A Comparison of Techniques of Internal Jugular Vein Cannulation: Anatomical Landmark, Ultrasound Guided Pre-location, and Real-Time Ultrasound Guided.

OBJECTIVE: The objective of our study is to compare the success rate, duration, and incidence of complications of a right internal jugular vein (IJV) cannulation by using three different techniques. METHODOLOGY: A randomised controlled trial was conducted at a tertiary care teaching hospital. A total of 201 patients were randomly allocated to one of the following three groups (67 in each group). Techniques were categorised as anatomical landmark technique group (Group ALT), ultrasound guided pre-location group (Group USG-Pre), and real-time ultrasound-guided technique group (Group USG-RT). INTERVENTIONS: Central venous catheter insertion via three techniques. RESULTS: In 138 (73.01%) patients' IJV canulated in the first attempt, USG-RT, USG-Pre, and ALT were 51 (83.6%), 44 (72.1%), and 43 (64.2%), respectively. On the other hand, 37 (19.57%) patients were required in the second attempt, while only 14 (7.40%) patients were required in the third attempt for successful IJV cannulation. The success rates, as defined in our study, were only 138 (73%) as, in 51 (27%), we cannulated in more than a single attempt or switched to another technique. We found a significant difference in preparation time in all techniques as P-value <0.05, but no significant difference was found in venous access time, cannulation time, and duration of the procedure. CONCLUSIONS: Any technique can be used for IJV cannulation, but the most acceptable is the real-time US technique. However, no difference in the overall procedure time among all three techniques was noted, and no major incidence of complication was found.

Adverse Respiratory Events After Removal of Laryngeal Mask Airway in Deep Anesthesia Versus Awake State in Children: A Randomized Trial.

Background The advent of the laryngeal mask airway (LMA) has reduced respiratory events in comparison to the conventional endotracheal tubes. Any manipulation under a light plane of anesthesia predisposes to increased airway sensitivity followed by adverse events. The reduced airway sensitivity in the deeply anesthetized state makes LMA removal feasible. In the past, the respective advantages and disadvantages of extubation in two planes of anesthesia have led to conflicting results. The primary objective of this study is to compare the incidence of adverse respiratory events at the time of LMA removal, in deeply anesthetized and awake groups. Our secondary objective was to record the management of complications. Materials and methods We conducted a prospective randomized control trial in 106 American Society of Anesthesiologists (ASA) I and II patients undergoing lower umbilical surgeries over a period of one year. The demographic details and intraoperative and postoperative variables, i.e., airway obstruction, laryngospasm, peripheral oxygen desaturations, cough, straining and vomiting, along with corrective measures were recorded by the primary research assistant in both groups. Regarding the management of peripheral oxygen desaturation (less than 90%), airway obstruction, and laryngospasm, 100% fractional inspired oxygen support and chin lift/jaw thrust were used. Results The average age was 32.58±15.81 months. The demographic characteristics of the patients were not significant between the two groups. The rate of adverse respiratory events like laryngospasm and airway obstruction was relatively high in the deep group but not statistically significant between the groups. A total of 7 (6.6%) patients had laryngospasm, 21 (20%) had airway obstruction, 16 (15%) had a cough and 11 (10%) patients had observed peripheral oxygen desaturation (less than 90%) between both groups.  Conclusion We concluded that adverse respiratory events could happen in both awake and deep planes of anesthesia after the removal of LMA in children. Furthermore, both techniques have an acceptably low frequency of complications, and it does not affect the current clinical practice.

Frequency of Prescribing and Administering Premedication in Paediatric Surgical Patients at a Tertiary Care Hospital: An Observational Study.

INTRODUCTION:  Preoperative period is a stressful event, especially for paediatric patients undergoing surgery. Stress may lead to the development of perioperative maladaptive behaviour, activation of stress responses, and susceptibility to postoperative infections. To alleviate preoperative stress, the use of a multimodal approach including preoperative pharmacological premedication in the ward is recommended. We conducted an observational study to determine the frequency of prescribing and administering premedication in paediatric surgical patients. METHODS: This three-month retrospective observational study was conducted in the main operating room of the Aga Khan University Hospital, Karachi, from October to December 2014. It included all paediatric patients (aged 1-16 years) coming for elective surgery. Patients' preoperative forms and medical records were reviewed, and data recorded for written orders of premedication and the timing of administration of the premedication drug in the inpatient ward/surgical day care ward. A p-value <0.05 was considered statistically significant. RESULTS: This study included 125 paediatric patients. Premedication was not prescribed to 40% (50/125) patients. In these patients, drug and dose were properly mentioned in 98.7% (74/75) of cases while the route and time of administration were not mentioned in 26.6% and 12% prescription orders, respectively. The premedication drug was administered in 67 out of 75 patients (89.3%) by ward nurses as per prescription. The administration of premedication was documented in 95.5% patients, but the time was missing in 46.3% of cases. CONCLUSION: A significant number of patients were not prescribed preoperative premedication by the anaesthetist. Moreover, the route and timing of administration of drug were not mentioned especially in cases when premedication was prescribed in the wards.

Comparison of upper lip bite test with Mallampati test in the prediction of difficult intubation at a tertiary care hospital of Pakistan.

OBJECTIVE: To determine the accuracy of the Upper lip bite test and Mallampati test in predicting difficult endotracheal intubation. METHODS: The cross-sectional study was conducted at the Aga Khan University Hospital, a tertiary care facility in Karachi, Pakistan. Between June 1,2007 and May 31, 2008, 324 adult patients undergoing elective surgeries requiring general anaesthesia with endotracheal intubations were enrolled. Pre-operatively upper lip bite test and Mallampati test were performed for the assessment of airway by a specifically trained observer. Laryngoscopic view was rated by using Cormack and Lehane laryngoscopic grading once the patient was fully anaesthetised using standard anaesthesia technique. Completed data sheets were analysed using SPSS version 10. McNemar test and rank correlation coefficient were used to compare the upper lip bite test and the Mallampati test. RESULTS: Of the 324 patients, 56 (17.3%) were classified as cases of difficult intubation. Upper lip bite test showed significantly higher accuracy, positive predictive value and negative predictive value than the Mallampati test. Comparison of specificity, however, did not reveal any significant difference between the two tests. CONCLUSION: Upper lip bite test is an acceptable alternative as a single test to predict difficult intubation in addition to other tests of airway assessment for the prediction of difficult intubation.

Effectiveness of premature epidural catheter termination as a quality indicator in a developing country.

BACKGROUND AND OBJECTIVE: Premature epidural catheter termination in the postoperative period is a common cause of epidural analgesia failure. The incidence varies from 5.7 to 13%. A higher incidence of unplanned epidural catheter termination was observed in our hospital. We took this as a quality improvement project, monitored the causes and applied remedial measures at the same time to reduce the incidence. METHOD: An audit was conducted by the Acute Pain Service between January 2004 and December 2007 to find the incidence and different causes of accidental epidural catheter pullout. Different strategies were applied simultaneously to counter the identified causes. A predesigned pro forma was used for audit while remedial measures included change in practice, counselling of the person responsible, group teaching and reinforcement of epidural care policy. RESULTS: The overall incidence of premature epidural termination was 3.9% during a 4-year period with a higher incidence in 2004 (5.59%), which was reduced in later years. The main reason for premature epidural catheter removal was mishandling of the catheter and filter (64%). The most common site for catheter disconnection was found to be at the filter end of the catheter (54.7%), although 39 (61%) epidural catheters were removed by the Acute Pain Service following disconnection or breakage to avoid danger of infection. CONCLUSION: Identification of premature epidural catheter termination as a quality indicator and continuous quality improvement efforts later on proved to be a useful approach in reducing the incidence. The present audit also helped to quantify the improvement in the quality of care.

Emergency airway management of a patient with tracheal stenosis.

We are presenting a case of a 26 year old healthy male, who came with gradual worsening of dyspnoea following prolonged intubation and ventilation, after a road traffic accident five months back. On arrival in ER, he was hypoxaemic with severe respiratory distress. He was transferred to the operation room (OR) for emergency tracheostomy. During the transfer, he was placed in an upright position with oxygen at 15 L/M. In the OR, anaesthesia was induced with sevoflurane gradually. Direct laryngoscopy was done which revealed normal vocal cords. A size 4.00 mm ID endotracheal tube was impossible to pass more than 1-2 cm distal to vocal cords. Due to a large leak, size 8 tube was passed below the cords and cuff was inflated slightly to reduce air leak. Oxygen saturation dropped to 95-96% and surgeon was asked to start tracheostomy. Findings included an almost complete subglottic stenosis, 2 cm below the vocal cords. A tracheostomy tube was inserted below the stenotic lesion which was followed by direct laryngoscopy.