The supraglottic airway devices (SADs) that allow direct (without an intermediary device like Aintree or airway exchange catheters) tracheal intubation can be invaluable for field use in conditions ideally managed by intubation. Whilst fiberscope-guided intubation is the method of choice, if these 'direct-intubation' SADs could provide high success rates for blind tracheal intubation, their scope of use can increase tremendously. Our study assesses intubating laryngeal mask airway (ILMA), i-gel and Ambu AuraGain for blind tracheal intubation in adults.Ninety adults undergoing elective surgery were randomized into three equal groups. After induction of anesthesia, the group-specific SAD was inserted and on achieving adequate ventilation, blind tracheal intubation was attempted over two attempts. Success rates and time of achieving adequate device placement and tracheal intubation through these were evaluated. Data were analyzed using SPSS version 17.0 and P < 0.05 was considered statistically significant.All three devices could achieve adequate ventilation within two allowed attempts. Successful tracheal intubation rates were significantly better with ILMA than i-gel on first attempt (87% vs. 27%, P < 0.001) and after second attempt that was supplemented with optimization maneuvers (100% vs. 40%, P < 0.001). No patient could be intubated through Ambu AuraGain within two attempts. Time taken for successful tracheal intubation did not differ significantly (P = 0.205) with ILMA or i-gel.Out of ILMA, I-gel and Ambu AuraGain, ILMA is the best device for blind tracheal intubation in adults with normal airways.
Postoperative upper airway complications are frequently encountered with the use of supraglottic airway devices (SADs). Cuff pressure is one of the risk factors for upper airway complications with SADs. Among SADs, i-gel has shown lesser incidence. The effect of different cuff pressures on the incidence of postoperative upper airway complications is not known with Ambu AuraGain and nor has Ambu AuraGain been compared with i-gel in this regard. So, we undertook this study.A total of 200 patients undergoing elective laparoscopic surgery were randomised into 3 groups based on the SAD used and intra-cuff pressure: i-gel (IG) (n = 66); Ambu AuraGain at 25 cmH2O cuff pressure (AL) (n = 67); and Ambu AuraGain at 60 cmH2O cuff pressure (AH) (n = 67). The oropharyngeal leak pressures (OLPs) were measured after insertion and generation of carboperitoneum. An observer who was blind to the intraoperative details assessed the patients for two postoperative days for sore throat, dysphagia, dysphonia, or any other upper airway complications.The OLPs before and after carboperitoneum in the 3 groups were (IG-24.22 ± 7.87 and 28.31 ± 8.52, AL-24.40 ± 5.84 and 26.94 ± 5.93, AH-25.02 ± 5.02 and 28.91 ± 5.6) cmH2O (P = 0.747 and P = 0.231). The overall incidence of postoperative sore throat among the 3 groups was: IG-5.7%, AL-14.9%, and AH-17.9%; P = 0.135. Dysphagia was seen only with Ambu AuraGain at high pressure in 4 patients (5.97%) (P = 0.017).Limiting cuff pressure in Ambu AuraGain to 25, as against 60 cmH2O, does not affect the OLP but has the potential of reducing the incidence of dysphagia.
Background and Aim: In hydrocephalus patients, after ventriculoperitoneal (VP) shunt, decrease in pulsatility index (PI) correlates with decrease in ventricle size. Also, increase in PI is noted in obstructed or malfunctioning VP shunts. However, previous studies were either done in infants and children or included patients of all age groups. Our aim was to compare PI before and after successful VP shunt surgery in adult patients and also the trend of transcranial Doppler (TCD) parameters for 3 days after surgery. Materials and Methods: A prospective, observational study was done in 20 adult patients undergoing VP shunt. Clinical features, vitals, Evans index, and TCD parameters were noted in the preoperative period. A computed tomography (CT) head was repeated 4–6 h after surgery, and the position of ventricular end of shunt was confirmed and Evans index was calculated. The vitals and TCD parameters were noted at same time and for the next 2 days. Repeated measures analysis of variance (ANOVA) and paired t -test were uses for statistical analysis. Results: A total of 18 patients were included for statistical analysis. The mean preoperative PI was 1.19 ± 0.24 and the postoperative PI after surgery was 0.97 ± 0.17, 0.97 ± 0.23, and 0.94 ± 0.21 ( P = 0.0039) on postoperative day (POD) 1 (POD1), POD2, and POD3, respectively. The mean preoperative value of Evans index was 0.37 ± 0.06 and there was statistically significant ( P = < 0.001) reduction to 0.33 ± 0.07 after VP shunt surgery. The change in PI and change in Evans index were found to be positively correlated ( r = 0.34 and P = 0.0013). Conclusions: The decrease in PI after VP shunt surgery correlates with decrease in ventricular size. Any increase in PI in the postoperative period should raise the suspicion of malfunctioning of VP shunt.
Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS.The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication.Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described.Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population.The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.
Madam, We report an indigenously prepared airway topicalization device using the principle of atomization made from the material available in the operation room (OR) with limited resources. Airway preparation for awake nasal endoscope-guided intubation, in addition to the use of antisialagogue and nasal vasoconstrictor, is achieved by airway topicalization. These include using lignocaine-soaked nasal pledgets (4%), lignocaine viscous gargling (2%), 10 and 15% lignocaine spray, 4% lignocaine nebulization, atomization of local anesthetic drug, nerve blocks, and transtracheal local anesthetic injection (lignocaine 1%–2%).[1] Lignocaine spray needs oral access hence cannot be used when patient is not able to open the mouth. In addition, spray as you go (SAYGO) or drop as you go can be added to any of these combinations.[2] Out of these, atomization may be the most effective single method of complete supraglottic topicalization.[1] Keeping this in mind, we made our atomization-cum-oxygenation device for airway topicalization. This requires a Foley catheter, a 3-way connector, a lignocaine-filled syringe, and an oxygen source. The Foley catheter is cut obliquely from its patient end so that a length measuring from the tip of the nose to the tragus of the patient + 2 cm is available beyond the Y (where the cuff inflating and drainage tubes meet) [Picture 1]. Once the catheter is cut, its inflating port is connected to a 3-way connector. The Foley catheter is lubricated and is gently slid along the floor of the patient's nose. One end of the 3-way connector (kept in ON position) is now connected to oxygen tubing and oxygen flow is started at 3–6 L/min. A 5 ml lignocaine (1 or 2%) filled syringe is attached to the other port (kept in OFF position). With the thumb of the hand holding the syringe applying gentle pressure on the plunger, the 3-way knob is turned such that both its ports (one connected to O2 and the other to the syringe) are open. As the drug is now injected with continuous flow through the smaller lumen, oxygen atomizes it into fine mist that appears at the cut end [Picture 2]. As the atomization begins, the process is continued at a steady pace while the catheter is pulled out gently with rotatory motion, thereby topicalizing the whole passage. Repeating the procedure in other nasal cavity completes topicalization of nasal route. The device can be tested ex vivo, before using it in the patient, to quantify the appropriate O2 flow rate and injection speed needed to get the desired atomization.Picture 1. (Clockwise from right top): Length of catheter being measured; local anesthetic and oxygen being introduced through the two ports of the 3-way connector; graphical representation of anatomical relationship of the device in its position where atomization beginsPicture 2. Our indigenous Foley catheter-based atomization device and its end on viewCommercially available lignocaine spray (10 or 15%) delivers 10–15 mg lignocaine per puff and one bottle can be used for many patients. However, their nozzle gets unsterile after each use. Commercial atomization devices produce fine atomized spray (30–100 microns) and can effectively topicalize most of upper airway quickly and have proven efficacy.[1] Our device offers (i) the speed of action of atomization without being as costly, (ii) sterile interface of desired thickness and length for each patient, (iii) softer and longer tubing than the nozzles of commercial sprays, and (iv) option to be used for oral topicalization as well by inserting a stylet inside the bigger lumen and then molding the catheter to the desired shape. Although our device has the limitation that the size of particles created is not defined and pushing plunger of the syringe too fast or slow may not create mist, the same is true about the commercial atomization devices as well. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship No financial support was taken from institution or hospital. Conflicts of interest There are no conf licts of interest.
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