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Byline: Rohan. Magoon, Surender. Malhotra, Vikas. Saini, Ridhima. Sharma, Jasleen. Kaur Background and Aims: The external jugular vein (EJV), often used for resuscitation, has been underutilised for central venous catheterisation [...]

One of the crucial responsibilities of an anesthesiologist is to secure the airway for anesthesia or resuscitative purposes. The patients of pediatric age group differ from adults, both anatomically and physiologically. This is the basic reason that an anesthesiologist has to carefully evaluate and use specific devices and methods to safely manage the airway in pediatric patients. There are various syndromes that pose challenges in children due to distinctive pathology leading to difficult airway. In the present scenario in the field of anesthesia, many gadgets and tools are available that may assist in airway management in pediatrics. Though these devices resemble the ones used in adult age group but specific changes in methods may be employed to overcome the anatomical differences. This article deals with the perfect evaluation of airway as well as specific problems and their solutions in pediatric age group. The advances in simulation technology are quite helpful in providing training in the field of difficult pediatric airway. Following the recommended guidelines and algorithms would go a long way in securing a safe airway in pediatrics. [ABSTRACT FROM AUTHOR]

Study Objective: Various randomized controlled trials and a meta‑analysis have compared i‑gel™ and laryngeal mask airway Supreme™ (LMA‑S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air‑Q™ with i‑gel™ and LMA‑S™ in adult patient. Hence, we designed this study to compare air‑Q™ with LMA‑S™ and i‑gel™ in adult patients. Materials and Methods: A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer‑generated random number sequence: group air‑Q™ (n = 25), group i‑gel™ (n = 25), and group LMA‑S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications. Results: The mean ± standard deviation OLP of air‑Q™, i‑gel™, and LMA‑S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H2O (P = 0.279). The first insertion success rate for air‑Q™, i‑gel™, and LMA‑S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air‑Q™, i‑gel™, and LMA‑S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air‑Q™ insertion was significantly higher than time taken for i‑gel™ (mean difference 5.8 s, P < 0.0001) and LMA‑S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices. Conclusions: We concluded that air‑Q™, i‑gel™, and LMA‑S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy. [ABSTRACT FROM AUTHOR]

The various studies conducted till date reveal that up to 40% patients undergoing coronary artery bypass surgery are associated with minor or persistent neuropsychological disorders. A significant concern has been emphasized on short and long term morbidity in cases of CABG procedure. The outcome in the form of morbidity after this surgery, irrespective of co-existing medical diseases, is prevalent in presence of neuropsychological problems, such as anxiety, depression and cognitive impairments, though the exact mechanism of this behavioural aspect is obscure. As such, there may not be serious psychological dysfunction but chances of incident delirium at the time of admission are quite high. These neuropsychological deficits may continue over time, especially if the features persisted in preoperative period, too. To improve the detection of these psychological disorders in CABG surgery cases, the clinicians must consider the use of specified screening methods. Perioperative factors, as well as patientrelated risk factors, play a vital role in development of cognitive dysfunctions. Recent literature emphasizes the possibility of a grave complication in the form of ischaemic stroke in post- CABG surgical patients. The microemboli may enter cerebral circulation during surgery leading to cognitive decline, postoperatively. In the recent literature, that include various studies covering the neuropsychological areas, conflicts and limitations in methodology are prevalent. [ABSTRACT FROM AUTHOR]

Background and Aims: Most vital aspect of Endoscopic Sinus Surgery (ESS) is an optimal visibility in the surgical field. This invariably requires controlled hypotension to facilitate surgical dissection and to decrease operative time. We used esmolol and magnesium sulfate to achieve controlled hypotension and assessed the quality of the surgical field in ESS. Material and Methods: A total of 30 patients undergoing ESS, were enrolled in three parallel groups of 10 patients each in a prospective randomized double-blind study. "Magnesium Sulfate group" received magnesium sulfate 40 mg/kg intravenously (i.v.) as a bolus over 10 min before induction of anesthesia, followed by 15-30 mg/kg/h through infusion. "Esmolol group" received 0.5 mg/ kg i.v. bolus over 10 min after induction followed by 150-300 μg/kg/min infusion and "control group" received normal saline in same volume schedule. The primary aim was to assess the quality of surgical field, using Fromme scale. Category Scale values of all the three groups were compared using Kruskal-Wallis analysis of variance (ANOVA) test. Hemodynamic data was compared using ANOVA test. Results: Quality of the surgical field was better in both magnesium sulfate and esmolol groups as compared to the control group. Durations of anesthesia and surgery were significantly lower in esmolol group as compared to the control group. Blood loss was comparable in all the three groups. Conclusion: Quality of the surgical field was better in esmolol and magnesium sulfate groups as compared to control group. Duration of surgery was significantly less in esmolol group as compared to other two groups. [ABSTRACT FROM AUTHOR]

Introduction: Acute coronary syndromes and non-Q-wave myocardial infarction are often initiated by platelet activation. Eptifibatide is a cyclic heptapeptide and is the third inhibitor of glycoprotein (Gp) IIb/IIIa that has found broad acceptance after the specific antibody abciximab and the nonpeptide tirofiban entered the global market. Gp IIb/IIIa inhibitors act by inhibiting the final common pathway of platelet aggregation, and play an important role in the management of acute coronary syndromes. Aims: This review assesses the evidence for therapeutic value of eptifibatide as a Gp IIb/IIIa inhibitor in patients with acute coronary syndromes. Evidence review: Several large, randomized controlled trials show that eptifibatide as adjunctive therapy to standard care in patients with non-ST segment elevation acute coronary syndrome is associated with a significant reduction in the incidence of death or myocardial infarction. Data are limited regarding the use of eptifibatide in patients with ST segment elevation myocardial infarction. Cost-effectiveness analysis indicates that eptifibatide is associated with a favorable cost-effectiveness ratio relative to standard care. According to US cost-effectiveness analysis about 70% of the acquisition costs of eptifibatide are offset by the reduced medical resource consumption during the first year. Eptifibatide was well tolerated in most of the trials. Bleeding is the most commonly reported adverse event, with most major bleeding episodes occurring at the vascular access site. Major intracranial bleeds, stroke, or profound thrombocytopenia rarely occurred during eptifibatide treatment. Place in therapy: Eptifibatide has gained widespread acceptance as an adjunct to standard anticoagulation therapy in patients with acute coronary syndromes, and may be particularly useful in the management of patients with elevated troponin or undergoing percutaneous coronary interventions. [ABSTRACT FROM AUTHOR]

Background: Transhiatal esophagectomy (THE) is a common operative procedure for carcinoma esophagus. Complications of this procedure include arrhythmias and hypotension during blunt dissection of the esophagus from posterior mediastinum. In the literature, exact incidence and type of arrhythmias have not been reported. We employed Holter monitoring during mediastinal manipulation in patients undergoing THE, for this purpose. Methods: This prospective study was carried out in 20 consecutive American Society of Anesthesiologists grade I-II patients undergoing THE. Anesthetic technique included induction with thiopentone and maintenance with morphine, vecuronium, and isoflurane. In addition to routine parameters, Holter monitoring was undertaken to record the exact incidence and types of arrhythmias. “Premanipulation” or control period included duration of 30 minutes preceding mediastinal manipulation, while “during manipulation” or study period included the duration of mediastinal manipulation. The incidence of arrhythmias was studied for 48 hours in the postoperative period. The Fisher exact test was applied to analyze incidence of arrhythmias and hypotension. Results: Out of 20 patients, only 2 had arrhythmias in the premanipulation period, while 13 had arrhythmias during the manipulation period (p < 0.01). During the manipulation period, arrhythmias included supraventricular ectopics and ventricular ectopics in 2 patients each and a combination of both in 9 patients. Arrhythmias were transient and had no correlation with either duration or degree of hypotension in all the patients. However, there was a linear relationship between hypotension and duration of mediastinal manipulation. Two patients (10%) had atrial arrhythmias in the postoperative period. Conclusions: In transhiatal esophagectomy, there is a significant incidence of both arrhythmias and hypotension during mediastinal manipulation. The incidence of arrhythmias can be minimized by limiting the duration of the manipulation. The incidence of postoperative arrhythmias was not significant. [Copyright &y& Elsevier]

The article focuses on the case of a 61-year old woman who had a single coronary artery with congenital absence of right coronary artery (RCA) without any associated coronary anomalies in the U.S. The coronary angiography revealed a normal looking left main coronary artery that gives rise to left anterior descending artery and a large caliber left circumflex. The results showed that congenital absence of RCA is a rare finding.

Laryngeal mask (LM) airway is commonly used for securing airway in day-care surgeries. Various problems have been described while using LM airway. Out of those, mechanical obstruction causing airway compromise is most common. Here, we describe a case report of 4-year-old child who had partial upper airway obstruction due to LM manufacturer's defect. There was a silicon band in upper one-third of shaft of LM airway. This band was made up of the same material as that of LM airway so it was not identifiable on external inspection of transparent shaft. We suggest that such as non-transparent laryngeal mask, a transparent LM airway should also be inspected looking inside the lumen with naked eyes or by using a probe to rule out any manufacturing defect before its insertion. [ABSTRACT FROM AUTHOR]

Objectives: Hypotensive anesthesia is necessary during endoscopic sinus surgery to achieve a bloodless surgical field. The aim of this study was to compare the quality of surgical field using propofol or desflurane anesthesia. Methodology: 40 patients of either sex, belonging to ASA physical status I and II, and age group of 18 - 60 years were randomized into two groups to receive either propofol and morphine or desflurane and morphine anesthesia. The target mean arterial pressure (MAP) was kept in a range of 65-75 mmHg. The quality of surgical field was assessed by using a validated scoring system (Fromme category scale) at every 15 min by the same surgeon in all the cases to avoid surgeon's bias. Results: The mean category scale value was 2.665 ± 0.243 in propofol group and 2.200 ± 0.410 in desflurane group (p=0.000). The time to emergence was significantly less in desflurane group (9.35 ± 1.27) as compared to propofol group (14.60 ± 2.06 min). Conclusion: We conclude that both the propofol and desflurane can be used to achieve a satisfactory surgical field quality but desflurane provides a rapid emergence as compared to propofol. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about the airway obstruction with a cuffed single-use plastic endotracheal tube in the previous issue.

Introduction: Acute coronary syndromes and non-Q-wave myocardial infarction are often initiated by platelet activation. Eptifibatide is a cyclic heptapeptide and is the third inhibitor of glycoprotein (Gp) IIb/IIIa that has found broad acceptance after the specific antibody abciximab and the nonpeptide tirofiban entered the global market. Gp IIb/IIIa inhibitors act by inhibiting the final common pathway of platelet aggregation, and play an important role in the management of acute coronary syndromes., Aims: This review assesses the evidence for therapeutic value of eptifibatide as a Gp IIb/IIIa inhibitor in patients with acute coronary syndromes., Evidence Review: Several large, randomized controlled trials show that eptifibatide as adjunctive therapy to standard care in patients with non-ST segment elevation acute coronary syndrome is associated with a significant reduction in the incidence of death or myocardial infarction. Data are limited regarding the use of eptifibatide in patients with ST segment elevation myocardial infarction. Cost-effectiveness analysis indicates that eptifibatide is associated with a favorable cost-effectiveness ratio relative to standard care. According to US cost-effectiveness analysis about 70% of the acquisition costs of eptifibatide are offset by the reduced medical resource consumption during the first year. Eptifibatide was well tolerated in most of the trials. Bleeding is the most commonly reported adverse event, with most major bleeding episodes occurring at the vascular access site. Major intracranial bleeds, stroke, or profound thrombocytopenia rarely occurred during eptifibatide treatment., Place in Therapy: Eptifibatide has gained widespread acceptance as an adjunct to standard anticoagulation therapy in patients with acute coronary syndromes, and may be particularly useful in the management of patients with elevated troponin or undergoing percutaneous coronary interventions.

Congenitally corrected transposition of the great vessels (CCTGA) is a rare congenital heart defect. Patients with CCTGA have the anatomical right ventricle as their systemic pumping chamber, with ventricular dysfunction and congestive heart failure (CHF) being relatively common in older adults. The most common presenting feature is bradycardia due to high-degree atrioventricular (AV) blocks. Patients with CCTGA are increasingly subject to CHF with advancing age; this complication is extremely common by the fourth decade. The majority of patients have an inverted coronary arterial pattern.1 We report a case of a patient with CCTGA who presented with rare but life-threatening ventricular tachycardia (VT) leading to syncope, with preserved systemic ventricular function. Coincidentally, the patient also had a single coronary ostium.

Studies on the associations between the nitric oxide synthase gene (NOS3) Glu298Asp polymorphism and hypertension status or blood pressure (BP) levels have had inconsistent results. Potential moderating influences of ethnicity, sex, and obesity on the effects of the NOS3 polymorphism have not been examined. We evaluated the influence of these factors on associations between the NOS3 polymorphism, nitric oxide metabolites (NOx), and hemodynamics at rest and during stress. Subjects were 235 African American (AA) and 262 European American (EA) young adults (18.5+/-2.6 years). Hemodynamic measurements and blood samples for NOx assays were taken before and after a competitive video game challenge. Glu298Asp polymorphism was detected by polymerase chain reaction-restriction enzyme digestion assay. A regression model was built using genotypes, ethnicity, sex, and obesity (body mass index >85th percentile) and their interactions controlling for age; 20.1% of AAs and 49.8% of EAs were carriers of the Asp allele. AAs, regardless of obesity status, exhibited high diastolic blood pressure (DBP) reactivity unless they were nonobese and noncarriers of the Asp allele. EAs exhibited lower DBP reactivity unless they were obese Asp allele carriers. AA nonobese carriers exhibited the greatest total peripheral resistance reactivity. Obese Asp allele carriers exhibited the greatest increases in cardiac output and the greatest decrease in NOx to the stressor. Results indicate the importance of examining impact of BP control-related genetic polymorphisms within the context of moderating factors such as adiposity and ethnicity.