Airway Instrumentation Research Articles

Supraclavicular Brachial Plexus Block with and without Dexamethasone as Local Anaesthetics

Background: Brachial plexus block is good alternative to general anesthesia for upper limb surgery. This avoids the unwanted effect of anesthetic drugs used during general anesthesia and the stress of upper airway instrumentation. Peripheral nerve blocks can be used for anesthesia, postoperative analgesia, diagnosis and treatment of chronic pain disorders. This study was carried out to compare onset and duration of sensory and motor blockade and duration of postoperative analgesia on addition of dexamethasone to local anestheic and local anesthetic alone in supraclavicular brachial plexus block. Methods: In this prospective randomized, controlled, double blinded study which was conducted at Department of Anesthesia, 250 Beded Hospital, Lalmonirhat, Rangpur, Bangladesh from January to June 2023. We included 70 ASA I & II patients who were aged between 18 years & 60 years, underwent elective upper limb surgeries. They were divided into two equal groups. Group 1 (cases) who received 15 milliliter of 2% lignocaine with adrenaline and 15 milliliter of 0.5% bupivacaine + dexamethasone 8mg (2ml). Group 2 (controls) who received 15 milliliter of 2% lignocaine with adrenaline and 15 milliliter of 0.5% bupivacaine + 0.9% normal saline (2ml). We observed the Onset of sensory and motor blockade, duration of sensory and motor blockade and postoperative analgesia between the two groups. Results: In this study of patients according to their age and weight. 37.26±15.55 years were mean age in group 1 and in group 2 it was 36.56±16.86 with p value being 0.8678. 58.466± 3.9642 kg was the mean weight in group 1 and in group 2 it was 60.4±4.95 kg with p value of 0.1002. So both the groups were comparable in terms of age and weight. In this study out of 70 patients, group1 consisted of 68.6% males whereas there were 60% in group 2 and group 1consisted of 31.4% of females and 40% in group2, hence males’ outnumbered females in both the groups. The mean duration of surgery in group 1 was 50±19.95 minutes and in group 2 were 46.6±15.55 minutes with p value of 0.4646. There was no statistical difference between both the groups. The onset of sensory blockade was within 7.3 min in group 1. In group 2 the onset of sensory blockade was 13.66 minutes. The onset of motor blockade was within 3.93 min in group 1. In group 2 the onset of motor blockade was 18.66 min. The duration of intra operative analgesia was 654.33 minutes in group 1. In group 2 the duration of intra operative analgesia was 292.6 minutes. The duration of post-operative analgesia was 815±13.57 minutes in group 1. The duration of post-operative analgesia in group 2 was 393.8±42.88 minutes. There were no complications in both the groups in intra operative period and post-operative period. Conclusion: Dexamethasone, when added to 15 millilitre of 0.5% bupivacaine and 15 millilitre of 2% lignocaine plus adrenaline, very effectively enhances the onset of sensory and motor blockade. It dramatically prolongs the duration of sensory and motor blockade and duration of analgesia. There were no untoward side effects with the use of dexamethasone as an additive in the brachial plexus block.

Prevalence and risk factors for ventilator-associated pneumonia after cardiac surgery: a systematic review and meta-analysis.

There is currently significant variation in the reported incidence of ventilator-associated pneumonia (VAP) among postoperative cardiac patients. Moreover, the risk factors for VAP in postoperative cardiac patients remain controversial. This study aims to assess the incidence and risk factors of VAP in postoperative cardiac patients to provide a basis for further prevention and treatment of VAP. We systematically reviewed PubMed, EMBASE, and Cochrane Library databases to select studies that met the inclusion criteria until November 2023. Fifteen studies involving 10,478 patients who underwent cardiac surgery were selected for meta-analysis. The incidence of VAP in postoperative cardiac patients was 10%. The preoperative risk factors for VAP after cardiac surgery included age >70 years, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, renal disease, and severe pulmonary hypertension. Furthermore, the perioperative risk factors for VAP after cardiac surgery included emergency surgery, redo surgery, airway instrumentation, gastric aspiration, reintubation, mechanical ventilation duration >3 days, intra-aortic balloon, New York Heart Association >3, American Society of Anesthesiologists >3, need for transfusion during surgery, and ascending aortic surgery. The incidence of VAP after cardiac surgery was found to be 10%, and the comprehensive risk factors for VAP were identified, emphasizing the critical need for targeted interventions, including optimization of preoperative health and refined surgical protocols, to effectively reduce the occurrence of VAP in postoperative cardiac patients.

Postoperative lingual nerve injury following airway management: A literature review.

Postoperative lingual nerve injury is a rare but serious complication following airway management and can lead to significant discomfort and disability. This literature review explores the aetiology, clinical presentation, management strategies and potential preventive measures for lingual nerve injuries associated with airway management during surgery. A search of PubMed, MEDLINE, EMBASE Science Direct, Cochrane library and Web of Science databases was done since inception to January 2024, including any observational studies and clinical trials describing patients diagnosed with lingual nerve injury following airway instrumentation. Multiple risk factors for lingual nerve injury were identified. Anaesthesia factors include difficulty with intubation and use of laryngeal mask airway. Surgical factors are long duration of operation and surgery of the head and neck. Patient factor includes female sex. Anaesthetists should proactively inform patients about the potential for this nerve injury and control modifiable risk factors to mitigate the risk of injury.

Difficult airway due to acute necrotizing mediastinitis: a case report

Descending necrotizing mediastinitis (DNM) due to odontogenic or oropharyngeal infections can change the airway anatomy and cause difficult intubation. A 56-year-old female patient, who was followed up for dental abscess, was taken to emergency surgery due to DNM. The patient with widespread edema on the face could only be intubated with a gamma elastic bougie. it should be kept in mind that patients with oropharyngeal infection and mediastinitis may have intubation difficulties and tendency to airway trauma, and it is important to use airway instruments carefully in these patients.

Brainstem anesthesia during awake craniotomy: illustrative case.

Awake craniotomy (AC) is performed to remove the lesions near or in eloquent areas, during which the patients are alert and without any airway instrument. Apnea is a severe complication in AC. Here, the authors describe a case of sudden apnea induced by unexpected local anesthesia of the brainstem during AC. A 42-year-old male underwent AC for a large, recurrent, bilateral frontal lobe mass and experienced transient apnea and loss of brainstem reflexes during the surgery. The patient recovered spontaneous breath rhythm just a few minutes after the removal of a lidocaine cotton pledget, which was found near the patient's midbrain. Then the patient awoke and cooperated to finish the surgery. The administration of a local anesthetic subdurally in AC is common but risky. The scouring action of cerebral spinal fluid can spread those agents and cause unexpected brainstem anesthesia. A lower concentration of the anesthetic and keeping away from the cistern can make it safer.

THE SYSTEMATIC REVIEW OF ADULTS AIRWAY DEVICES IN AWAKE TRACHEAL INTUBATION

Background: Although flexible bronchoscopes are often used for awake tracheal intubation, other airway instruments including videolaryngoscopes, direct laryngoscopes, and optical stylets are becoming more and more useful. Aims : This systematic review is to review the the effects for airway devices on patients with awake tracheal intubation. Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. So, the experts were able to make sure that the study was as up-to-date as it was possible to be. For this search approach, publications that came out between 2014 and 2024 were taken into account. Several different online reference sources, like Pubmed and SCIENCE DIRECT, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search brought up 431 articles, whereas the results of our search on SCIENCE DIRECT brought up 289 articles. The results of the search conducted for the last year of 2014 yielded a total 23 articles for PubMed and 115 articles for SCIENCE DIRECT. In the end, we compiled a total of 6 papers, 5 of which came from PubMed and 1 of which came from SCIENCE DIRECT. We included six research that met the criteria. Conclusion: In summary, in the context of awake tracheal intubation, flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically equivalent airway devices. The time to tracheal intubation was longest with flexible bronchoscopes and shortest with optical stylets.

A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol

IntroductionRespiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes.Methods and analysisThe Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27–34+6 weeks’ gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25–0.35 in the first 2–24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05.Ethics and disseminationEthical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004).Trial registrationPACTR202307490670785

Anesthetic management of a parturient with tuberous sclerosis for emergency cesarean section- a case report

BackgroundTuberous sclerosis is an autosomal dominant neurocutaneous disorder characterized by hamartoma formation in various organ systems leading to highly variable clinical presentation. These patients pose a challenge to anesthesiologists due to multisystem involvement.Case presentationHerein, we report the successful anesthetic management of a 25-year-old parturient with tuberous sclerosis who underwent an emergency cesarean section in view of cephalopelvic disproportion. She had a seizure disorder, bilateral renal angiomyolipomas, angiofibroma over the cheeks, periungual fibroma on the right toe, and nodular lesions near the base of the tongue and oropharynx. We opted for regional anesthesia to avoid airway instrumentation, drug interaction, and renal insult.ConclusionsAnesthetic management of tuberous sclerosis depends upon the extent and severity of the involvement of various organs. Careful assessment, thorough evaluation, and preoperative planning are crucial for dealing with the difficulties and complications encountered during the management of these cases.

Comparison between Dexamethasone and Clonidine as an adjuvant to 0.5% Levobupivacaine in Supraclavicular brachial plexus block

Background: Regional anesthesia avoids airway instrumentation, preserves conscious level and provide rapid recovery with significant postoperative analgesia. There has always been a search for adjuvants to the regional nerve block with drugs that prolong the duration of analgesia but with lesser adverse effects. The search for the ideal additive still continues, and therefore in this study, we investigated the effects of addition of dexamethasone versus clonidine to levobupivacaine for supraclavicular brachial plexus block. The primary outcome of this study was the onset and duration of sensory block, motor block, and the secondary outcome was postoperative analgesia. Aims and Objectives: The aim of the study was to compare the effect of dexamethasone and clonidine on onset and duration of anesthesia, when used as an adjuvant to levobupivacaine in supraclavicular brachial plexus block. 7. Materials and Methods: In this prospective, double-blind, randomized controlled trial, 60 patients with American Society of Anaesthesiologists physical status I/II scheduled to undergo upper limb surgeries below shoulder were enrolled. The patients were randomly divided into two groups: Group I (n=30): 20 mL of 0.5% isobaric levobupivacaine with 2 mL of dexamethasone. Group II (n=30): 20 mL of 0.5% isobaric levobupivacaine and 30 mcg clonidine (diluted in normal saline, making volume of 2 mL). Results: Clonidine when added to levobupivacaine provide early onset of sensory and motor block but less duration of analgesia and motor blockade as compared to dexamethasone. Conclusion: Dexamethasone should be preferred as compared to clonidine as an adjuvant whenever longer duration of post-operative analgesia is required.

COMPARATIVE EVALUATION OF HAEMODYNAMIC RESPONSE AT EXTUBATION BETWEEN TRACHEAL TUBE AND BAILEY'S MANOEUVRE USING i-gel® IN ADULT PATIENTS WITH CONTROLLED HYPERTENSION FOR ELECTIVE SURGERY

Background and Aims: Airway instrumentation leads to haemodynamic disturbances like rise in heart rate, blood pressure and risk of cardiac arrhythmias. These changes are seen more in hypertensive patients sometimes leading to serious consequences. This study evaluates and compares the changes in haemodynamic parameters (Heart Rate, Blood Pressure) in standard tracheal extubation and in Bailey's manoeuvre using i-gel ® in adult patients with controlled hypertension. Materials and methods: Sixty American Society of Anaesthesiologists (ASA) physical status II adult patients (controlled hypertensives) undergoing general anaesthesia were randomised into group E (n = 30) and group I (n = 30). In Group E endotracheal extubation was performed by employing the standard technique of extubation and in Group I Bailey's manoeuvre was employed using i-gel®. All haemodynamic data was measured on arrival in operation theatre i.e. baseline, before extubation, after extubation at 1, 3, 5, 7 and 9 min by an independent observer. Results: Both endotracheal extubation and Bailey's manoeuvre were associated with rise in Heart Rate (HR), Blood Pressure (Systolic, Diastolic and Mean Arterial Pressure) when compared with baseline values. This rise was observed higher in group E (endotracheal extubation) as compared to Group I (Bailey's manoeuvre). The percentage increase in HR, Systolic Blood Pressure, Diastolic Blood Pressure and Mean Arterial Pressure parameters was seen maximal at 1 minute after extubation than at 3 minutes, 5 minutes, 7 minutes and 9 minutes. The rise in HR at one minute of extubation was signicantly higher (p value 0.046) in E group than I group. The rise in blood pressure was also more in E group than I group but it was not statistically signicant. Conclusion: Bailey's manoeuvre using i-gel ® attenuates the increase in heart rate when compared to endotracheal extubation but it insufciently mitigates the increase in blood pressure.

Perioperative management of a patient with incidentally detected pulmonary artery aneurysm undergoing non-cardiac surgery—a case report

BackgroundThere are few case reports in which non-cardiac surgery under regional anesthesia has been described in a patient with a pulmonary artery aneurysm. We report a case in which we managed a 74-year-old lady with a hip fracture for fixation under spinal anesthesia after thorough evaluation and meticulous planning. The patient was discharged home after 5 days without any perioperative events.Case presentationA 74-year-old, hypertensive lady with an incidentally detected pulmonary artery aneurysm was posted for a dynamic hip screw. Two-dimensional echocardiography revealed normal biventricular function with an ejection fraction of 60%, no regional wall motion abnormalities, concentric right ventricular hypertrophy (tricuspid annular plane systolic excursion or TAPSE of 19 mm), severe calcific pulmonary stenosis (PS) with pressures 90/61 mm Hg, pulmonary valve annulus of 12 mm, and pulmonary artery systolic pressure of 35 mm Hg. The left and right pulmonary artery diameters were 17 mm and 20 mm, respectively. She was clinically asymptomatic with an oxygen saturation of 98% on room air. A sequential lumbar epidural anesthesia was planned for this patient given her age, overall frail condition, and to avoid airway instrumentation. As epidural was difficult due to fused spaces, a sub-arachnoid block was administered with continuous monitoring. Surgery was uneventful and the patient was discharged on the 5th postoperative day.ConclusionsWith this case report, we suggest that a central neuraxial blockade could be administered in presence of severe PS with meticulous monitoring and careful planning.

COMPARISON OF DEXMEDETOMIDINE VERSUS FENTANYL IN ATTENUATING PRESSOR RESPONSE DURING LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION

Background and objectives: Laryngoscopy and intubation is associated with a sympathetic response that results in a rapid increase in blood pressure and heart rate. The mechanisms underlying these hemodynamic changes are incompletely understood. They may be caused by a reex sympathetic discharge due to stimulation of the upper respiratory tract. It has been observed that hemodynamic responses to tracheal intubation are associated with an increase in plasma catecholamine concentrations and are attenuated by β-adrenergic blockade. This study was conducted to compare the efcacy of dexmedetomidine and fentanyl for attenuation of pressor response during laryngoscopy and intubation. Materials and methods Following approval by ethical committee, 60 ASA grade I and II patients of either sex undergoing general anaesthesia for elective surgery were included in this study. Patients were randomly divided into two groups of 30 patients each. Dexmedetomidine in a dose of 1μg/kg i.v was given to Group A patients and Fentanyl 2 μg/kg i.v was given to Group B patients. Both the drugs were diluted with normal saline solution to make 10ml and were administered slow intravenous 10 min before induction. The hemodynamic parameters were recorded, demographic data was analyzed using unpaired t-test and hemodynamic variables were analyzed by using unpaired and paired t-test. Side effects were analyzed using chi square test. Result: The two groups were comparable in their demographic proles. Dexmedetomidine proved itself to be an excellent drug when given intravenously in dose of 1μg/kg to attenuate hemodynamic response to laryngoscopy and intubation. It blunted the hemodynamic response to laryngoscopy and intubation to a greater magnitude than fentanyl in a dose of 2μg/kg intravenously as a premedication. Conclusion: We conclude that fentanyl 2μg/kg i.v. given ten minutes prior to airway instrumentation shows an inconsistent response to laryngoscopy and intubation. Between the two drugs under study, the use of dexmedetomidine 1μg/kg i.v. is satisfactory and produces a more favorable hemodynamic prole while fentanyl 2μg/kg is found to be non- dependable and less effective for the attenuation of the pressor response to laryngoscopy and endotracheal intubation.

Airway management in a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis: a case report

Stevens-Johnson syndrome (SJS), of which toxic epidermal necrolysis (TEN) is a more severe variant, is a cutaneous hypersensitivity reaction, usually triggered by certain prescribed medications. Airway management in SJS/TEN poses significant challenges, particularly when there is facial skin and oropharyngeal mucosal and/or laryngeal involvement. There is limited literature guiding definitive airway management in patients with severe SJS/TEN. We describe a case utilizing transnasal humidified rapid insufflation ventilatory exchange (THRIVE) to preoxygenate and maintain apneic oxygenation as a means of avoiding facemask ventilation and excessive airway instrumentation in a patient with SJS/TEN involving the face and oral mucosa. This case report demonstrates the use of THRIVE as a tool to optimize oxygenation and safe airway management in situations where conventional approaches may be challenging.

Comparative study between ketamine versus betamethasone gargles in attenuating post-operative sore throat after endotracheal intubation

: Postoperative sore throat (POST) is a commonly encountered side effect which causes patient discomfort after airway instrumentation during general anesthesia (GA). This study was conducted to investigate the efficacy of preop­erative gargling with Ketamine, a NMDA receptor an­tagonist and Betamethasone gargles, a steroidal anti inflammatory drug in reducing POST in patients being intubated for surgery under GA. This was a randomized, single blinded, prospective study conducted after obtaining the Institutional Ethics Committee approval. 90 patients undergoing surgery under GA with endotracheal intubation were enrolled in the study after obtaining written informed consent from all. They were further divided into 3 groups; group B, group K and group C who received Betamethasone gargles, Ketamine gargles and Dextrose Saline gargles respectively, 5 minutes before GA. Results obtained were compared statistically by using Kruskal-Wallis test, which showed significant difference between median POST grading. The Mann-Whitney U test was used for the statistical intergroup analysis. There was no statistical difference among groups as far as age, height, weight by using ANOVA test; p value > 0.05. Age of patients varied between 16-60 years in three groups. The severity of sore throat were noticeably reduced after Ketamine, Betamethasone gargles in group K and group B (p < 0.05) as compared to group C when statistically analysed by Mann-Whitney U test. But Betamethasone gargles in group B patients more efficiently reduced the incidence, severity of sore throat compared to Ketamine gargles (p<0.05) during postoperative period. The incidence & severity of POST decreased with use of pre-operative Ketamine gargles or Betamethasone gargles during post-operative period in patients with tracheal intubation. The Betamethasone gargles were more effective than Ketamine gargles in reducing the incidence, severity of POST.

Use of a Spinal-Caudal Epidural Technique for Abdominal Surgery in a Newborn With Noonan Syndrome and Severe Hypertrophic Cardiomyopathy.

Features of Noonan syndrome include a distinctive facial appearance, short stature, a broad or webbed neck, congenital heart disease, bleeding problems, skeletal malformations, and developmental delay. Although pulmonary stenosis is most commonly reported, up to 20% of patients have hypertrophic cardiomyopathy (HCM). We report the use of a combined spinal-caudal epidural anesthesia technique during urologic surgery (pyeloplasty) in an 8-week-old infant with Noonan syndrome and HCM. A spinal-caudal epidural technique provides favorable hemodynamic conditions, avoids the need for airway instrumentation, and may serve as an alternative to general anesthesia in these high risk patients.

A Comparative Evaluation of Dexmedetomidine vs Clonidine used as Adjuvants with Hyperbaric Bupivacaine in Patients with Preeclampsia Undergoing LSCS

Relief of operative as well as post operative pain should be the prime responsibility of an anesthesiologists. The most common treatment for post operative pain remains conventional intramuscular injection of narcoticswhich are associated with several side effects like nausea, vomiting, itching, hypotension, bradycardia,urinary retention, dysphoria,respiratory depression, early and later. Pregnancy induced hypertension is a major cause of morbidity and mortality in obstetrics, complicating 3-8% of pregnancies. Severe preeclampsia poses a dilemma for anesthesiologists, and there is some controversy about the best anaesthetic technique for caesarean delivery in such cases. Though spinal anasthesia reduces the risk of airway instrumentation in high risk patients of preeclampsia, there are still limitations about its limited duration of analgesia. In present study we intend to compare dexmedetomidine and clonidine used with hyperbaric bupivacaine for spinal anaersthesiain patients with preeclampsia undergoing LSCS. Primary Objective: To compare the clinical efficacy of intra the caldexmedetomidine vs Clonidine on: (a) Onset and duration of sensory block (b) Onset and duration of motor block (c) Duration of analgesia (d) Side effects if any. Secondary Objective: to compare the haemodynamic profile among patients of the two group. Methodology: All eligible patients were randomly assigned into two groups of 50 each by chit and envelope method: Group A: SAB was given with 2ml, 0.5 % Bupivacaine(H) + 45 µg Clonidine. Group B: SAB to be given with 2ml, 0.5% Bupivacaine (H) + 5µg dexmedetomidine. Results: Regression of sensory block was prolonged in group B as compared to group A.(p value <0.0001). There was regression of motor block in group B as compared to group A. p value<0.0001Heart rate remained stable and comparable at different time points in 2 groups. Except three patients in group A and one patient in group B, no other patient in either group developed bradycardia. Three patients in group A and in group B developed hypotension which responded to intravenous fluid therapy. Sedation score decreased to 0 within 5 hours. At no time, sedation score exceeded 2 and no patient developed signs of respiratory depression. Conclusion: Dexmedetomidine in the dose of 5µg added to 10 mg 0.5% Hyperbaric Bupivacaine in SAB for LSCS surgery in parturients with preeclampsia provides comparable onset for sensory and motor blockade but significantly prolonged duration as compared to 45µg of clonidine. Longer duration of postoperative analgesia with 5µg Dexmedetomidine makes it superior to clonidine in respect to postoperative analgesia. Both the drugs produce desirable level of intraoperative and postoperative sedation, stable hemodynamics and minimal side effects.

Evaluation of the Efficacy of Propofol-Magnesium Sulfate Combination for Sedation in Paediatric Magnetic Resonance Imaging of Brain.- a Randomized Controlled Trial

Background and Aims: The key to successful sedation for pediatric magnetic resonance imaging (MRI) is to keep the child completely immobile while ensuring rapid recovery. We compared the efficacy of propofol-midazolam and propofol-magnesium sulfate sedation for MRI of the brain in the paediatric population. Methods: Total 60 paediatric patients, aged 1 to 8 years awaiting for MRI brain were randomly allocated into two groups. Group I patients received midazolam 0.05mg/kg and Group II patients received magnesium sulfate 30 mg/kg infusion in the preinduction room. In the MRI room all patients were sedated with 1-2 mg/kg bolus and 100 ug/kg/min infusion of propofol. The two groups were compared for sedation characteristics like discharge time, total number of additional propofol boluses, agitation scores, haemodynamic parameters and adverse events. Fisher exact test was used for all quantitative data. Results: Induction time, scan quality, requirement of additional propofol boluses and awakening time were comparable for the groups (P>0.05). There was no statistically significant incidence of airway instrumentation between both groups (p=0.14)). Heart rate remained on lower normal side, 20 minutes after induction in Group II (P<0.00). Incidence of emergence agitation was significantly lower in Group II (P<0.01). The discharge time was shorter in Group II (41.03 ± 8.39 min versus 32.83 ± 5.97 min; P<0.001). Conclusion: Propofol-magnesium sulfate sedation is a better alternative to propofol-midazolam combination for paediatric brain MRI, as it provides a shorter discharge time and a lower incidence of emergence agitation.

Comparative evaluation of the hemodynamic effects of inclusion versus exclusion of dexmedetomidine to pregabalin and fentanyl premedication regimen during airway instrumentation in laparoscopic abdominal surgeries

Background: Airway instrumentation leads to an aggravated hemodynamic response due to increased sympathetic activity, imposing a risk of myocardial ischemia. A premedication regimen using fentanyl and pregabalin blunts the pressure response but not the rate response. Objective: To compare the effects of pregabalin and fentanyl regimen versus pregabalin, fentanyl, and dexmedetomidine regimen on the hemodynamic pressor response during airway instrumentation in laparoscopic abdominal surgery (LAS). Methods: Sixty patients (ASA I and II), undergoing elective LASunder general anesthesia, were randomly divided into 2 groups - Group A (n=30) premedicated with oral pregabalin (150mg) and IV fentanyl (2μg/kg) and Group B (n=30) premedicated with IV dexmedetomidine (0.25μg/kg) in addition to pregabalin-fentanyl regimen. Both groups were managed with the same anesthetic protocol. The preoperative sedation level was assessed before induction. The heart rate (HR), systolic and diastolic BP (SBP, DBP), and mean arterial pressure (MAP) were recorded at baseline as well as preoperatively, prior to intubation and at 1, 3, 5, 10, and 15 min after intubation. Results: Both groups had similar distribution of age, weight, gender, physical status, sedation level as well as intra-operative fentanyl and postoperative analgesic requirements.

The Importance of Acknowledging an Intermediate Category of Airway Management Devices in the Prehospital Setting.

Prehospital airway devices are often classified as either basic or advanced, with this latter category including both supraglottic airway (SGA) devices and instruments designed to perform endotracheal intubation (ETI). Therefore, many authors analyze the impact of SGA and ETI devices jointly. There are however fundamental differences between these instruments. Indeed, adequate airway protection can only be achieved through ETI, and SGA devices all have relatively low leak pressures which might compromise both oxygenation and ventilation when lung compliance is decreased. In addition, there is increasing evidence that SGA devices reduce carotid blood flow in case of cardiac arrest. Nevertheless, SGA devices might be particularly useful in the prehospital setting where many providers are not experienced enough to safely perform ETI. Compared to basic airway management (bag-valve-mask) devices, SGA devices enable better oxygenation, decrease the odds of aspiration, and allow for more reliable capnometric measurement by virtue of their enhanced airtightness. For all these reasons, we strongly believe that SGA devices should be categorized as “intermediate airway management devices” and be systematically analyzed separately from devices designed to perform ETI.

Aerosol Generation During Nasal Airway Instrumentation.

Airborne aerosol transmission, an established mechanism of SARS-CoV-2 spread, has been successfully mitigated in the health care setting through the adoption of universal masking. Upper airway endoscopy, however, requires direct access to the face, thereby potentially exposing the clinic environment to infectious particles. This study quantifies aerosol production during rigid nasal endoscopy (RNE) and RNE with debridement (RNED) as compared with intubation, a posited gold standard aerosol-generating procedure. Prospective cross-sectional study. Subspecialty single-center clinic and surgical study. Three aerosol detectors (NANOSCAN-3910, OPS-3330, and APS-3321) with a particle size sensitivity of 10 to 20,000 nm were utilized to detect particulate production during the clinical care of 209 patients undergoing RNE/RNED and 25 patients undergoing intubation. RNE and RNED produced statistically significant particles over baseline in 29.3% and 51.0% of subjects (P = .003-.049 and .002-.047, respectively). Intubation produced statistically significant particles in 31.2% (P = .001-.015). The mean ± SD particle diameter in all tests was 69.9 ± 10.5 nm with 99.7% <300 nm. There were no statistical differences in particle production among RNE, RNED, and intubation. The presence of concomitant cough, sneeze, or prolonged speech similarly did not significantly affect particle production during any procedure. Instrumentation of nasal airway produces airborne aerosols to a similar degree of those seen during intubation, independent of reactive patient behaviors such as cough or sneeze. These data suggest that an improved understanding is necessary of both the definition of an aerosol-generating procedure and the functional consequences of procedural aerosol generation in clinical settings.