Insertion Attempts Research Articles

Even the Simplest Devices May Malfunction: Split Septum Design Revisited.

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

Comparison between I-gel and Classic Laryngeal Mask Airway for Airway Management of Patients with Anticipated Difficult Airway: A Randomised Clinical Trial

Introduction: I-gel and classic Laryngeal Mask Airway (cLMA) are two Supraglottic Airway Devices (SAD) used for management of airway in various situations, including for management of difficult airway. Despite widespread use of these devices, there are very few trials studying I-gel and classic LMA for management of patients with difficult airway. The outcome of present study determines which SAD is better for managing difficult airway. Aim: To compare I-gel and cLMA in managing anticipated difficult airway. Materials and Methods: This randomised and single blinded clinical trial study was conducted in King George’s Medical University, Lucknow, Uttar Pradesh, India, between February 2019 to January 2020. Adult patients with Mallampati class 3 or 4, thyromental distance <6 cm, sternomental distance <12 cm, restricted neck movement, micrognathia/retrognathia or short/thick neck undergoing elective short duration surgery under general anaesthesia were included in this study. Total 50 patients divided into group C received cLMA while group I patients received I-gel for airway management. Fifty patients were recruited in each group. Nominal variables were analysed using chi-squared test. A two-sided p<0.05 were considered significant for all the tests. Analysis was performed using Statistical Package for Social Sciences (SPSS) version 25.0 for windows. Results: Mean age in group C was 40.38±12.96 (years) and in group I was 37.94±11.77 (years) with p-value 0.327. Overall (n=44 in group C, 50 in group I, p-value=0.012) and first attempt (n=10 in group C, 40 in group I, p-value <0.001) success rate of device placement was higher for I-gel. Number of attempts, manipulations, time needed to insert and Leak Fraction was significantly lower for I-gel (p-value <0.001). Compared to cLMA, Oropharyngeal Leak Pressure (OLP) was higher with I-gel. Fibreoptic view on a four-point scale was better with I-gel. Desaturation, tachycardia, bradycardia, and postoperative sore throat was more frequent with cLMA. Conclusion: Compared to cLMA, I-gel has higher success rate of insertion in patients with difficult airway and has added advantage of more rapid insertion, higher OLP and need for fewer insertion attempts and manipulations with lower rates of complications.

Even the Simplest Devices May Malfunction: Split Septum Design Revisited

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

A Randomized Prospective Study to Compare Use of I-GELTM and LMA ProsealTM in Patients undergoing Laparoscopic Cholecystectomy

Introduction: With the availability of supraglottic devices in providing effective seal even in conditions of raised airway pressures, use of these devices in laparoscopic surgeries has become popular. Of the various supraglottic devices being used in laparoscopic surgery LMA ProSealTM and i-gelTM airway are commonly used with efficacy. The aim of this study was to compare the use of i-gelTM and LMA ProSealTM in patients undergoing Laparoscopic cholecystectomy. Methodology: This was a prospective randomized, hospital based study conducted at a tertiary care hospital. Adult inpatients of either gender posted for elective laparoscopic surgery were recruited in the study. A total of 100 patients were included out of which 50 each were randomly allocated to either i-gelTM group (Group I) or LMA ProSealTM group (Group P). After randomization, the chosen supraglottic airway device (i-gel/Proseal LMA) was inserted. Airway insertion attempts, time to successful ventilation, Gastric tube placement, Airway sealing quality, Numbers of attempts required for correct placement and complications were recorded and the data was assessed. Results: Demographic data were comparable in the two groups. The Ventilation time was found to be significantly faster with PLMA as compared to i-gel. I-gel and Proseal showed no significant differences in the airway and gastric tube insertion attempts, ventilation success rate, airway sealing pressures, SpO2, EtCO 2, airway sealing quality score and intra abdominal pressures. Conclusion: Both i-gel and Proseal both provide adequate ventilation in laparoscopic cholecystectomy surgeries. Complications such as airway injury and bleeding with Proseal LMA are significantly more as compared to i-gel.

Propofol vs Sevoflurane for Laryngeal Mask Airway Insertion Under General Anaesthesia in Day Care Surgeries

Background: Laryngeal mask airway (LMA) is an excellent airway device used in day care surgeries. We aimed to compare two induction anaesthetic agents, propofol and sevoflurane for LMA insertion conditions in day care surgeries. Patients and Methods: This prospective, randomized study was conducted on 80 adult, ASA grade I and II patients, of either gender, undergoing elective day care surgical procedures. Patients were randomly divided in two groups of 40 each. Group P received intravenous propofol infusion at the rate of 800ml/ hour for induction followed by LMA insertion. Group S received 8% sevoflurane for induction followed by LMA insertion. Both groups were compared for LMA insertion conditions in terms of time taken from the start of induction to loss of verbal contact, loss of eyelash reflex, jaw relaxation, successful LMA insertion conditions, number of attempts of LMA insertion and effective airway establishment time. Unpaired student – t test and Chi square test were used for statistical analysis. Results: Patients in Group P achieved earlier LMA insertion conditions as compared to Group S i.e. shorter time to loss of verbal contact (33.48 ± 6.55 seconds vs 41.30 ± 4.12 seconds), loss of eye lash reflex (36.50 ± 6.67 seconds vs 44.40 ± 4.06 seconds), adequate jaw relaxation (40.35 ± 7.64 seconds vs 49.02 ± 4.45 seconds), and effective airway establishment time (44.88 ± 8.86 vs 54.65 ± 4.28 seconds) (P value <0.001). Conclusion: We concluded that both the agents can be used for insertion of LMA however induction and insertion of LMA is faster with propofol.

Comparing the ease of identifying the subarachnoid space at midline of L3 -L4 interspace by preprocedural ultrasound versus landmark technique - A randomized control study

Introduction: The role of ultrasound in central neuraxial blockade has been underappreciated, partly because of the relative ease of the landmark-guided technique and falsely perceived difficulty in imaging through the narrow acoustic windows. This study was designed to compare conventional landmark technique with preprocedural ultrasonography for identification of the subarachnoid space in patients for elective surgeries under spinal anaesthesia. Materials and Methods: Total 120 patients who were scheduled for elective surgery under spinal anaesthesia were included in this prospective randomised control trial and divided into 2 group, Group L (n = 60) (landmark guided technique) and Group U (n = 60) (ultrasound guided technique). Parameters such as time taken for the identification of the interspace, number of insertion attempts (the primary outcome), number of passes and time taken were recorded in both the groups. Result: The time taken for identification of interspinous space was significantly more in Group U (4.7 ± 2.1 mins) as compared to Group L (1.17 ± 0.52 min) but the number of attempts for needle insertion (1.12 ± 0.41 vs. 1.86 ± 0.91), number of passes in the same interspinous space (3.32 ± 1.44 vs. 6.98 ± 2.51) and the total time for successful lumbar puncture (38.72 ± 12.30 vs. 56.65 ± 11.32 s) were significantly less in Group U as compared to Group L. Conclusion: The ultrasound guided identification of subarachanoid space was time consuming, but resulted in fewer attempts to enter the subarachnoid space when compared to the conventional landmark-based approach. Keywords: Neuraxis, Subarachnoid space, Ultrasonography.

A prospective randomised comparative study of proseal LMA, I-gel and endotracheal tube in laparoscopic cholecystectomy

A prospective randomised comparative study of proseal LMA, I-gel and endotracheal tube in laparoscopic cholecystectomy - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/2394-4994.2018.0008, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

Ease of ProSeal laryngeal mask airway insertion in children (after placement) using suction catheter: A comparison with conventional techniques

Objectives: The ProSeal Laryngeal Mask Airway (PLMA) mostly inserted by finger technique and by an introducer tool method. Recently a newer Suction Catheter Guided (SC) insertion technique has been successfully used in children. We performed a study in children with aims and objective to compare the ease of PLMA insertion using SC and conventional techniques. Methods: 126 American Society of Anaesthesiologist’s class I and II children in age group of 1-12 years weighing 10-50 kg, admitted in our hospital, undergoing an elective surgery in under general anaesthesia in supine position were included in our study. An appropriate size PLMA was inserted using Suction Catheter, introducer tool or digital technique in Groups SC, I and D respectively (n=42) after induction of general anaesthesia. Correct placement of the PLMA was confirmed by using appropriate clinical tests. Ease of PLMA insertion with hemodynamic response was done by time to insertion, number of insertion attempts to achieve effective ventilation and number of cases which required lateral approach of insertion. Results: In Group SC, PLMA device was inserted after a single attempt in 41 (97.6%) patients, but PLMA insertion was failed in 5 patients in Group I (11.9%) and 6 patients in Group D (14.3%) even after two attempts, and the difference was statistically significant (p=0.044). Time taken for successful placement was statistically shorter in the SC-guided group (SC 22.5±4.021 seconds, I 31.4± 17.57 seconds, D 27.10±12.9 seconds, p value Conclusion: Suction Catheter guided ProSeal LMA insertion was an easier, faster, more successful and a relatively atraumatic technique which also ensures correct placement of the PLMA in the hypopharynx as compared to the routine conventional PLMA insertion techniques with no hemodynamic pressor response to PLMA insertion using any of the three techniques. Keywords: ProSeal LMA, Suction Catheter insertion.

Proficiency of Laryngeal Mask Airway Insertion Skill in NRP Certified Providers.

Objective In 2015, Neonatal Resuscitation Program (NRP) recommended laryngeal mask airway (LMA) as an alternative to the endotracheal tube (ETT) in situations where the provider is “unable to intubate and unable to ventilate.” LMA insertion is being taught in the NRP routinely. However, endotracheal intubation is the primary method considered as the standard of care in neonatal resuscitation. LMA insertion is a relatively simple procedure with an average insertion time of < 10 seconds. Newer generation LMA can have the added advantage of reducing the risk of aerosol generation and improving the safety of the providers. Only a few recent studies have evaluated the LMA insertion skills of neonatal resuscitation providers. We wanted to study the proficiency of NRP providers in the technique of LMA insertion. We hypothesized that NRP providers would have LMA insertion skills equivalent to the standard of care (ETT insertion). Study Design A manikin-based study was done from July 2019 to December 2019. We enrolled 31 NRP providers with 1 or more years since the first certification and current valid NRP provider/instructor status. The participants were instructed to insert an ETT and LMA in the manikin. The procedures were video recorded. The time taken to insert and start ventilation with each device, including the number of attempts for successful insertion, was noted. A Likert scale questionnaire was filled by each participant indicating the level of confidence, perception of ease, and the ability to provide effective positive pressure ventilation (PPV) with each of the procedures. The paired t -test, chi-square test, and Kruskal–Wallis' test were used for the statistical analysis. Results Eight (25.8%) out of the 31 participants failed to insert any one of the devices. So, 23 providers were analyzed for the outcomes. We found that the mean duration taken to insert the ETT and LMA was not statistically different (32 vs. 36 seconds). LMA insertion had a higher failure rate compared with ETT. Providers did not perceive confidence to insert LMA when compared with ETT. They did not recognize LMA insertion as a more effortless procedure relative to endotracheal intubation. The providers felt that their ability to provide effective PPV using LMA was inferior to ETT. Conclusion The NRP certified providers in this study did not demonstrate proficiency in the insertion of LMA equivalent to the endotracheal intubation. Key Points LMA insertion skill was studied in NRP providers using a manikin.Providers had a higher frequency of failure in inserting LMA compared to ETT.Providers' perceived confidence and effectiveness of the LMA procedure were inferior to ETT.

Estimation of effective dose of propofol mono-sedation for successful insertion of upper gastrointestinal endoscope in healthy, non-obese Chinese adults.

Propofol is effective in sedation for upper gastrointestinal (UGI) endoscopy. However, the optimum dose is ill-defined. This study aimed to estimate the effective dose of propofol mono-sedation for successful endoscope insertion in healthy, non-obese Chinese adults undergoing single UGI endoscopy. Twenty-six adult patients undergoing elective single UGI endoscopy were enrolled in this study. A modified Dixon's up-and-down method was utilized to assess the effective dose of propofol for successful endoscope insertion. The initial dose of propofol administered, 1.6mg/kg, was adjusted with 0.1mg/kg as a step size. The patient's responses to endoscope insertion were classified as either 'movement' or 'no movement'. When patient's responses were changed from 'movement' to 'no movement' or from 'no movement' to 'movement', a crossover was defined. After eight crossovers had been obtained, patient recruitment was stopped. The mean of midpoints of all crossovers obtained by the modified Dixon's up-and-down method in all 26 patients was defined as calculated median effective dose (ED50 ) of propofol for successful endoscope insertion. Furthermore, probit regression analysis was used to determine the dose of propofol where 50% (ED50 ) and 95% (ED95 ) of endoscope insertion attempts were successful. The calculated ED50 of propofol for successful endoscope insertion was 1.89±0.12mg/kg. The probit regression analysis showed that ED50 and ED95 of propofol for successful endoscope insertion were 1.90mg/kg (95% CI, 1.78-2.10mg/kg) and 2.15mg/kg (95% CI, 2.01-3.56mg/kg), respectively. No any patient had hypoxaemia and gag reflex during the UGI endoscopy with propofol mono-sedation. In healthy, non-obese Chinese adults, propofol mono-sedation can provide excellent conditions of UGI endoscopy and the estimated ED50 of propofol for successful endoscope insertion is 1.89±0.12mg/kg.

Abstract 206: Effect of Airway Strategy Upon Chest Compression Quality in the Pragmatic Airway Resuscitation Trial

Background: Chest compression (CC) quality is associated with improved out-of-hospital (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART). Methods: We analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques (MATLAB) to identify and calculate CC quality measures. We defined a CC interruption as ≥3 second pause in chest compressions. We determined CC fraction, rate and interruptions (number and total duration) in 1-minute epochs for the entire resuscitation. We compared differences in CC quality between LT and ETI using t-tests. We repeated the analysis stratified by time before/after airway insertion as well as by successive 3-minute time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between BVM-only vs. ETI or LT. Results: Of 3,004 patients enrolled in PART, CPR process data were available for 1,996 (1,001 LT, 995 ETI). Mean resuscitation duration was: LT 22.6±10.8 min, ETI 25.3±11.3 min. Mean CC fraction (88% vs. 87%, p=0.045) and rate (114 vs. 114 bpm, p=0.59) were similar between LT and ETI. Median number of CC interruptions was similar between LT and ETI (11 vs. 12). Total CC interruption duration was lower for LT than ETI (160 vs. 181 sec, p=0.002); this difference was largest before airway insertion (56 vs. 78 sec, p=0.001). There were no differences in CC quality when stratified by 3-min time epochs. Total CC interruption duration was shorter for single than multiple airway insertion attempts (127 vs. 153 sec, p=0.005). Total CC interruption duration was shorter for BVM-only than LT or ETI (104 vs. 135 sec, p&lt;0.001). Conclusion: In PART, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. Single-attempt airway insertion and BVM-only were associated with shorter total CC interruption duration. OHCA airway management may influence CC quality.

Improving Peripheral Intravenous Catheter Care for Children with Cancer Receiving Chemotherapy in Malawi

PurposeTo change pediatric oncology nursing management of peripheral intravenous catheter (PIVC) insertion and care based on current best evidence. Design and methodsPractice change strategies were developed, and nurses completed education on proper PIVC insertion, dressing placement, and ongoing PIVC assessment with emphasis on preventing chemotherapy extravasation. Nurses also completed a chemotherapy course as part of their orientation program. The plan for PIVC practice change was based on evidence from published research and established PIVC care guidelines. Pre-assessment data revealed numerous PIVC attempts and a high incidence of extravasation (42%) in children with cancer receiving treatment in Malawi. ResultsPost-assessment data nine months later resulted in a reduced extravasation rate from 42% to 4% using point prevalence assessments. PIVC insertion attempts reduced following education and guideline implementation; 81% of children required more than 3 PIVC insertion attempts before the practice change. Only 1% of PIVC insertions required more than 3 attempts after education and practice change implementation. Nurses completed a 32-item written examination before the chemotherapy course; the mean score was 50/100. Upon completion of the chemotherapy course, nurses obtained a mean score of 97/100 on the written examination. ConclusionsUsing an organized approach to nursing practice change improved PIVC care in children with cancer. Practice implicationsThis project provides evidence that nursing practice change strategies can be used in any setting including countries like Malawi with limited resources.

Vascular Access Care in Patients with Multimorbidity

Highlights Multimorbid patients with DIVA required more catheters than those without DIVA. The DIVA group required devices of smaller calibre and more insertion attempts. Catheter dwell time was similar but adverse events rate was higher in DIVA group. Nearly 20% of catheters were inadequate for the therapy prescribed in all patients. The results evidenced the need to improve adherence to clinical practice guidelines.

Peripheral Venous Access for Collection of Immune Effector Cells and Hematopoietic Stem Cells Is Feasible and Safe in Older Children and Young Adult Patients

Introduction: Collection of hematopoietic stem cells (HSC) for HSC transplantation (HSCT) and immune effector cells (IEC) for cellular manufacturing (e.g. CAR T-cells) in children and young adults has unique challenges. In order to maintain adequate flow rates, central venous catheters (CVCs) are often utilized at pediatric institutions. However, CVCs are associated with additional procedural risks (anesthetic complications, thrombotic events) and resource utilization (anesthesia, interventional radiology). In adults collection through peripheral venous catheter (PVC) access has become increasingly standard practice, but has not yet been routinely used in pediatrics. The aim of this study was to determine if it is feasible and safe to utilize PVC access in a select population of older children and young adults to reduce the need for CVC insertions. Methods: All individuals undergoing HSC and IEC collections at our institution (patients and sibling donors) between February 2019 and July 2020 were considered for PVC collection if in the treating physicians assessment the patient would be able to tolerate the procedure (arms outstretched for up to 6 hours) and venous vessels were deemed suitable for an 18 gauge PVC. For blood return patients received either a second PVC (minimum 20 gauge) or if present their port/central line was used. For patients screened after April 2020, assessment by ultrasound was performed prior to the procedure to determine venous vessel size. All patients had topical analgesia applied prior to PVC insertion. All collections were carried out using the Continuous mononuclear cell collection (CMNC) protocol on an Optia apheresis device. Collection-related parameters such as demographics, collection efficiency (CE2), collection time, flow rate and product quality were collected. Results: A total of 27 patients were screened for PVC collection from February 2019 until July 2020. The median age was 16.1 years (range 9.7-27.3) and median weight 67.7 kg (range 29.4-115.4). Ten out of 27 patients had ultrasound screening prior to collection on which one patient was deemed not suitable for PVC collection due to a venous anomaly. Cells were collected successfully by PVC in 24/26 (92%) of patients, 2/26 (8%) patients required CVC insertion after an unsuccessful PVC attempt due to inability to maintain an adequate flow rate. Average PVC collection flow rate was 50.3 ml/min (range 34-91) with median collection time of 244.5 min (range 87-397 min). Median collection efficiency (CE2) for CD3 cells was 59% (range 21-88), for CD34 cells 55% (range 28-69), product cell viability was 100%. Collection and product parameters were comparable to institutional collections performed utilizing CVCs. PVC collections were well tolerated, no patient had to stop the procedure due to discomfort or patient safety concerns. Conclusion: PVC collection of IEC and HSC is feasible and safe in older children and young adults. Ultrasound screening prior to PVC insertion and collection attempt can reduce failure rate and streamline the collection process. Disclosures Krueger: Novartis: Consultancy, Other: Travel support; no honoraria, Speakers Bureau; Kite, a Gilead Company: Other: Travel support; Atara: Other: Travel support.

Verbal Analgesia Is As Good As Oral Tramadol Prior to Intrauterine Device Insertion Among Nulliparous Women: A Randomized Controlled Trial

Study Objective To evaluate pain management strategies during insertion of intrauterine device (IUD) among nulliparous women as compared to the analgesic effects of oral tramadol and 'verbal analgesia' on pain relief. Design We conducted a randomized controlled trial from December 2015 to December 2018. Setting A multi-center outpatient clinics. Patients or Participants 54 nulliparous women. Interventions Patients who underwent Levonorgestrel-releasing intrauterine device (IUD) insertion were randomized for analgesic treatment or 'verbal analgesia' prior the IUD insertion. Measurements and Main Results All the patients were Caucasian. There was no difference between the two groups regarding gravidity, age, smoking or body mass index (BMI). No significant differences were detected between the groups on the procedure manner including ease of insertion (p=.415), number of insertion attempts (p=.514) and complicating events during the insertion (p=.150). Mean level of pain by VAS was 4.5±1.6 (2-8) for the tramadol group and 4.8±2.4 (0-10) for the verbal analgesia group. There was no spontaneous ejection of the IUD in either group, no case of endometritis, or discomfort that resulted in IUD removal. Conclusion There was no benefit for pain analgesia prior to the insertion of a IUD in nulliparous women. Verbal analgesia can be a suitable tool for this process and clinicians should become more familiar with its use.

Routine chest X-ray following ultrasound-guided internal jugular vein catheterization in critically ill children: A prospective observational Study.

Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications. To assess the usefulness of routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular veins in critically ill children. A prospective observational study was conducted at a pediatric intensive care unit of a tertiary, university-affiliated pediatric medical center. All children under the age of 18 who underwent ultrasound-guided central venous catheter insertion through the right or left internal jugular vein between May 2018 and November 2019 were evaluated for eligibility. Procedures were prospectively documented, and chest X-ray was screened for pneumothorax, hemothorax, central venous catheter tip position, and resultant corrective interventions. Of 105 central venous catheter insertion attempts, 99 central venous catheters (94.3%) were inserted. All were located within the venous system. None were diagnosed with pneumo/hemothorax on chest X-ray. Twenty (20.2%; 95% CI 12.8%-29.5%) were defined as malpositioned by strict criteria; however, only one (1%) was judged significantly misplaced by the clinical team leading to its repositioning. In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.

Comparison of intubating LMA and I-gel for ease of insertion and as a conduit for endotracheal intubation

Background: Tracheal intubation provides the most effective means of direct airway Ventilation and protection against aspiration, but it is not free from complexities and complications.Objectives: to compare ease of insertion and Number of attempts for successful device placement and time taken for insertion. Study design: Randomised controlled prospective study. Participants: 80. Sampling: Systematic Random Sampling. Study period: from October 2016 to October 2018. Results: When insertion attempts were compared between two groups, I-gel was inserted in first attempt in 95% patients and I-lma was inserted first attempt in 90% patients. Data was comparable between the two groups (p>0.05). ET tube Insertion was successful on first attempt in 65% of patients in group G and 75% of patients in group I-LMA. The data was comparable between the two groups (p>0.05). The mean time taken for placement of I-GEL was 20.98± 2.36 seconds and for I-lma it was 17.85 ± 2.07 seconds. The difference between two groups was extremely significant (p<0.01). When mean time for insertion of ET tube through SAD was compared ET tube was inserted with mean time of 23.98 ± 1.42 seconds in Group G and in Group L it was 20.85 ± 1.70 seconds. The difference between two groups did not reveal any significance (p<0.01). Conclusion: we came to conclusion that Time taken to insert ET tube via I-LMA is significantly less than that of. I-gel. I-gel can be used as a conduit for endotracheal intubation.

Landmark-guided versus modified ultrasound-assisted Paramedian techniques in combined spinal-epidural anesthesia for elderly patients with hip fractures: a randomized controlled trial

BackgroundCombined spinal-epidural (CSE) anesthesia is considerably challenging for elderly patients with hip fractures due to spine degeneration and limitations in positioning. This study aimed to investigate the ability of a modified preprocedural ultrasound-guided technique to improve the success rate and efficacy of CSE anesthesia for elderly patients with hip fractures.MethodsThis prospective, single-blinded, parallel-group randomized controlled trial included 80 patients (aged ≥65 years) who were scheduled for elective hip fracture surgery with CSE anesthesia. Patients were randomly allocated into landmark group (n = 40) or the ultrasound group (n = 40). The primary outcome was first-pass success rate. Secondary outcomes included first-attempt success rate; number of needle insertion attempts; number of needle passes; locating, puncture, and total time; level of block; procedural adverse reactions and postoperative complications; and patient satisfaction score. Patients were blinded to group allocation.ResultsEighty patients completed the study and were included in the final analysis. The first-pass success rates for the landmark and ultrasound groups were 20 and 70%, respectively (P < 0.001). The first-attempt success rates in the landmark and ultrasound groups were 42.5 and 85%, respectively (P < 0.001). The median number of attempts was lower in ultrasound-assisted group (1 [1, 1]) than landmark-guided group (2 [1, 2]), P < 0.001). The median number of needle passes was lower in ultrasound group (1 [1, 2]) than in landmark-guided group (3 [2, 4], P < 0.001). The locating time (P < 0.001) and total time (P = 0.001) were longer in the ultrasound group, while puncture time was shorter (P = 0.003). No significant difference was found regarding the incidence of adverse reactions and complications. More patients in the ultrasound group had a high satisfaction score of 4–5 (P = 0.007). Interestingly, subgroup analysis demonstrated benefits for ultrasound in patients with scoliosis.ConclusionsModified ultrasound-assisted CSE anesthesia increases first-pass and first-attempt success rates, and reduces needle insertion attempts, passes, and puncture time for elderly patients with hip fracture, especially those with scoliosis. This technique improves patient satisfaction and warrants consideration for application in clinical practice.Trial registrationChinese Clinical Trial Register (identifier, ChiCTR1900020819; date of registration, January 20, 2019).

Clinical trial for comparison of clinical performance of I-Gel with LMA-proseal in elective surgeries

The I-gel is genuinely interesting second era aviation route gadget with delicate gel like non inflatable sleeve. The objective of this study was to evaluate and compare the ease of insertion and number of insertion attempts, airway sealing pressure, and evaluation of device position and occurrence of complication. Total70 adult patients were allocated to either i-gel group or P-LMA group with 35patients in each group. Both i-gel and P- LMA were introduced with standard technique. The outcomes measured ease of insertion, number of insertion attempts, airway sealing pressure, changes, evaluation of device position and complications. the i-gel group the success rate at ease of insertion was greater (97% vs72% respectively;P=0.012). Airway sealing pressure was lesser (24.72±1.37 cmH2Ovs 30.09±2.64 cmH2O respectively; P=0.0003). The incidence of postoperative sore throat was lower (2.8% vs 25.7% respectively;P=0.01). Changes in parameters were not clinically significant. The i-gel is easier to insert than P-LMA however with a lower airway sealing pressure. It has a lower incidence of postoperative complications.

Verbal analgesia is as good as oral tramadol prior to intrauterine device (IUD) insertion, among nulliparous women: A randomized controlled trial

ObjectiveTo compare two pain management strategies: oral tramadol or a verbal analgesia technique during insertion of an intrauterine device (IUD) among nulliparous women. Study designIn this randomized, controlled trial, 54 nulliparous women undergoing insertion of a levonorgestrel-releasing intrauterine device (IUD), from December 2015 to December 2018 were randomized to receive oral tramadol for analgesia or verbal analgesia prior to IUD insertion. Demographic data, clinical symptoms, visual analogue scale (VAS) and complications were reviewed from patient records. ResultsThere was no difference between the two groups regarding gravidity, age, smoking or body mass index. No significant differences were detected between the groups regarding the procedure, including ease of insertion (p = .415), number of insertion attempts (p = .514) and complications during the insertion (p = .150). Mean pain level by VAS was 4.5 ± 1.6 (range 2−8) for the tramadol group and 4.8 ± 2.4 (0−10) for the verbal analgesia group (p = .610). There was no spontaneous ejection of the IUD in either group, and no endometritis or discomfort that resulted in IUD removal. ConclusionThere was no benefit in using oral tramadol for analgesia prior to IUD insertion among nulliparous women. Verbal analgesia can be a suitable technique for this process and clinicians should become more familiar with its use.