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Background and Aims: The second-generation supraglottic airway device is conventionally inserted blindly, which might result in suboptimal placement. Limited literature exists on under-vision insertion techniques, particularly in paediatric patients. The primary objective of this study was to compare the oropharyngeal leak pressure (OPLP) between the blind insertion of the LMA Blockbuster[sup.®] and the Miller laryngoscope-guided insertion in children. Secondary outcomes included the number of insertion attempts, haemodynamic disturbances, insertion time and airway complications. Methods: This randomised controlled trial study enroled 100 patients aged 1-4 years undergoing elective surgery. Patients were randomised into blind insertion (Group A) or Miller laryngoscope-guided insertion (Group B) of the LMA Blockbuster[sup.®]. The primary outcome measure was OPLP. Insertion time, haemodynamic changes and postoperative complications were also assessed. The Chi-square, Fisher's exact and t-test were applied appropriately, with the significance level set at P < 0.05. Results: Significantly higher mean OPLP was observed in Group B compared to Group A - 27.9 [standard deviation (SD): 1.58] cmH[sub.2]O versus 25.94 (SD: 0.63) cmH[sub.2]O [mean difference (MD): 1.96 (95% confidence interval {CI}: 1.48, 2.44; P < 0.001)]. Mean insertion time was longer in Group B, that is, 11.9 (SD: 1.91) s versus 8.7 (SD: 0.6) s [MD: 3.2 s; (95% CI: 2.63, 3.76; P < 0.001)]; however, the difference was not clinically relevant. First-attempt insertion, haemodynamic stability and postoperative complications were comparable (P > 0.05). Conclusion: Miller laryngoscope-guided under-vision insertion of LMA Blockbuster[sup.®] improves alignment with epiglottic structures compared to blind insertion. Keywords: Blind insertion, haemodynamic, laryngeal mask airway, laryngoscope, LMA Blockbuster, paediatric anaesthesia, ventilation, Author(s): Pooja Bihani [1]; Shivanand [2]; Rishabh Jaju [3]; Naveen Paliwal (corresponding author) [1]; Sarita Janweja [1]; Ankit Vyas [4] INTRODUCTION Effective airway management is crucial in paediatric anaesthesia, where [...]

Byline: Yashshwani. Gaur, Rishabh. Jaju, Naveen. Paliwal, Usha. Choudhary, Pooja. Bihani, Sarita. Janweja Background and Aims: Supraglottic airway (SGA) devices are a boon to paediatric airway management. The clinical performances [...]

Objective: Placement of the supraglottic airway devices under direct vision has been shown to decrease the incidence of malposition in adults. This study was designed to compare the clinical performance of C-MAC guided and blind placement of i-gel® in paediatric patients. Methods: The present prospective, randomized controlled study was conducted on 102 paediatric patients scheduled to undergo elective infraumbilical surgeries under general anaesthesia. Patients were randomly divided into group “B” (blind) and group “C” (C-MAC) based on the technique used for placement of i-gel®. The primary objective of the study was to compare the incidence of malposition based on the fiberoptic bronchoscope (FOB) score of the glottic view. Oropharyngeal leak pressure (OPLP), hemodynamic parameters, and insertion characteristics (time taken to insert and the number of attempts) were secondary objectives. Categorical data were presented as ratio or percentage and continuous data were presented as mean ± standard deviation or median [95% confidence interval (CI)]. Results: The incidence of malposition (Brimacombe score 1 or 2) was significantly lower in group C compared to group B (7.8% vs 49% respectively) (P < 0.001); implying a relative risk reduction of 2.42 (95% CI 1.72 to 3.40) with C-MAC. On FOB assessment, the median (interquartile range) Brimacombe score was significantly better in group C [4 (4-4)] compared to group B [3 (2-3)] (P < 0.001). The OPLP was significantly higher in group C compared to group B. Other insertion characteristics were comparable in both the study groups. Conclusion: Compared to blind placement, C-MAC guided placement ensures proper alignment of i-gel® with periglottic structures and proper functioning of i-gel®. [ABSTRACT FROM AUTHOR]

Introduction: After introduction of ultrasound, there is paradigm shift towards under vision performance of procedures in anaesthesia. Blind puncture and dissection of submental space may lead to vascular injury and injury to salivary glands. We describe the ultrasound guided Seldinger technique assisted submental intubation for panfacial trauma. Methodology: Modified ultrasound guided Seldinger technique for submental intubation in 10 patients, who were posted for open reduction and fixation of panfacial fractures. Total procedural time, peri-procedural complications such as bleeding, dislodgment of tube, desaturation and postoperative complications such as injury to sublingual glands/submandibular glands, hematoma, cheloid or hypertrophic scar formation or skin site infection were noted. Results: The mean time to perform submental intubation was 8.9 ± 0.94 minutes (range, 8-11 minutes). Only one patient had minor bleeding during procedure which was stopped after local application of pressure. All patients had a clean scar with no formation of cheloid or hypertrophic scar in the postoperative follow up. Conclusion: Ultrasound assisted submental intubation increases safety of the procedure in patients presenting with maxillafacial trauma. [ABSTRACT FROM AUTHOR]

Byline: Pradeep. Bhatia, Pooja. Bihani, Swati. Chhabra, Vandana. Sharma, Rishabh. JajuIntroductionThe transversus abdominis plane (TAP) block is a field block and it involves myocutaneous nerves supplying the anterior abdominal wall [...]

Introduction: Appropriate implementation of a ventilator bundle (VB) is the key step in the prevention of ventilator-associated pneumonia (VAP). However, knowledge and compliance of critical care staff for VB are inconsistent in developing countries. This cross-sectional survey was planned to evaluate critical care practitioners' knowledge of, adherence to, and barriers toward implementation of VB in the ICUs of a tertiary care institute. Methodology: All registered nurses and resident doctors who are direct care providers to patients of the ICU were included. Two sets of questionnaires were given to access knowledge and to identify potential barriers in the implementation of VB. To determine compliance with the VB, direct observation was done for three nonconsecutive days, and mean compliance per component of the bundle and overall compliance to VB was determined. Data were analyzed using descriptive and analytic statistics. Results: Of these 75 participants, 43 (57.33%) were resident doctors and 32 (42.67%) were staff nurses. The median knowledge score of resident doctors and staff nurses for VB was 7 (range 3--10) and 6 (range 2--9), respectively, with an overall score of 7 (range 2--10). Self-reported adherence to individual components of VB ranged from 75% to 95%, among these, adherence to oral care protocol, including use of chlorhexidine oral rinse, was most, and adherence to DVT prophylaxis was least. The most common potential barriers identified were fear of potential adverse effects and unawareness of guidelines. Conclusion: Considerable gap is observed between knowledge and implementation of VB among critical care practitioners. Despite knowledge, fear of adverse events and lack of proper training are key barriers in implementation of VB. [ABSTRACT FROM AUTHOR]

Objective: Patients' airway assessment is one of the foremost responsibilities of every anaesthesiologist. Several preoperative predictive methods have been studied by various authors to find the best difficult airway predictor. We conducted this study to compare 3 methods to predict the difficulty of laryngoscopic endotracheal intubation viz ratio of patient height to thyromental distance, ratio of the neck circumference to thyromental distance, and thyromental height in adult patients. Methods: This prospective observational study was conducted on 330 adult patients, American Society of Anaesthesiologists (ASA) status I and II, aged 18-60 years of either sex, weighing 50-80 kg scheduled for elective surgeries under general anaesthesia. Patients' height, weight, and body mass index were recorded, and thyromental distance, neck circumference, and thyromental height were measured preoperatively. Laryngoscopic view was graded according to the Cormack-Lehane grade. Predictive indices and optimal cutoff values were calculated using the receiver operating characteristic curve analysis. Results: Difficulty in laryngoscopic endotracheal intubation was encountered in 12.42% of patients. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve for thyromental height were 100%, 95.2%, 75.54%, 100%, and 0.982, respectively; for the ratio of patient height to thyromental distance the respective values were 75.6%, 72.7%, 28.18%, 95.45%, and 0.758 and for the ratio of the neck circumference to thyromental distance, the values were 82.9%, 65.4%, 25.37%, 96.42%, and 0.779, respectively. There was no statistically significant difference to predict the difficulty of laryngoscopic intubation between any of them (P < .05). Conclusion: Among these 3 parameters, thyromental height was found to be the best preoperative method to predict difficult laryngoscopic endotracheal intubation with the highest predictive indices and area under the curve. The ratio of the neck circumference to the thyromental distance method was found to be a more sensitive and useful method than the ratio of patient height to the thyromental distance method to predict the difficulty of laryngoscopic endotracheal intubation. [ABSTRACT FROM AUTHOR]

Byline: Rishabh. Jaju, Bharat. Paliwal, Priyanka. Sethi, Pradeep. BhatiaSir,Epidural catheter migration or displacement is a known entity with an incidence up to 50%.[1] We report a case in which catheter [...]

Background: The COVID-19 has a varied mode of presentation in different regions of the world. This multicentric study was planned to evaluate the survival outcomes in intensive care unit-admitted patients admitted during the third wave of the COVID-19 pandemic on the basis of clinicodemographic profile and vaccination status. Methodology: Data from 299 patients admitted to three tertiary care centers in Western India were collected and analyzed. Based on survival outcomes, all patients were divided into two groups: survivors and nonsurvivors. Univariate analysis of the demographic profile, comorbidities, vaccination status, and disease severity was performed, whereas multivariate analysis was performed to predict independent factors associated with mortality. Results: Among total 299 studied patients, 208 (69.5%) patients survived and 91 (30.4%) did not. The number of elderly patients and patients with comorbidities such as diabetes, tuberculosis, chronic obstructive pulmonary disease, cardiovascular and respiratory diseases, and malignancy were more prevalent among nonsurvivors. Patients who did not receive a single dose of vaccine were higher in the nonsurvivor group (P = 0.037); however, no significant difference in survival outcome was found if patients had received the first or both doses of vaccine. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24 h after admission and Sequential Organ Failure Assessment (SOFA) score at admission were significantly higher in nonsurvivors compared to survivors (P < 0.0001). On multivariate analysis, APACHE II and SOFA scores were found to be independent predictors of outcome. Conclusions: Older age, presence of comorbidities, nonvaccination and higher disease severity scores affected mortality during the third wave of COVID-19. [ABSTRACT FROM AUTHOR]

COVID-19 has caused tectonic changes in the personal and professional lives of anesthesiologists and, among several aspects, anesthesiology residency and sub-specialty training has also undergone an unforeseen overhaul. We read the articles published on the impact of COVID-19 on training of anesthesiologists and set out to extract and narrate all the significant observations. At the outset, we begin by explaining how this pandemic posed a threat to the safety of the residents and mitigating measures like PPE and barriers that have now become 'the new normal'. Sub-specialties like critical care, cardiac anesthesia, pain and palliative care have also faced difficulty in imparting training due to an initial dearth in elective surgery case load but have adapted innovative measures to overcome that. Initially, conducting thesis and research became difficult due to problems in achieving the desires sample size needed to get significant results, but this pandemic has emerged as a dynamic laboratory where topics like 'psychological impact of COVID-19' and 'development of artificial intelligence models in COVID -19 ICUs' came into the fore. Pattern of examination has also become virtual and webinars showed how knowledge, with the right medium, has the potential of global outreach. As the pandemic took a toll on the mental health of the residents, attention was paid to this previously neglected aspect and ensuring their emotional well-being became a priority to avoid the issue of burn-out. We comment on how what initially was considered a scary problem, actually paved way for growth. It brought attention to safety, innovation, new tools for training, finding solutions within constraints, continuing developing our residents into future leaders who were also trained for mitigating disasters. Changes like online education, research on socio-economic impact, priority to mental health and artificial intelligence are here to stay and by imbibing it, we ensure that 'the show must go on'. [ABSTRACT FROM AUTHOR]

Background and Aims: This study was designed to compare the efficacy of Macintosh laryngoscope-guided insertion of I-gelTM with the conventional blind insertion technique. Methods: A total of 156 adult patients scheduled to undergo elective surgery under general anaesthesia were included.All participants were randomly divided into two groups; I-gelTM was inserted with conventional blind and Macintosh laryngoscopic-guided technique in group A and B respectively. The primary objective of the study was to determine the incidence of optimal positioning in both the groups based on fibreoptic bronchoscope score of the glottic view. Oropharyngeal leak pressure, haemodynamic parameters and insertion characteristics were also compared.Categorical data were presented as ratio or percentage, continuous data were presented as mean ± standard deviation or median (95% confidence interval). The strength of association between insertion technique and the anatomical fit of the device was calculated by relative risk ratio. Results: Fibreoptic scores were significantly better in laryngoscope-guided insertion group when compared to the blind insertion group (P < 0.0001). The incidence of malposition was 3.85% in the laryngoscopic insertion group and 39.4% in the blind insertion (P < 0.0001). Oropharyngeal leak pressure was higher in laryngoscope-guided insertion group than in blind insertion group (26.89 ± 3.37 cm H2O versus 24.42 ± 3.00 cm H2O; P < 0.0001).Other insertion characteristics except time taken to insert the device were comparable in both groups. Conclusion: When compared to the standard blind insertion technique, laryngoscope-guided insertion of I-gelTM results in better alignment with the laryngeal inlet providing a proper anatomical fit and better airway seal pressure. [ABSTRACT FROM AUTHOR]

Byline: Rishabh. Jaju, Pooja. Jaju, Mamta. Dubey, Sadik. Mohammad, A. Bhargava Background and Aims: Although volume controlled ventilation (VCV) has been the traditional mode of ventilation in robotic surgery, recently [...]

Objective: Classic laryngeal mask airway (cLMA) is a prototype supraglottic airway device, and Air-Q is a newly introduced device for use as a primary airway and as an aid for intubation. Due to paucity of literature comparing Air-Q with cLMA, this prospective, randomized, single-blinded study was performed, to evaluate their clinical performance as a primary airway conduit. Methods: Sixty patients of either sex with the American society of anesthesiology Grade I or II, weighing between 50 and 70 kg, were randomly allocated to either the cLMA (n = 30) or Air-Q (n = 30) group. After induction of anesthesia, the assigned airway device was introduced. The ease of insertion, vital parameters, oropharyngeal seal pressure (OSP), airway morbidity, and fiberoptic grades of laryngeal view was recorded. Results: There was no significant difference in ease of insertion, the time taken for successful device placement, number of attempts, or postoperative morbidities. Air-Q was found better with respect to hemodynamic stability during placement of the device. There was a significant difference in the OSP between the Air-Q (22.12 ± 1.740 cm H2O) and cLMA (16.28 ± 2.052 cm H2O), P < 0.001. Fiberoptic laryngeal view through Air-Q was also superior (P < 0.001). Conclusion: Air-Q was found to be superior to cLMA for controlled ventilation in view of better OSP and a superior fiberoptic laryngeal view. [ABSTRACT FROM AUTHOR]

Background: Ventilator-associated pneumonia (VAP) is a significant nosocomial infection in intensive care units (ICUs). Ventilator bundle (VB) implementation has been shown to decrease the incidence of VAP. This study presents a 1-year quality improvement (QI) project conducted in the ICU of a tertiary care hospital with the goal of increasing VB compliance to greater than 90% and evaluating its impact on VAP incidence and ICU length of stay., Methods: A series of Plan-Do-Study-Act (PDSA) cycles, including educational boot camps, checklist implementation, and simulation-based training, was implemented. Emphasis on standardization and documentation for each VB component further improved compliance. Data were compared using a chi-square test, unpaired t-test, or Mann-Whitney U-Test, as appropriate. A P-value <0.05 was considered statistically significant., Results: The initial observed compliance was 40.7%, with a significant difference between knowledge and implementation. The compliance increased to 90% after the second PDSA cycle. In the third PDSA cycle, uniformity and standardization of all components of VAP were ensured. After increasing the VB compliance at greater than 90%, there was a significant decline in the incidence of VAP, from 62.4/1,000 ventilatory days to 25.7/1,000 ventilatory days, with a 2.34 times risk reduction in the VAP rate (P= 0.004)., Conclusions: The study highlights the effectiveness of a structured QI approach in enhancing VB compliance and reducing VAP incidence. There is a need for continued education, protocol standardization, and continuous monitoring to ensure the sustainability of this implementation.

Background and Aims: Propofol is a commonly used sedative agent, in a dose of 1.5-4.5 mg.kg -1 .h -1 . Following liver transplantation (LT), drug metabolism may be altered due to liver mass, altered hepatic blood flow, reduced levels of serum proteins, and liver regeneration. Thus, we hypothesized that propofol requirements in this group of patients would be different as compared to the standard dose. This study evaluated the dose of propofol used for sedation in electively ventilated living donor liver transplantation (LDLT) recipients., Material and Methods: After patients were shifted to the postoperative intensive care unit (ICU) following LDLT surgery, propofol infusion was started at a dose of 1 mg.kg -1 .h -1 and titrated to maintain a bispectral index (BIS) value of 60-80. No other sedatives such as opioids or benzodiazepines were used. Dose of propofol, noradrenaline, and arterial lactate levels were noted 2 hourly., Results: The mean propofol dose required in these patients was 1.02 ± 0.26 mg.kg -1 .h -1 . Noradrenaline was gradually tapered off and stopped within 14 h of shifting to ICU. The mean duration between the time of cessation of propofol infusion till extubation was 2.06 ± 1.44 h. Propofol dose did not correlate with respective lactate levels, ammonia levels, or graft-to-recipient weight ratio., Conclusion: The dose range of propofol required for postoperative sedation in LDLT recipients was lower than the conventional dose., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: This study was designed to compare the efficacy of Macintosh laryngoscope-guided insertion of I-gel™ with the conventional blind insertion technique., Methods: A total of 156 adult patients scheduled to undergo elective surgery under general anaesthesia were included. All participants were randomly divided into two groups; I-gel™ was inserted with conventional blind and Macintosh laryngoscopic-guided technique in group A and B respectively. The primary objective of the study was to determine the incidence of optimal positioning in both the groups based on fibreoptic bronchoscope score of the glottic view. Oropharyngeal leak pressure, haemodynamic parameters and insertion characteristics were also compared. Categorical data were presented as ratio or percentage, continuous data were presented as mean ± standard deviation or median (95% confidence interval). The strength of association between insertion technique and the anatomical fit of the device was calculated by relative risk ratio., Results: Fibreoptic scores were significantly better in laryngoscope-guided insertion group when compared to the blind insertion group ( P < 0.0001). The incidence of malposition was 3.85% in the laryngoscopic insertion group and 39.4% in the blind insertion ( P < 0.0001). Oropharyngeal leak pressure was higher in laryngoscope-guided insertion group than in blind insertion group (26.89 ± 3.37 cm H 2 O versus 24.42 ± 3.00 cm H 2 O; P < 0.0001). Other insertion characteristics except time taken to insert the device were comparable in both groups., Conclusion: When compared to the standard blind insertion technique, laryngoscope-guided insertion of I-gel™ results in better alignment with the laryngeal inlet providing a proper anatomical fit and better airway seal pressure., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Journal of Anaesthesia.)