Comparison of airway collapsibility following single induction dose ketamine with propofol versus propofol sedation in children undergoing magnetic resonance imaging: A randomised controlled study.

Background and Aims: Adequate sedation is essential for children undergoing magnetic resonance imaging (MRI) console. Propofol is commonly used for sedation, but it has the drawback of upper airway collapse at higher doses, which may be overcome by ketamine. This study was designed to evaluate the beneficial effect of ketamine on propofol in preventing airway collapse. Methods: Fifty-eight children undergoing MRI were randomised to Group P (propofol bolus dose followed by infusion or Group KP (bolus dose of ketamine and propofol followed by propofol infusion). The primary aim is to compare the upper airway cross-sectional area (CSA) and diameters (transverse diameter [TD] and anteroposterior diameter [APD]) obtained from MRI during inspiration and expiration. Results: Upper airway collapse as measured by delta CSA in mean (SD) [95% confidence interval] was statistically more significant between the two groups [at the soft palate level, 16.9 mm2 (19.8) [9.3-24.4] versus 9.0 mm2 (5.50) [6.9-11.1] (P = 0.043); at the base of the tongue level, 15.4 mm2 (11.03) [11.2-19.6] versus 7.48 mm2 (4.83) [5.64-9.32] (P < 0.001); at the epiglottis level, 23.9 (26.05) [14.0-33.8] versus 10.9 mm2 (9.47) [7.35-14.5] (P = 0.014)]. A significant difference was obtained for TD at all levels and for APD at the soft palate and base of tongue level. Conclusion: Adding a single dose of ketamine to propofol reduced the upper airway collapse significantly, as evidenced by the MRI-based measurements of upper airway dimensions, compared to propofol alone.

Comparison of Postoperative Analgesic Efficacy of Ultrasound-Guided Bilateral Rectus Sheath Block With That of Local Anaesthetic Infiltration in Patients Undergoing Emergency Midline Laparotomy Surgeries: A Randomised Controlled Trial.

Purpose Rectus sheath block (RSB) is increasingly utilised as a part of multimodal analgesia in laparotomy surgeries. We proposed this study to compare the analgesic efficacy of ultrasound-guided bilateral RSB with local anaesthetic (LA) infiltration. The primary outcome was the visual analogue scale (VAS) at rest and cough. The secondary outcomes were the postoperative morphine consumption, time to first rescue analgesia, incidence of postoperative nausea and vomiting (PONV) and patient satisfaction score. Methods In our prospective, single-centre, randomised clinical trial, we enrolled a total of 100 patients undergoing emergency midline laparotomy surgeries. They were randomly allocated into two groups and were administered either LA infiltration (group L, n=50) or ultrasound-guided bilateral RSB (group R, n=50) with 15-20 ml of 0.25% bupivacaine end operatively. The categorical and ordinal variables were analysed using Chi-square/ Fisher's exact test. The continuous and discrete variables were analysed using Mann-Whitney/independent Student t-test. Results The median VAS scores in the postoperative period were significantly lower with RSB when compared with LA. Statistically significant differences in median VAS scores were noticed at one hour (P<0.001), four hours (P=0.001), eight hours (P<0.001), and 12 hours (P=0.014) at rest, and at one hour (P<0.001), four hours (P<0.001) and eight hours (P<0.001) during cough. The median morphine consumption was less with RSB (P<0.001). The time to first rescue analgesia was prolonged with RSB (P<0.001). The incidence of PONV was significantly lower with RSB (P=0.027). Conclusion Bilateral ultrasound-guided RSB provides extended postoperative analgesia at rest and cough for patients undergoing emergency laparotomy surgeries when compared with LA infiltration. There was a significant reduction in morphine consumption, incidence of PONV, and prolonged time to first rescue analgesia with RSB.

Comparative evaluation of three methods of endotracheal tube cuff inflation for adequacy of seal.

Background and Aims: Intubation with cuffed endotracheal tube (ETT) is common in operation rooms, critical care, and emergency rooms. The pressure exerted by the cuff on the tracheal mucosa can lead to a reduction in blood flow to the tracheal wall and result in mucosal ischemia. There are many methods for ETT cuff inflation. Aim of the study was to compare the cuff pressures and volumes between the three methods of ETT cuff inflation. Material and Methods: One hundred and twenty patients were randomized into three groups: Group SG (stethescope guided), group AL (audible leak), and group P (palpation). In group SG, the cuff was inflated by auscultating with the bell of the stethoscope over the thyroid cartilage for leak around cuff. In group AL, the cuff was inflated by listening for an audible leak around the cuff with observer's ear 5 cm away from the mouth of the patient. In group P, the cuff was inflated by palpating for a leak over the cricoid and trachea. The adequacy of the cuff seal was compared between the groups by assessing the volumes of additional air needed to stop the leak around the cuff as confirmed by supraglottic capnometry. Results: The initial volumes needed to inflate the cuff were significantly more in the stethoscope (SG) and hearing (AL) groups than in the palpation (P) group (SG = 5.1 ± 1.4 ml, AL = 4.6 ± 1.6 ml, P = 3.1 ± 0.9 ml; SG and AL vs. P, P < 0.001). Additional cuff volumes required to achieve zero leak around cuff by supraglottic capnometry were 0.85 ± 1 ml in group SG, 1.3 ± 1.1 ml in group AL, and 2.237 ± 0.8 ml in group P (SG vs. P and AL vs. P; P < 0.001). Conclusion: Out of the auscultation-guided, audible leak-guided, and palpation-guided methods of ETT cuff inflation, the auscultation-guided and audible leak-guided methods achieve significantly better tracheal seal than the palpation-guided method.

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.

Comparison of ease of administration of intranasal midazolam spray and oral midazolam syrup by parents as premedication to children undergoing elective surgery.

BACKGROUND: The efficacy of midazolam as premedication in children for providing pre-operative sedation and reducing parental separation anxiety has been well established. Many studies have compared the effectiveness and medication acceptance of midazolam via oral and intranasal routes. In this study, we have compared the ease of administration of oral midazolam syrup and intranasal midazolam spray as premedication, administered by parents to children. METHODS: Ninety children were randomly allocated into one of the two groups: group N received nasal midazolam spray 0.2 mg/kg and group O received oral midazolam syrup 0.5 mg/kg administered by the parent. The parent recorded ease of administration score and facial hedonic score. The observer recorded modified medication acceptance score. Vitals and sedation scores were assessed at specific intervals. Thirty minutes after drug administration the child was separated from the parent, and parental separation anxiety score was recorded. Mask acceptance score was recorded after application of mask upon arrival in the OT. RESULTS: Oral midazolam syrup was found to have better ease of administration than intranasal midazolam spray as felt by the parent. Medication acceptance was better for oral midazolam. Both the groups had similar sedation scores at 15 and 30 min. Children in the oral group had a better reduction in parental separation anxiety at 30 min after drug administration and better mask acceptance than the nasal group. CONCLUSION: Oral midazolam syrup is easier for parents to administer and has better medication acceptance in children when compared to intranasal midazolam spray.

Infrarenal aortic clamp reviving a patient from acute surgical haemorrhagic shock: a novel management technique.

Surgical management of renal cell carcinoma extending into the inferior vena cava (IVC) is almost always accompanied by massive intraoperative blood loss and associated complications. It is a widely recognised problem, and its active management is essential in improving the perioperative morbidity and mortality. We share our experience with a similar case of open radical nephrectomy with massive blood loss of twice the circulating volume in a duration of <8 surgical hours. Although we emphasise the goals of securing haemostasis, restoration of circulating volume, and efficient management by replacing blood components, in the present case, despite the above-mentioned goals being fulfilled, we were unable to extricate the patient from haemorrhagic shock by conventional means and therefore resorted to desperate measures, namely the novel approach of infrarenal aortic clamping along with higher than recommended vasopressor support. We resorted to this in order to maintain the haemodynamic parameters and to prevent avoidable morbidity and mortality related to persistent intraoperative hypotension. With such an approach, we successfully managed the patient perioperatively, ultimately resulting in the patient being discharged after a week of intensive care unit stay without major complications.

Use of i-gel for caesarean section with kyphoscoliosis.

We describe the anaesthetic management using i-gel for airway maintenance in a patient with kyphoscoliosis presenting for emergency caesarean section due to fetal distress and scar tenderness. The patient had a history of previous caesarean section under general anaesthesia, and presently her cardiorespiratory status is stable. We used i-gel, the new supraglottic airway device, for maintaining the airway under intravenous anaesthesia using propofol.