perimetry showed right homonymous inferior quadrantanopia. His MRI showed numerous small cystic lesions with eccentric nodules, diffusely distributed in bilateral cerebral and cerebellar hemispheres. There was also focal hydrocephalus involving occipital and temporal horns of the left lateral ventricle leading to its selective dilation. Stool examination showed ova of Taenia solium. He was treated with albendazole, prednisone and sustained release sodium valproate for 1 month. His headache resolved and he is free of seizures. Repeat perimetry at 1 month also showed resolution of visual field defect.

Bilateral subhyaloid haemorrhage in a conscious patient: a new spectrum of ocular involvement by Plasmodium falciparum.

A 24-year-old woman presented with a history of high-grade fever with rigours since 3 days and bilateral sudden loss of vision since 6 h. She was conscious, oriented and her vitals were stable. She had a temperature of 101°F, anaemia, thrombocytopaenia, normal white cell count and moderate splenomegaly. On testing visual activity, she could only perceive hand movements although her pupils were bilaterally equal, and normal in size and reaction. On indirect ophthalmoscopy, optic discs were normal bilaterally; however, fovea of both eyes was masked by subhyaloid haemorrhage. Peripheral smear showed gametocytes of Plasmodium falciparum. The patient was started on arteminsinin-combined therapy and advised to be in propped-up position to help resolution of the haemorrhage. The patient was afebrile in 4 days and follow-up fundus examination showed gradual resolution of the haemorrhage. After two months, the patient regained normal visual acuity in both eyes; however, it took nearly 3 months for complete resolution of the haemorrhage.

Symmetrical peripheral gangrene due to Plasmodium falciparum malaria.

A 45-year-old man presented with a 4-day history of high-grade fever with rigours and a 2-day history of painful bluish black discolouration of extremities (acrocyanosis). He was haemodynamically stable and all peripheral pulses palpable, but the extremities were cold with gangrene involving bilateral fingers and toes. Mild splenomegaly was present on abdominal examination but rest of the physical examinations were normal. On investigating he was found to have anaemia, thrombocytopaenia with gametocytes of Plasmodium falciparum on peripheral blood smear. His blood was uncoagulable during performance of prothrombin time with a raised D-dimer. Oxygen saturation was normal and the arterial Doppler test showed reduced blood flow to the extremities. A diagnosis of complicated P. falciparum malaria with disseminated intravascular coagulation (DIC) leading to symmetrical peripheral gangrene was performed. Artemisinin combination therapy was started and heparin was given for DIC. A final line of demarcation of gangrene started forming by 12th day.

Assessment of Truflex articulating stylet versus conventional rigid Portex stylet as an intubation guide with the D-blade of C-Mac videolaryngoscope during elective tracheal intubation: study protocol for a randomized controlled trial.

BACKGROUND: A variety of videolaryngoscopes with angulated blade have been recently introduced into clinical practice. They provide an indirect view of the glottic structures in normal and challenging clinical settings. Despite the very good visualization of the laryngeal structures by these devices, the insertion and advancement of the endotracheal tube may be prolonged and occasionally fail as it does not conform to the enhanced angulation of the blade. To overcome this handicap, it is recommended to use a pre-shaped, styleted tracheal tube during intubation. Unfortunately, these malleable rigid stylets permit only a fixed shape to the advancing endotracheal tube. This may necessitate withdrawal of endotracheal tube-stylet assembly for reshaping, before undertaking a new attempt. This may cause soft tissue injury and hemodynamic disturbance.This single-blinded randomized clinical trial aims to overcome these handicaps using a novel method of dynamically changing the shape of the advancing endotracheal tube by Truflex articulating stylet as per need during D-blade C-Mac videolaryngoscopy. METHODS: One hundred and fifty four patients between 18 and 60 years of age belonging to either sex undergoing tracheal intubation under uniform general anesthetic technique will be randomly divided into Portex malleable stylet group and Truflex articulating stylet group. The primary efficacy variable of success/failure between the two groups will be analyzed using the chi square test. For comparison of intubation times and the Intubation Difficulty Score, ANOVA will be used. Primary efficacy endpoint results will be successful or failed tracheal intubation in the first attempt, total intubation time and the intubation difficulty score. Secondary efficacy endpoints will be overall user satisfaction graded from 1 to 10 (1 = very poor, 10 = excellent), Cormack and Lehane's grading, glotticoscopy time and ETT negotiation time and total number of intubation attempts. Result of safety endpoints will include dental and airway trauma, hemodynamic disturbances, arrhythmias or cardiac arrest. TRIAL REGISTRATION: Current Controlled Trials ISRCTN57679531; Date of registration 12/02/2013.

Glomus jugulare: high index of clinical suspicion is important for optimal management.

Glomus tumour is a type of extra-adrenal chemodectoma or paraganglioma, originating within the wall of jugular bulb. We report a case of a 60-year-old woman who presented with hearing loss and pulsatile tinnitus. High index of suspicion and appropriate use of imaging led to early diagnosis. However, the patient did not give consent for surgery and was managed satisfactorily with radiotherapy.

Neonatal sacrococcygeal teratoma with acute renal failure.

Teratomas are germ cell tumours composed of multiple types of cells derived from more than a single germ cell layer. The most common site of an extragonadal teratoma is the sacrococcygeal region. We report a case of a 16-day-old female child with a large swelling in the sacrococcygeal region extending laterally into the buttocks with severely deranged renal functions. Ultrasonography and CT helped in making the diagnosis and, more importantly, to delineate the extent of the tumour and the involvement of adjacent organs and tissues: in our case, lower bilateral ureters. Imaging findings and clinical presentation led to the diagnosis of sacrococcygeal teratoma with renal failure.