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   Table of Contents - Current issue
January-April 2019
Volume 2 | Issue 1
Page Nos. 1-53

Online since Thursday, April 25, 2019

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Evidence-Based Medicine: New Paradigm Towards Sound Medical Practice p. 1
Venkateswaran Ramkumar
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Comparison of high-flow nasal cannula versus conventional oxygen therapy following extubation after paediatric cardiac surgery p. 4
Vijitha Burra, Adalagere Sathyanarayana Lakshmi, Anand V Bhat, V Prabhakar, N Manjunatha
Background: Respiratory complications after cardiac surgery increase morbidity, mortality and length of hospital stay. Oxygen administered using a high-flow nasal cannula (HFNC) improves oxygenation because of its ease of implementation, tolerance and clinical effectiveness. We sought to compare this technique with conventional oxygen therapy (OT) after extubation following paediatric cardiac surgery. We compared HFNC versus conventional OT in postoperative paediatric cardiac surgical patients. Our primary objective was to evaluate the relative efficiency of improving PaCO2elimination in the first 48 h following extubation. Patients and Methods: A single-centre, prospective, unblinded, randomised controlled trial was conducted in a 15-bedded post-cardiac intensive care unit on 50 paediatric cardiac surgical patients <2 years of age undergoing elective surgery with Risk Adjustment for Congenital Heart Surgery score ≥2. At the start of weaning off ventilation, patients were randomly assigned to either of the following groups: HFNC or OT. Arterial blood samples were collected before and following extubation at the following time points: 1, 6, 12, 24 and 48 h. While the primary outcome was comparison of arterial PaCO2post-extubation, the secondary outcomes were PaO2and PaO2/FIO2 ratios and any complications associated with either technique. Continuous data were expressed as mean ± standard deviation and compared using independent samples t-test or the Mann–Whitney U-test. Chi-square test was used for categorical parameters. Results: Demographic and clinical variables were comparable in the two groups. PaO2and PaO2/FIO2 ratios were significantly improved in the HFNC group (P < 0.05) with lesser requirement of FIO2(P < 0.05) in comparison to conventional OT. No complications were observed during HFNC therapy, nor was there any treatment failure. Conclusion: Compared with conventional OT, the use of HFNC following extubation in paediatric cardiac surgical patients appears to be safe, improves oxygenation and carbon dioxide elimination with lesser inspired oxygen concentration.
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Comparison of channelled blade with non-channelled Blade of King Vision™ videolaryngoscope for orotracheal intubation: A randomised, controlled, multicentric study Highly accessed article p. 10
Amit Shah, Apeksh Patwa, Vijitha Burra, Deepshikha Shah, Bhavin Gandhi
Introduction: We conducted a randomised, controlled, prospective, multicentric comparison of channelled blade versus non-channelled blade of the King Vision™ videolaryngoscope for orotracheal intubation. Patients and Methods: A total of 66 patients included in the study were divided into two groups as follows: Group CH for intubation with channelled blade and Group NC for intubation with non-channelled blade. We compared the intubation time, ease of intubation and best laryngeal view obtained. Ease of intubation was categorised into ease of device insertion and ease of passage of endotracheal tube. Various impingements which occurred at the laryngeal inlet were observed and manoeuvres used to accomplish intubation were noted. Results: The grade of laryngeal exposure and time of laryngeal exposure were similar in both types of blade. We found a shorter intubation time of 15.24 ± 10.6 s in Group CH, whereas it was 28.57 ± 14.09 s in Group NC (P < 0.001). Impingement of the endotracheal tube at the glottic inlet was similar in both the groups, but manoeuvring of the device was not needed after laryngeal exposure in the case of the non-channelled blade. Manoeuvres needed to accomplish successful intubation were different in each group. Intubation with channelled blade requires anticlockwise rotation of the endotracheal tube as it is advanced in the slot while slight withdrawal and redirection towards the centre was needed most often with the non-channelled type of blade. Conclusions: We conclude that when used with the channelled blade, the King Vision videolaryngoscope requires shorter intubation time as compared to its use with the non-channelled blade. Anticlockwise rotation of the advancing endotracheal tube within the channel slot overcomes major impingement at the larynx and facilitates intubation with the use of channelled blade while slight withdrawal and redirection towards the centre are needed for successful intubation using the non-channelled blade.
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Is neck roentgenogram essential for airway assessment in thyroid swelling? A 3-year audit in a tertiary care centre p. 17
Radhakrishna Shetty Sumalatha, Balaram Chandana, Kandavar Siri
Introduction: Thyroid swelling leading to airway compromise offers a challenge to the anaesthesiologist. Neck roentgenograms are routinely done as a part of preanaesthetic evaluation in thyroid swellings in our institute. With this audit, we wished to analyse whether routine neck roentgenograms had any role in the airway assessment and management for thyroidectomy. Methodology: After obtaining clearance from the Institutional Ethics Committee, data of all patients who underwent thyroidectomy under general anaesthesia between January 2015 and December 2017 were collected from the Medical Records Department. We collected demographic details along with the details of anaesthetic management of these patients. Our primary objective was to know whether neck roentgenogram was essential in thyroidectomy, and the secondary objective was to analyse the airway management in these patients. Qualitative data were represented as frequencies and percentages and quantitative data as mean and standard deviation. Chi-square test was used to compare the qualitative variables and t-test for quantitative variables, and P < 0.05 was considered statistically significant. Results: A total of 317 thyroidectomies were conducted in our hospital between January 2015 and December 2017. Neck X-ray was done in 275 patients (86.75%), whereas the X-ray was not found or documented in 15 patients (5.45%). X-rays of only 42 patients (16.15%) had positive findings. In 66.7% of the cases with positive finding on neck X-ray, airway was managed with direct laryngoscopy and intubation without any difficulty. Conclusion: We conclude that neck roentgenographs are not a sensitive method for predicting difficult airway in patients with thyroid swelling and could be avoided in routine practice to decrease radiation exposure.
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Correlation of anticipated difficult airway with concurrent intubation: A prospective observational study p. 22
Gayatri Rajeev Sakrikar, Prerana Nirav Shah
Background: Neither all anticipated difficult airways prove to be difficult intubations nor can all difficult intubations be accurately predicted. We conducted this prospective observational study to evaluate the incidence of anticipated difficult airway and concurrent difficult intubation and look for any correlation between them. Patients and Methods: In this study, 352 patients aged >18 years posted for elective surgery requiring general anaesthesia with the placement of endotracheal tube were recruited after obtaining the Ethical Committee approval and written informed consent. The airway was examined at the time of preanaesthetic check up and assigned the modified Mallampati class and Wilson's score. The modified Mallampati Class III/IV and Wilson's score of >4 were considered a difficult airway. Concurrent intubation was graded according to the Cormack–Lehane classification on laryngoscopy. Other parameters such as the duration of laryngoscopy, time taken for intubation and number of attempts were also noted. The incidence of anticipated and unanticipated difficult airway was calculated separately for each score along with its sensitivity, specificity, positive predictive value and negative predictive value. The significance of this association was analysed using the Chi-square test. Results: The incidence of the anticipated difficult airway by the modified Mallampati classification was 6.8%, whereas that by Wilson's score was 2.5%. The incidence of actual difficult intubation was 13%. Actual difficult airways out of those anticipated by the modified Mallampati classification were only 8, whereas those anticipated by Wilson's score were 27. Correlation between them was calculated using the Chi-square test with P < 0.05 considered as statistically significant. Conclusions: Modified Mallampati classification could fairly predict the true-negative results and Wilson's score even though not routinely used is a better indicator for true-positive values. Thus, Wilson's score should be included in routine preanaesthetic evaluation.
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Teaching and training in airway management: Time to evaluate the current model? p. 28
Joanne Spaliaras, Agathe Streiff, Glenn Mann, Tracey Straker
Management of the airway is central to the practice of anaesthesiology and yet surveys reveal that trainees frequently feel poorly trained in this area. Good skills in airway management include not only technical proficiency with an increasingly complex and wide range of equipment but also the clinical judgement and experience to use them appropriately. Lapses in judgement, education and training are leading causes of patient morbidity and mortality. It is now more imperative than ever for anaesthesiology training programmes to carefully review their curricula and evaluate the educational tools being used for effective advanced airway education of the next generation of airway specialists. Residency programmes have also seen the need to incorporate a formalised airway rotation into their curricula. One to 2-year long airway fellowships are now being advocated to provide the trainee a unique opportunity to master the advanced clinical knowledge and techniques necessary to successfully manage the most challenging clinical scenarios in airway management. It is essential for educators and practitioners alike to consider innovative models of training, advancing and retaining of skills. Such advanced skills can ensure the safe airway management and delivery of quality care to patients of all ages and medical complexity. Before preparation of the manuscript, a PubMed and Cochrane search of the scientific literature published in the past 10 years with the terms 'anesthesiology training', 'airway management education' and 'advanced airway management skills' was conducted.
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Types of data, methods of collection, handling and distribution p. 36
Umesh Goneppanavar, Zulfiqar Ali, S Bala Bhaskar, Jigeeshu V Divatia
Statistics is assumed to be a tough nut to crack by novices and young researchers mainly because of the lack of understanding of the fundamentals. This article describes the types of data and the methods for compiling the raw data in an orderly fashion, followed by appropriate handling of the collected data to ensure completeness and quality. Once the data are entered into statistical software, distribution of the data should be assessed to apply appropriate statistical tests. Since the type and nature of distribution of data are the main determinants of the type of statistical test to be applied, researchers should have a thorough understanding of these aspects to help derive meaningful outcome from their research.
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Anaesthetic management of panfacial injury using submental endotracheal intubation p. 41
Mahendrabhai Gautam Vaishali, Vijaykumar Desai Pushkar
Hernandez first described the submental route for endotracheal intubation in 1986 as a valuable alternative to tracheostomy for maxillofacial procedures. Over a 5-year period, we have successfully managed 25 patients of panfacial trauma using the submental route of endotracheal intubation without facing significant adverse outcomes. Submental intubation is contraindicated in patients suffering from neurological deficits who may require prolonged ventilation postoperatively. However, patients who require ventilation for short procedures may be managed using the submental route for endotracheal intubation without significant perioperative comorbidities.
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Airway management of an infant with an impacted subglottic foreign body p. 45
Sarika M Shetty, HR Rakshitha, MR Anil Kumar, CL Gurudatt
Foreign body (FB) aspiration is common in children and constitutes a life-threatening clinical situation. A high index of suspicion is necessary in the investigation of a child with stridor. Rigid bronchoscopy is frequently used for both diagnosis and treatment of FB aspiration. Occasionally, tracheostomy is required for securing airway during retrieval of a subglottic FB.
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Awake videolaryngoscopy-guided intubation in a patient with laryngocoele p. 48
Yudhyavir Singh, Purabi Acharya, Alkananda Behera, Puneet Khanna
Laryngocoele is a rare, benign laryngeal disease causing a variety of symptoms. However, this condition can lead to upper airway obstruction, thus posing problems in airway management and ventilation. Therefore, prior planning of anaesthetic and airway management of such patients is desirable, wherein awake intubation techniques are safer methods of securing a definite airway. Awake videolaryngoscopy-guided intubation can be safely used as an alternative to awake fibreoptic bronchoscopy-guided intubation.
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Submental intubation: Does it still find a place in modern era p. 52
Pradeepika Gangwar, Manoj Giri
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