Indian Journal of Clinical Anaesthesia

78-81

Authors: Sambhunath Das, Pankaj Kumar

Background: Appropriate management of endotracheal tube (ETT) cuff pressure is essential during mechanical ventilation of an intubated patient. The ETT cuff should be inflated in order to seal the airway without volume loss or pharyngeal content aspiration. It is desirable that the cuff seal the airway without exerting high pressure on the trachea to compromise mucosal circulation. The aim of this study is to assess importance of monitoring of ETT cuff pressure in intubated patients and effect of intervention in preventing complications related to over and under inflation of ETT cuff . Method: An observational prospective study performed between January and April 2015. All patients having cardiac surgery with cuffed ETT insertion were included. In Group1 cuff pressure manometer was used to monitor the cuff pressure and adjusted in the range of 20-30 cm H2O within 15 min before going on cardiopulmonary bypass. In Group2 only minimal leak test (MLT) done to guide inflation and cuff pressure measured by cuff pressure manometer but no intervention was made. Patients were followed in postsurgical care till extubation and observed till discharge for complication like sore throat, voice changes and tracheomalacia. Results: In group 1 9(25.7%) patient had cuff pressure within normal limit whereas 25 (71.4%) patient had cuff pressure higher than normal and 1 (2.9%) patient had cuff pressure measurement less than 20 cm H2O. Volume of air added or removed from cuff was -0.89 ± 1.14 to optimize cuff pressure. Cuff pressure ranged from 15 to 120(47 ± 23) cm H2O.In group 2 11(32.4%) patient had cuff pressure within normal limit whereas 22 (64.7%) patients had cuff pressure higher than normal and 1 (2.9%) patient had cuff pressure measurement less than 20 cm H2O. Cuff pressure ranged from 18 to 100(47.4±20.3) cm H2O. In group 1, 11 patients developed hoarse voice compared to 32 patients in group 2. P=0.000 In group 1, 15 patient developed sore throat versus 21 patients in group 2, P = 0.187. Conclusion: Measurements of endotracheal tube intra cuff pressure are essential to avoid over or under inflation of ETT cuff. Adjusting the cuff pressure to 20-30cmH2O will prevent volume loss during ventilation and complications like sore throat, hoarseness of voice and tracheomalacia. Measurement of cuff pressure with timely intervention should be made standard of care in operation theatre and ICU.

86-91

Authors: Vikas Gupta, Nandita Mehta, Sunana Gupta, Kulbhushan Mahotraq

Background and Aim: Supraglottic airway devices are increasingly being used as an excellent alternative to mask ventilation and tracheal intubation with least complications. The present randomized, prospective study was conducted to compare the I-Gel with LMA-Supreme with respect to time taken for insertion, insertion success rate, ease of insertion of gastric tube, hemodynamic changes before and after insertion and post-operative airway morbidity. Materials and Methods: Sixty American Society of Anaesthesiologist (ASA) grade-I and II patients between 18-60 years age, of either sex, were randomly assigned to two groups of 30 patients each. Group A: I-gel was inserted and Group B: LMA- supreme was inserted by grasping firmly along the integral bite block (Digital Technique). Hemodynamic responses were recorded before induction and at the intervals after insertion of LMA Supreme/I-Gel. Time taken for insertion, insertion success rate and ease of insertion of gastric tube was noted. Patients were inspected for any trauma to mouth, lip and tongue in the immediate postoperative period and asked about sore throat, hoarseness and dysphonia 24 hours after the surgery. Statistical analysis was carried out with student’s t-test and chi-square test and value of P0.05 was considered statistically significant. Results: Insertion time of I-Gel (11.07±1.93 seconds) was faster than the LMA-Supreme (12.50±2.35 seconds) and the results were statistically significant (P=0.01). Ease of insertion of gastric tube was more in LMA Supreme (28/30) as compared to I Gel (26/30) but statistically this difference came out to be non-significant (P=0.157).The two groups were comparable as far as the insertion success rate , hemodynamics and post-operative airway morbidity were concerned. Conclusion: I-Gel is better than LMA-Supreme in terms of faster insertion time. Insertion success rate, ease of insertion of gastric tube, hemodynamics and post-operative airway morbidity is comparable in both the groups.

97-101

Authors: Shilpin Solanki, Nayna Solanki

Background: LMA insertion requires sufficient depth of anesthesia and depression of airway reflexes. Propofol is the agent of choice for LMA insertion as it is very effective in suppressing cough and gag reflexes. On the other hand addition of low dose scoline improves correct position of the laryngeal mask. Our main aim of study was to compare the hemodynamic changes, time taken for LMA insertion and ease of LMA insertion using Propofol v/s propofol with low dose scoline in both groups. Method: The study was conducted in sixty ASA-1 and ASA-2 grade patients. All patients were investigated preoperatively for routine investigations. Written informed consent was taken. After applying monitors all patients were premedicated with Inj. Ondensetron (4 mg), Inj. Glycopyrrolate (0.2 mg), injection midazolam 0.03 mg/kg IV two minutes before three minutes of preoxygenation. Gr p received Inj propofol 2.5 mg/kg/iv and Gr (P+S) received Inj propofol 2.5 mg/kg/iv with Inj Scoline 0.2 mg/kg/iv. Overall Grading of Insertion score, Rescue Drug Usage Grade, LMA Insertion time were noted. Patients were observed for any complication postoperatively. Result: Jaw opening was comparable but statistically insignificant in both groups. No vigorous movements were noted in (P+S) group while 6.67% patients in P group had vigorous movements. This was statistically significant (p<0.05). Overall grading of insertion score was statistically significant (p<0.05) between two groups. Overall satisfactory conditions for LMA Insertion were possible to increase from 73.33% to 93.33% by rescue drug usage propofol in Gr P. Conclusion: We concluded that to yield better LMA Insertion low dose scoline 0.2 mg/kg/IV in addition to propofol and midazolam is required.

107-110

Authors: Rakesh Kumar, Ghansham Biyani, Sadik Mohammed, Rakesh Karnawat, Priyanka Sethi, Vandana Sharma

Various adjuvants like opioids, alpha-2 agonists, steroids and many more drugs have been mixed with local anaesthetic (LA) solutions for Intravenous Regional Anaesthesia (IVRA). These drugs are added with the aim of hastening the onset of action and prolonging the duration of analgesia. They may also allow for a reduction in the total dose of LA used and related side effects. In this article, we have reviewed clinical trials using nitroglycerine (NTG) as an adjuvant to LA in IVRA and have summarized the advantages, disadvantages and current role of this drug. To the best of our knowledge, no meta-analysis, or review article has analysed the role of NTG as an adjuvant to Bier’s block.

114-116

Authors: Kevin Koshy Jacob, Sangeetha Balakrishnan

Von Willebrand disease(vWD) is a common hemostatic disorder encountered inobstetric anesthesia practice. This needs appropriate pre-operative evaluation to choose the best technique of anesthetic management. Evaluation needs to be individualized to consider the risk and benefits of each technique, either general or neuraxial anaesthesia. There are only a few published cases on use of spinal anesthesia in vWD patients for caesarean delivery. We present a case of vWD patient who was given spinal anesthesia for emergency caserean delivery. We were not able to determine the type of the disease, but based on clinical features it was assumed to be of type I or II. Intranasal desmopressin was given as bleeding prophylaxis. Anaesthetic considerations and peri-operative management are discussed.