Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report

Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report.

Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Postpartum Hypernatremia with Extrapontine Rhabdomyelinolysis: A Case Report.

Hypernatremia (serum sodium>160 meq/L) present with diverse neurological manifestations, ranging from flaccid paralysis to impaired cognition, encephalopathy, and even deep coma. Osmotic demyelination refers to changes in brain cells because of an acute change in plasma osmolality. It is further divided into two types, i.e., central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM). Patients with EPM, besides spasticity, may also present with other movement disorders such as catatonia, parkinsonism, and dystonia. We present a case of a postpartum woman bought to the emergency department by her relatives in an unconscious state. In view of poor sensorium (Glasgow coma scale < 7), she was intubated and received mechanical ventilatory support. On admission, computed tomography ofthebrain was normal, and the patient was transferred to the intensive care unit (ICU) for further management. The preliminary work-up in the ICU showed hypernatremia (serum sodium of 182 mEq/L) with hyper-osmolality (359 mOsm/kgH2O). She was managed as per the ICU protocol for hypernatremia. During her ICU stay, her sensorium improved, but she developed flaccid paralysis and was quadriplegic. Thus, a tracheostomy was performed, and she was weaned from the ventilator. After ventilator weaning, she was transferred to the ward for further rehabilitation. During rehabilitation, the patient was able to sit and takefoodorally.To date, only a few cases are reported in postpartum women with acute severe hypernatremia caused by high-grade fever and loss of body fluids leading to extra-pontine demyelination and flaccid paralysis. This case highlightsthat prompt recognition and appropriate intervention can improve the outcomes in these patients.

A study on physicochemical, antioxidant and microbial properties of germinated wheat flour and its utilization in breads.

Wheat is consumed worldwide because of its high nutritional content and convenience to form different products. Whole wheat is an important source of dietary fiber and its consumption is known to lower the risk of colon cancer, diabetes mellitus and cardiovascular disease. Germination of wheat results in better availability of nutrients and offers many health benefits. In this study, germinated wheat flour (GWF) was prepared and analyzed for its proximate composition, functional properties, antioxidant activity and microbial count along with whole wheat flour (WWF). The GWF was having 9.2% higher protein content than that of WWF. No significant change was observed in the ash, fat and crude fiber content after germination. GWF showed higher oil absorption capacity and water solubility index. Falling number of GWF was found to be lower. The total phenolic content increased more than two folds after germination and antioxidant activity increased from an initial of 12.35% in WWF to 33.28% in GWF. The microbial counts of GWF were within acceptable range for processing. Breads were prepared by replacing WWF with GWF at 0-100% levels and were analyzed for their proximate composition and acceptance on Hedonic Scale. The 100% GWF bread was having 8.7% higher protein content than 100% WWF bread. The overall acceptability score for all breads were high (> 7.3) whereas the bread prepared with 50% GWF got the highest overall acceptability score of 8.4. The results of this study indicate that bread with improved nutrition and acceptable quality can be prepared from GWF.

Comparison of Conventional Technique versus Modified Tube First Technique of Awake Nasotracheal Fiber-optic Intubation: A Randomized Control Open-Label Trial.

BACKGROUND: Although the conventional awake fiber-optic nasal intubation is most commonly used in anticipated difficult tracheal intubation, it has several potential difficulties. AIMS: The aim of this study is to compare another technique modified tube first (MTF) technique with the conventional one in terms of time taken, ease of glottis visualization, number of attempts needed, and complications. SETTINGS AND DESIGN: This was a prospective, randomized, open-label trial conducted on 60 patients with an anticipated difficult airway undergoing oromaxillofacial surgery at a tertiary care center. MATERIALS AND METHODS: The patients were randomized into the MTF and conventional technique groups. Times from insertion of the fiber-optic scope into nares till vocal cord visualization (T1) and from T1 to complete intubation (T2) were measured and compared. STATISTICAL ANALYSIS USED: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21. RESULTS: Time taken to visualize glottis was significantly less in the MTF technique as compared to the conventional method (mean ± standard deviation = 108.6 ± 43.1 vs. 142 ± 49.2 s, respectively, P = 0.007). Similarly, the total time taken for nasotracheal intubation with modified technique is significantly less as compared to the conventional technique (P = 0.004). Furthermore, there is significantly better ease of glottis visualization (P = 0.001), higher success in minimal attempts (P = 0.02) with significantly lesser incidence of desaturation in MTF technique (P = 0.026). CONCLUSION: The alternative technique (MTF) is a quicker, easier approach with higher success rate and lesser complications for the placement of an endotracheal tube in a difficult airway scenario.

Parturient Controlled Epidural Analgesia with and without Basal Infusion of Ropivacaine and Fentanyl: A Randomized Trial.

INTRODUCTION: Parturient controlled epidural analgesia (PCEA) is an established method of providing safe and effective labor analgesia. OBJECTIVE: The aim of this single-blind, randomized controlled trial was to compare the efficacy of PCEA with or without basal infusion (BI) of ropivacaine and fentanyl for the effective management of labor pain associated with normal vaginal delivery. MATERIALS AND METHODS: A total of 78 nulliparous parturients with vertex presentation at term and with cervical dilatation of 3-5 cm demanding for epidural analgesia (EA) were enrolled in the study. EA was initiated and maintained with ropivacaine 0.125% and fentanyl 2 µg/mL. Following an initial epidural loading volume of 8-10 mL, parturients were randomly allocated in two groups of 39 each. PCEA group received bolus of 5 mL at 200 mL/h with lockout interval of 15 min and with maximum volume of local anaesthetic was 20 mL/h and PCEA + BI group - receiving added BI rate of 5 mL/h along with same programmed parameters of PCEA pump. RESULTS: No statistically significant difference was observed between the groups in terms of demographic characteristics, duration of labor, delivery methods, maternal satisfaction as well as Apgar score. Mean demand bolus in group PCEA + BI was 0.39 ± 0.59, whereas in group PCEA was 3.31 ± 0.77 (P < 0.05). Mean volume of drug used in group PCEA + BI was 25.57 ± 2.75 mL, while in group PCEA was 22.42 ± 4.56 mL (P = 0.0005). In PCEA + BI group, Visual Analog Scale (VAS) score was 0.07 ± 0.35 at 60 min and 0.06 ± 0.33 at 120 min, whereas in PCEA group, VAS was 0.32 ± 0.62 at 60 min and 0.26 ± 0.50 at 120 min (P = 0.05), respectively. CONCLUSION: BI when added to PCEA, it significantly reduces breakthrough labor pain and demand boluses without prolonging labor duration but at the cost of increased requirement of drug volume when compared to PCEA only group.

Anaesthetic management of pacemaker implantation in a child with dilated cardiomyopathy and acquired complete atrioventricular heart block.

We report a case of an 8-year-old girl who presented with syncopal attacks and a history of viral illness a month ago. On examination, she was conscious, oriented but had a heart rate of 42/min which was unresponsive to atropine. She was started on dobutamine and isoproterenol. Electrocardiography and echocardiography revealed complete heart block with moderate tricuspid regurgitation, dilated cardiomyopathy and low ejection fraction. Patient was planned for urgent permanent pacemaker insertion. General anaesthesia was administered with endotracheal tube and controlled ventilation using fentanyl, ketamine and pancuronium. For patient safety, invasive arterial monitoring was instituted and external pacing was kept standby. Transvenous pacemaker leads were implanted onto the right ventricular wall through the left subclavian vein.

Assessment and comparison of clinical dental status and its impact on oral health-related quality of life among rural and urban adults of Udaipur, India: A cross-sectional study.

BACKGROUND: Dental diseases negatively influence people's oral health-related quality of life (OHRQoL) and thus their perceived need for dental care. QoL is increasingly acknowledged as a valid, appropriate and significant indicator of service need and intervention outcomes in contemporary public health research and practice. OBJECTIVES: (1) To assess the psychometric properties of oral health impact profile-14 (OHIP-14) scale among rural and urban OHIP of Udaipur population. (2) To assess and compare clinical dental status (dental caries, periodontal disease and prosthetic status) and its impacts on OHRQoL rural and urban population of Udaipur. MATERIALS AND METHODS: A cross-sectional descriptive survey was conducted among rural (600) and urban (600) population of Udaipur that have age ranges between 20 and 79 years, chosen from outpatient department of Pacific Dental College and Hospital. The OHIP-14 was tested for validity and reliability. Chi-square, Student's t-test, analysis of variance and multiple logistic regression analysis were employed for statistical analysis. RESULTS: The Cronbach's alpha of the scale was found to be 0.85 among the rural population and 0.89 among the urban population. Prevalence of periodontal disease (community periodontal index and loss of attachment) was found greater among the rural population than the urban population. Urban population showed significantly greater proportion of subjects with prosthesis (including partial, fixed and total) as compared to the rural population. Among study population, OHIP-14 was significantly (P ≤ 0.05) associated with age, gender, presence of decayed teeth (DT), missing teeth (MT), and location. Significantly greater odds ratio (OR) (OHIP-14) were revealed among males (OR = 1.35, P = 0.02), urban residents (OR = 1.13, P = 0.002), those < 45 years of age (OR = 1.23, P = 0.01), those without DT (OR = 1.48, P = 0.002) and without MT (OR = 1.08, P = 0.03). CONCLUSION: The rural and urban study subjects had a fair clinical status. The presence of dental caries had greatest impacts on OHRQoL. In addition, rural subjects faced greater impact than urban subjects.

Comparison of the Debonding Characteristics of Conventional and New Debonding Instrument used for Ceramic, Composite and Metallic Brackets - An Invitro Study.

BACKGROUND: Debonding procedure is time consuming and damaging to the enamel if performed with improper technique. Various debonding methods include: the conventional methods that use pliers or wrenches, an ultrasonic method, electrothermal devices, air pressure impulse devices, diamond burs to grind the brackets off the tooth surface and lasers. Among all these methods, using debonding pliers is most convenient and effective method but has been reported to cause damage to the teeth. Recently, a New Debonding Instrument designed specifically for ceramic and composite brackets has been introduced. As this is a new instrument, little information is available on efficacy of this instrument. The purpose of this study was to evaluate the debonding characteristics of both "the conventional debonding Pliers" and "the New debonding instrument" when removing ceramic, composite and metallic brackets. MATERIALS AND METHODS: One Hundred Thirty eight extracted maxillary premolar teeth were collected and divided into two Groups: Group A and Group B (n = 69) respectively. They were further divided into 3 subGroups (n = 23) each according to the types of brackets to be bonded. In subGroups A1 and B1{stainless steel};A2 and B2{ceramic};A3 and B3{composite}adhesive precoated maxillary premolar brackets were used. Among them {ceramic and composite} adhesive pre-coated maxillary premolar brackets were bonded. All the teeth were etched using 37% phosphoric acid for 15 seconds and the brackets were bonded using Transbond XT primer. Brackets were debonded using Conventional Debonding Plier and New Debonding Instrument (Group B). After debonding, the enamel surface of each tooth was examined under stereo microscope (10X magnifications). Amodifiedadhesive remnant index (ARI) was used to quantify the amount of remaining adhesive on each tooth. RESULTS: The observations demonstrate that the results of New Debonding Instrument for debonding of metal, ceramic and composite brackets were statistically significantly different (p = 0.04) and superior from the results of conventional debonding Pliers. CONCLUSION: The debonding efficiency of New Debonding Instrument is better than the debonding efficiency of Conventional Debonding Pliers for use of metal, ceramic and composite brackets respectively.

Effect of fluoridated toothpaste on white spot lesions in postorthodontic patients.

INTRODUCTION: This article illustrates a new treatment approach and evaluates the effect of use of fluoridated toothpaste on the remineralization of white spot lesions (WSLs) diagnosed at debonding. MATERIALS AND METHODS: Thirty-one orthodontic patients (mean age: 19.6 years), with a minimum of four WSLs on the buccal surfaces of the maxillary and mandibular incisors, canines, premolars and first molars after orthodontic therapy, were enrolled in a double-blind, randomized, longitudinal trial lasting 8 weeks. The subjects were divided into two groups using fluoridated toothpaste (test group, n = 31) and nonfluoridated toothpaste (control group, n = 31). A custom-made mouth tray, covering the maxillary dentition, was used while brushing with the fluoridated toothpaste three times per day. Maxillary dentition acted as control and mandibular as the test. The WSLs were scored by using the International Caries Detection and Assessment System (ICDAS II) index, at baseline and 8 weeks after debonding. RESULTS: The ICDAS II index of the WSLs decreased in the test group in the mandibular dentition but not on the maxillary dentition during the 8-week trial (p < 0.0001). There was also a slight improvement in the control group (not significant). CONCLUSION: The frequent use of fluoridated toothpaste had a remineralizing effect on WSLs. How to cite this article: Agarwal A, Pandey H, Pandey L, Choudhary G. Effect of Fluoridated Toothpaste on White Spot Lesions in Postorthodontic Patients. Int J Clin Pediatr Dent 2013;6(2):85-88.