Air-Q ILA as a conduit for orotracheal intubation in children: A randomized control trial for comparison between supine and lateral patient positions.

Background and Aims: Airway management in children is always challenging and becomes a concern if required in the lateral position. We evaluated the efficacy of orotracheal intubation using the Air-Q intubating laryngeal Airway (Air-Q ILA) in supine and lateral positions in children. Material and Methods: This study included 100 children weighing 7-30 kg, scheduled for elective surgeries under general anesthesia. They were randomized into the supine (S) group or lateral (L) group. After anesthesia induction, the child was placed in a standard sniffing position for conventional laryngoscopy in the S group, and the child was turned into the lateral position in the L group. Both Air-Q ILA and endotracheal tube were placed blindly in the supine position in the S group and lateral position in group L. The grading of glottic view, success rate, insertion time of the Air-Q ILA, and endotracheal intubation were noted in both the groups. Results: The Air-Q ILA was successfully placed at the first attempt in 47 children in group S and 48 in group L. The overall blind orotracheal intubations, including first and second attempts, were successful in 45 children in the S group and 47 in the L group (P = 0.715). Eighty percent of patients in group L and 70% in group S had glottis grade 1 or 2 compared to grade 3, 4,5 (P = 0.249). The mean time of Air-Q ILA placement in groups S and L was 15.73 ± 5.64 s and 14.42 ± 4.16 s (P = 0.195). The mean duration of blind endotracheal intubation through the Air-Q ILA was 24.88 ± 14.75 s in group S and 17.57 ± 5.35 s in group L (P = 0.002). In both the groups, none of the children had bronchospasm, laryngospasm, desaturation, or aspiration. The airway trauma evident by blood staining on the Air-Q ILA on removal was revealed in 2 cases in group S, and 3 cases in group L. None of the children in group S and 4 children in group L had postoperative stridor. Postoperative hoarseness was reported in 3 children in group S and none in group L within 24 hours. Conclusion: The Air-Q ILA can be used as a conduit for blind orotracheal intubation in children in both supine and lateral positions while maintaining an effective airway seal.

Sympathetic Blocks for Raynaud's Phenomena in Pediatric Rheumatological Disorders.

OBJECTIVE: Sympathetic blocks are invaluable to prevent morbidity from Raynaud's phenomenon (RP). RP may occur in children with rheumatological disorders and causes severe pain, discoloration of digits, gangrene, and auto-amputation. We describe the planning and execution of sympathectomy blocks in children with rheumatological disorders presenting with RP. METHODS: With upper-limb involvement, ultrasound-guided stellate ganglion block (USGB) was given with ropivacaine and clonidine. When all four limbs were involved, intrathecal block with bupivacaine and clonidine was also given. RESULTS: A total of 68 sympathectomy blocks were performed: 28 bilateral USGBs, two unilateral USGBs, and 10 intrathecal injections. Multiple interventions in a single day were frequently required. For safety, all USGBs were performed with an ultrasound with strict adherence to local anaesthetic volume was maintained, with periprocedure monitoring of 2-3 hours. All blocks were performed by an experienced specialist. All children reported immediate pain relief with prevention of major amputation. CONCLUSION: With meticulous planning, monitoring, and precautions, sympathectomy of limbs in pediatric rheumatological disorders with RP can be safely undertaken. Bilateral stellate ganglion block with ultrasound is safe in children, and clonidine is a useful adjunct for vasodilation and prolongation of the effect of sympathectomies in children.

Ultrasound is a reliable and faster tool for confirmation of endotracheal intubation compared to chest auscultation and capnography when performed by novice anaesthesia residents - A prospective controlled clinical trial.

BACKGROUND: Anesthesia trainee may initially take longer time to intubate and unintentionally place the endotracheal tube (ETT) in the esophagus. The present study determined if ultrasound is the fastest method of confirmation of correct placement of ETT compared to capnography, and chest auscultation in trainees. METHODS: First year anesthesia residents performed intubation in 120 patients recruited after ethical clearance and informed consent. Time to visualize flutter in trachea, double trachea sign, time to appearance of first and sixth capnography, and time to execute chest auscultation was noted. RESULTS: Ultrasonography was statistically fastest method to determine endotracheal intubation (36.50 ± 15.14 seconds) vs unilateral chest auscultation (50.29 ± 15.50 seconds) vs bilateral chest auscultation (51.90 ± 15.98 seconds) vs capnography first waveform (53.57 ± 15.97 seconds) vs capnography sixth waveform (61.67 ± 15.88 seconds). CONCLUSION: When teaching endotracheal intubation to novice anesthesia residents using conventional direct laryngoscopy, ultrasonography is the fastest method to confirm correct ETT placement compared to capnograph and chest auscultation. Mentor can guide trainee to direct ETT towards trachea and can promptly detect esophageal intubation by double trachea sign.

Most Hemodynamically Stable Method for Change From High to Low Anesthesia Flow: A Randomized Controlled Trial Comparing State Entropy, High Fresh Gas Flow for 10 Minutes, and 0.8 Ratio of End-Expired Agent Concentration to Inspired Agent Concentration.

This study was undertaken to determine the most hemodynamically stable method to low-flow anesthesia (LFA) between 10-minute administration of high fresh gas flow, 0.8 equilibration ratio (Fe/Fi), and state entropy (SE) between 40 and 60, a marker for adequate depth of anesthesia. Change from high fresh gas flow to LFA was done in 3 groups of 30 patients each: group T (time): 10 minutes; group R (ratio): Fe/Fi = 0.8, and group SE: SE = 40 to 50. A decrease in mean blood pressure or heart rate was treated with ephedrine or atropine, with study termination at more than 2 boluses of either. In group SE, no patient required ephedrine or atropine. The requirement for ephedrine was statistically higher in groups R and T than group SE. Atropine requirement was statistically higher in group R vs groups T and SE. In group R, the mean (SD) time to LFA was 43.9 (20.37) minutes, and in group SE was 151.9 (74.4) seconds. Hypotension or bradycardia did not occur when LFA was started at SE of 40 to 50 after anesthesia induction compared with LFA at 10 minutes, which caused hypotension, and Fe/Fi of 0.8, which caused hypotension and bradycardia.

Addition of Fentanyl to Ropivacaine Infusion in Continuous Thoracic Paravertebral Infusion Does Not Improve Its Analgesic Effect Following Modified Radical Mastectomy: A Randomized Controlled Trial.

A randomized controlled trial was conducted to evaluate pain scores in patients given continuous thoracic paravertebral (TPV) block with ropivacaine alone or with fentanyl in modified radical mastectomy (MRM). Forty female patients ASA classes 1 and 2, aged 18 to 60 years, undergoing MRM were recruited. Preanesthesia with 0.5% ropivacaine, 20 mL, was injected at the T4 TPV space. After 2 hours, patients were randomly assigned to receive a 0.1 mL/kg/h infusion of either 0.2% ropivacaine (group R) or 0.19% ropivacaine plus fentanyl, 2 µg/mL (group RF). Postoperatively, patient-controlled analgesia (PCA) with fentanyl was provided. Visual analog scale (VAS) pain scores at rest and movement were significantly less in group RF at 8 AM on postoperative day 1 (R vs RF: rest: 2 [interquar-tile range, 0-7] vs 1 [0-6]; P = .016; movement: 2.5 [1-8] vs 2 [1-8], P= .042) and on movement 60 minutes postoperatively (R vs RF: 2 [0-9] vs 2 [1-2]; P = .01). Mean total fentanyl consumed via PCA in group R was significantly more (206 ± 31.68 µg vs RF 82.5 ± 35.07 µg, P < .001). Mean total fentanyl consumed via PCA plus TPV infusion was comparable (R: 206 ± 31.68 µg vs RF: 211 ± 25.52 µg, P < .2). Because the mean VAS score was below 3 in all timeframes, addition of fentanyl to ropivacaine in continuous TPV infusion in MRM had no clinical advantage.

Perioperative complications of cochlear implant surgery in children.

Cochlear implant is a commonly performed surgery for hearing loss in pre-school and school children. However, data on anesthesia management and anesthesia-related complications are sparse. We retrospectively reviewed the data of our institute from January, 2007 to December, 2012. Medical records and anesthesia charts of all the patients who had undergone cochlear implant under general anesthesia between this period were reviewed. Information related to the demographic profile, preoperative evaluation, anesthetic techniques, and perioperative complications were collected and analyzed. A total of 190 patients underwent cochlear implant surgery for pre-lingual (175) and post-lingual (15) deafness. General endotracheal anesthesia with inhalational agents was used in all the cases. Difficult intubation was encountered in three patients. Anesthesia-related complications were laryngospasm at extubation (4.73 %), emergence agitation (2.63 %), and postoperative nausea and vomiting (1.05 %). Major surgical complications were CSF leak without meningitis (3.15 %), device migration/failure (1.05 %), and flap infection (1.57 %). Cochlear implant under general anesthesia in small children is safe and anesthesia-related complications were minimal. Surgical complications, although more frequent, were predominantly minor and self-limiting.

Comparative efficacy and safety of the Ambu(®) AuraOnce(™) laryngeal mask airway during general anaesthesia in adults: a systematic review and meta-analysis.

Previous comparisons between the Ambu(®) AuraOnce(™) and other laryngeal mask airways have revealed different results across various clinical studies. We aimed to perform a systematic review with meta-analysis on the efficacy and safety of the AuraOnce compared with other laryngeal mask airways for airway maintenance in adults undergoing general anaesthesia. Our search of PubMed, PubMed Central, Scopus and the Central Register of Clinical Trials of the Cochrane Collaboration yielded nine randomised controlled trials eligible for inclusion. Comparator laryngeal mask airways were the LMA Unique(™) (four trials), the LMA Classic(®) (five trials) and the Portex(®) Soft Seal(®) (three trials). The AuraOnce provided an oropharyngeal leak pressure higher than the LMA Unique (304 participants, mean (95% CI) difference 3.1 (1.6-4.7) cmH2 O, p < 0.0001) and equivalent to the LMA Classic. The Soft Seal provided a higher leak pressure than the AuraOnce (229 participants, mean (95% CI) difference 3.5 (0.4-6.7) cmH2 O, p = 0.03). Insertion was significantly faster with the AuraOnce than the LMA Unique (304 participants, mean (95% CI) difference 5.4 (2.1-8.71) s, p = 0.001) and Soft Seal (229 participants, mean (95% CI) difference 9.5 (3.0-15.9) s, p = 0.004), but similar to the LMA Classic. The first-insertion success rate of the AuraOnce was equivalent to the LMA Unique, LMA Classic and Soft Seal. We found a higher likelihood of bloodstaining on the cuff with the Soft Seal and a higher incidence of sore throat with the LMA Classic. We conclude that the AuraOnce is an effective alternative to the LMA Classic and LMA Unique, and easier to insert than all three other devices studied.

Perioperative concerns of recurrent urinary bladder phaeochromocytoma with skeletal metastasis.

We report the perioperative management of a 61-year-old man diagnosed with recurrent urinary bladder phaeochromocytoma with vertebral and rib metastasis following partial cystectomy and nephrectomy. His blood pressure was controlled with antihypertensive agents. Epidural analgesia was avoided in view of vertebral metastasis; instead, analgesia was provided with fentanyl infusion. Intraoperative hypertensive episodes were managed with nitroglycerine, sodium nitroprusside and esmalol. However, after surgery, the patient required inotropic support and was moved to the intensive care unit. Analgesia was maintained with fentanyl infusion, and inotropic support was gradually weaned off. Nuclear ablative therapy was planned for bony metastasis. We recommend that recurrences of extra-adrenal phaeochromocytoma be investigated for bony metastasis and cautiously managed in the perioperative period so as to avoid neurological complications.

Hemiparesis after robotic laparoscopic radical cystectomy and ileal conduit formation in steep Trendelenburg position.

Robotic surgery is becoming popular for minimally invasive surgical procedures as robotic devices allow unprecedented control and precision. We report a case of robotic radical cystectomy with ileal conduit urinary diversion surgery having perioperative neurological complications related to prolonged surgery in the steep head-down position. There was a neurological deficit in the form of hemiparesis, which resolved with conservative management. We suggest that duration and positioning should be optimized for such prolonged surgery in the steep head-down position, and make some recommendations. Moreover, in such surgeries great vigilance must be observed in the perioperative period.

Low- versus high-dose combination of midazolam-ketamine for oral premedication in children for ophthalmologic surgeries.

INTRODUCTION: Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication. METHODS: This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKL received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted. RESULTS: A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. At 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in Group MKL and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation scores, mean response to induction and mask acceptance. The time to reach Aldrete score of 10 was shorter in Group MKL (22 +/- 5 min) and Group M (36 +/- 1 min) compared to Group MKH (52 +/- 2 min). Group MKH had a higher incidence of excessive salivation compared to the other groups. CONCLUSION: A combination of low-dose midazolam and ketamine is as effective as high-dose midazolam and ketamine for achieving optimum anxiolysis and a faster recovery, with a lower incidence of excessive salivation in children undergoing ophthalmic surgery.

Low-dose spinal anaesthesia for a parturient with Takayasu's arteritis undergoing emergency caesarean section.

Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetiology. Anaesthesia for patients with Takayasu's arteritis is complicated by severe uncontrolled hypertension leading to end-organ dysfunction, stenosis of major blood vessels affecting regional circulation, and difficulties in the monitoring of arterial blood pressure. The anaesthetic approach for parturients with Takayasu's arteritis has not been standardised in the literature, and previous reports have documented the use of general as well as regional anaesthesia. There are few instances in the literature where low-dose spinal anaesthesia alone is used in patients with Takayasu's arteritis undergoing emergency caesarean section. We present a case of the successful management of a parturient with Takayasu's arteritis, who underwent an emergency caesarean section under low-dose spinal anaesthesia.

Perianesthetic management of the first robotic partial cystectomy in bladder pheochromocytoma. A case report.

The authors report the perianesthetic considerations of a rare case of pheochromocytoma of the urinary bladder for which the first reported robotic partial cystectomy and ureteric reimplantation were performed. A 59-year-old male patient, known to be hypertensive, was posted for transurethral resection of a bladder tumor. In the operation room, after attaching the monitors, a subarachnoid block was given. Upon manipulation of the tumor, the blood pressure and heart rate increased markedly. A pheochromocytoma was suspected and was later confirmed by raised urine catecholamine levels and meta-iodobenzyl-guanidine scan. The patient was started on tablet prazosin and atenolol. After optimization, a robotic partial cystectomy was planned. In the operating room, an epidural catheter and a radial artery cannula were inserted. After the induction of anesthesia and the securing of the airway, surgery was started. After the insertion of the verres needle, pneumoperitoneum was created very slowly, and then the patient was positioned in 40 degrees Trendelenburg. Surges in arterial blood pressure (ABP) were managed with titrated doses of sodium nitroprusside and nitroglycerine and boluses of esmolol and labetalol. ABP drops postoperatively were managed with fluid and dopamine infusion. Robotic surgery is a safe alternative to the open technique for pheochromocytoma of the urinary bladder. Care should be taken during the positioning of the patient for robot placement and during pneumoperitoneum creation.