A Prospective Crossover Study Evaluating the Efficacy of King Vision Video Laryngoscope in Patients Requiring General Anesthesia with Endotracheal Intubation.

BACKGROUND: Direct laryngoscopy used for tracheal intubation requires aligning the pharyngeal, laryngeal and oral axes to achieve a line of sight. Video laryngoscopy provides a better view of the glottis without the need for aligning the three axes. AIMS: To evaluate the effectiveness of King vision laryngoscope over Macintosh laryngoscope in visualizing the glottis and intubating the trachea, when used on a same patient as in a cross over manner. SETTINGS AND DESIGN: Department of Anaesthesia, Mediciti Institute of Medical Sciences, prospective crossover study conducted over a period of six months. SUBJECTS AND METHODS: Sixty adult patients belonging to ASA physical status class I-II, requiring tracheal intubation were randomly assigned to intubation by King vision or Macintosh laryngoscope. Improvement, if any, in the Cormack-Lehane grading using the King vision scope, following initial grading with the Macintosh blade in the same patient was analyzed. STATISTICAL ANALYSIS: Mean and Standard deviation were calculated for different parameters under the study. Where appropriate, results were analyzed using the Mc Nemar χ2 test. A 'p' value less than 0.05 was considered statistically significant. RESULTS: In the King Vision group, Cormack and Lehane grade improved in the majority (9/12) of patients in whom the initial Cormack and Lehane grade was >1 using the Macintosh blade. CONCLUSIONS: The use of the King vision blade significantly improved the laryngoscopic view over the Macintosh blade but the time for intubation was prolonged.

Effect of adding clonidine to intrathecal bupivacaine on the quality of subarachnoid block: A prospective randomized double-blind study.

CONTEXT: The purpose of adding an adjuvant to local anesthetic in a central neuraxial blockade is to augment the desirable pharmacological actions of the agent and/or to minimize its undesirable pharmacological effects. Clonidine is an alfa-2 receptor agonist which has gained popularity in recent times as an adjuvant in spinal anesthesia. AIMS: To evaluate the influence of clonidine on the hemodynamic stability and the duration of anesthesia when added to intrathecal hyperbaric bupivacaine. SETTINGS AND DESIGN: Prospective randomized double blind study. SUBJECTS AND METHODS: Fifty patients scheduled for spinal anesthesia were randomized into two Groups A and B with 25 in each. Group A patients received 3 ml 0.5% heavy bupivacaine + 30 µg (0.2 ml) clonidine and Group B patients received 3 ml 0.5% heavy bupivacaine + 0.2 ml normal saline in the subarachnoid space. The blood pressure and heart rate were closely monitored. The time for attaining peak sensory block, time for two segment regression, decrease in the heart rate, total requirement of mephentermine to counter the hypotension, and the number of patients requiring mephentermine in each group was tabulated and analyzed. STATISTICAL ANALYSIS USED: Descriptive and inferential statistical methods were used to analyse the data. The power of the study was calculated using online power calculator for two independent sample study. RESULTS: The time for attaining peak sensory block was similar in both the groups. The time for two segment regression in Group A was 62.6 min and in Group B was 38.08 min. Twelve percent of patients in Group A and 52% of patients in Group B required mephentermine with the mean consumption being 0.72 mg in Group A and 5.65 mg in Group B. CONCLUSIONS: Addition of low-dose clonidine to intrathecal bupivacaine not only prolonged the duration of spinal anesthesia but also provided a stable intraoperative hemodynamic profile.

Comparison of GlideScope video laryngoscope with Macintosh laryngoscope in adult patients undergoing elective surgical procedures.

BACKGROUND: GlideScope (GS) is a video laryngoscope that allows a real-time view of the glottis and endotracheal intubation. It provides a better view of the larynx without the need for alignment of the airway axes. AIM: This prospective randomized comparative study is designed to compare the intubation time, hemodynamic response, and complications associated with intubation using a GS or Macintosh laryngoscope (ML) in adult subjects undergoing elective surgical procedures. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists physical status 1-2 patients were included in this prospective randomized comparative study. Patients were randomized to be intubated using either a GS or an ML. The primary outcome measure was the intubation time. The secondary outcome measures were the hemodynamic response to intubation and the incidence of mucosal injury. STATISTICAL ANALYSIS: Mean and standard deviation were calculated for different parameters under the study. The observed results were analyzed using Student's t-test for quantitative data and Z-test of proportions. P<0.05 was considered statistically significant. RESULTS: Intubation time was longer in GS group (45.7033 ± 11.649 s) as compared to ML (27.773 ± 5.122 s) P< 0.0001 with 95% confidence interval (95% CI) -13.2794 to -22.5806. GS provided better Cormack and Lehane laryngoscopic view (P = 0.0016 for grade 1 view) with 95% CI -0.1389 to -0.5951. GS group exhibited more laryngoscopic response than ML group with more increase in blood pressure and heart rate, but the difference was not statistically significant. More cases of mucosal trauma were documented in GS group. CONCLUSION: Use of GS to facilitate intubation led to better glottic view but took a longer time to achieve endotracheal intubation. GS was associated with more hemodynamic response to intubation and mucosal injury in comparison with an ML.

Comparison of the ease of tracheal intubation by postgraduate residents of anesthesiology using Airtraq™ and Macintosh laryngoscopes: An observational study.

CONTEXT: Airtraq™ (Prodol Meditec, Vizcaya, Spain) is a recently developed laryngoscope, which facilitates easy visualization of glottis through a matrix of sequentially arranged lenses and mirrors. In this observatory study, we sought to compare the ease of tracheal intubation with Airtraq™ and Macintosh laryngoscope when performed by 2(nd) year postgraduate residents of Anesthesiology in NRI Medical College, Mangalagiri. AIMS: To compare the ease of tracheal intubation by Airtraq™ laryngoscope with that by Macintosh laryngoscope among the 2(nd) year postgraduate residents of anesthesiology in terms of time taken for intubation and the rise of rate-pressure product (RPP) with intubation. SETTINGS AND DESIGN: Prospective randomized observational study. SUBJECTS AND METHODS: Eighty adult and healthy patients with an easy airway, scheduled for general anesthesia were allocated into two groups A, and M. Patients in Group A were intubated with Airtraq™ laryngoscope and those in Group M were intubated with Macintosh laryngoscope by the 2(nd) year postgraduate residents of anesthesiology. The time taken for intubation, the RPPs at baseline, after induction of general anesthesia, postintubation, at 3 and 5 min after intubation, the rise of RPP to intubation and the occurrence of a sore throat were compared between the two groups. STATISTICAL ANALYSIS USED: Descriptive and inferential statistical methods were used to analyze the data. RESULTS: The mean time for intubation in Macintosh group was 28.18 s and was 40.98 s in Airtraq group. The mean rise of RPP to intubation was 4644.83 in Airtraq group and 2829.27 in Macintosh group. The incidence of a sore throat was equal in both the groups. CONCLUSIONS: The time for intubation and the sympathetic response to airway instrumentation were more with Airtraq™ laryngoscope than with Macintosh laryngoscope.

Comparison of equipotent doses of rocuronium and vecuronium.

BACKGROUND: Rocuronium (R) bromide and vecuronium (V) are monoquaternary aminosteroid compounds. The aim of this study was to evaluate the onset time, conditions of intubation and duration of action of equipotent doses (3ED95) of R and V. MATERIALS AND METHODS: The study was carried out in 60 adult American Society of Anesthesiologists physical status 1-2 patients of age 20-60 years. The patients were divided into two groups of 30 each and received either 0.9 mg/kg of R (Group R) or 0.168 mg/kg of V (Group V) to facilitate endotracheal intubation. Neuromuscular blockade was assessed at corrugator supercilii and adductor pollicis muscles to evaluate onset time and duration of neuromuscular block, respectively. RESULTS: The mean onset time was significantly rapid in Group R as compared to Group V (P -0.011). Overall intubating conditions were excellent in 100% of patients in Group R as compared to 70% in Group V. The mean duration of action did not show a significant variation between the groups. CONCLUSION: At equipotent doses, R provides clinically acceptable intubation conditions much earlier than V without significant variation in clinical duration of action.

Critical upper limb ischemia due to thrombus in the right subclavian artery: An uncommon complication of right internal jugular vein cannulation.

Internal jugular catheterization is associated with arterial puncture in 6.3-9.4% of cases and subclavian artery (SCA) injuries are probably under-reported. Several complications like hemothorax, delayed presentation of hemomediastinum due to SCA injury have been reported. We report a case of critical upper limb ischemia due to SCA thrombosis developing a few hours after a difficult right internal jugular vein cannulation without any evidence of initial arterial injury with the finder or introducer needle and which was successfully treated by surgical thrombectomy. Arterial trauma should be kept in mind during subsequent manipulations and at all stages, particularly if a technical difficulty arises during the procedure. Although the ultrasound (US) was not used in this case, US should be used not just to identify the vein, but also to verify guide-wire and catheter insertion. High index of suspicion is necessary for detection of postprocedure thrombosis of SCA. Close monitoring for neurologic and vascular sequelae after the procedure is suggested in all difficult catheter insertions, even without a direct arterial puncture.

Out of the blue! Thyroid crisis.

A 45-year-old male patient with an irregularly irregular rhythm and fast ventricular rate was posted for an emergency laparotomy for hollow viscus perforation. His history was not suggestive of any systemic disorders. An echocardiography revealed left ventricular dysfunction with an ejection fraction of 47% without any valvular or chamber abnormality. Thyromegaly noticed during placement of central venous catheter was suspected to be the etiology for his cardiovascular status and was successfully managed. Thyroid crisis in an undiagnosed case of hyperthyroidism poses a diagnostic and therapeutic challenge. Timely and aggressive management is essential to correct the homeostatic decompensation characteristic of thyroid storm.

Cramps and tingling: A diagnostic conundrum.

Tetany a syndrome of sharp flexion of the wrist and ankle joints (carpopedal spasm), muscle twitching, cramps and convulsions, sometimes with an attack of stridor, is due to hyperexcitability of nerves and muscles caused by decreased extracellular ionized calcium. Hyperventilation secondary to anxiety can result in tetany. We report a case of hyperventilation induced tetany 2 h following spinal anesthesia for inguinal hernia repair.

Ischemic pain mandating unconventional position for epidural placement.

Positioning has always been a special and important concern for any regional anesthetic technique. The standard positions recommended for epidural anesthesia include lateral decubitus, sitting and prone. We report a special situation where we employed the standing position for placing epidural catheter. A 40-year-old man presented with severe ischemic pain of right lower limb due to near total thrombosis of right common iliac artery. He was scheduled for peripheral angiogram and referred to us for pain management as his pain was not permitting him to sit or lie down. Epidural analgesia was planned for managing the pain in the catheterization laboratory and for any other possible management intervention later. As the patient was not tolerating any position other than standing because of severe pain, we placed the lumbar epidural catheter in the standing position and quickly activated the analgesia in the supine position. Patient had good pain relief immediately and an infusion was commenced. Safety and comfort are the major issues to be addressed, while positioning for any procedure. Standing position was chosen for this particular case as it was the only comfortable position for the patient and the safety was not compromised.

Comparison of the efficacy of dexmedetomidine with that of esmolol in attenuating laryngoscopic and intubation response after rapid sequence induction.

CONTEXT: Laryngoscopy and tracheal intubation produce sympathetic overdrive by catecholamine release resulting in hypertension and tachycardia. Various agents are being tried to combat the intubation response over years. AIMS: This study is aimed at comparing dexmedetomidine which is a highly selective alpha-2 agonist with an ultra-short acting beta blocker, esmolol to see which among the two is better in attenuating the hemodynamic response to laryngoscopy and tracheal intubation. SETTINGS AND DESIGN: This was a prospective randomized double-blind control study. SUBJECTS AND METHODS: Sixty patients scheduled for general anesthesia were divided into two groups, D and E with 30 patients in each group. Group-D patients received dexmedetomidine 0.5 mcg/kg and Group-E patients received esmolol 0.5 mg/kg as intravenous premedication over 5 min before a rapid sequence induction and tracheal intubation. Systolic, diastolic and mean arterial pressures along with heart rate were measured using invasive arterial line at various time points. The percentage change of hemodynamic parameters at those time points from the baseline was compared between the groups. STATISTICAL ANALYSIS USED: Descriptive and inferential statistical methods were used to analyze the data. RESULTS: The percentage change of all hemodynamic parameters from base line were less in the dexmedetomidine group than in esmolol group at all-time points of measurement. However, a statistically significant difference was observed often at the time points within 1 min after tracheal intubation. CONCLUSIONS: Dexmedetomidine is superior to esmolol in attenuating the hemodynamic response to laryngoscopy and tracheal intubation.