Anaesthetic Management of Ebstein Anomaly in a Patient with Cleft Palate

Ebstein anomaly is a challenge to the anaesthetist in terms of large right atrium, atrialised right ventricle and various valve abnormalities associated with it like Tricuspid Regurgitation(TR), Mitral Stenosis(MS), Mitral Regurgitation(MR). In this case study, we report a 14-year-old female child presented with ebstein anomaly and cleft palate in our institution, SMS medical college & hospitals, Jaipur, Rajasthan. Cone’s operation was planned but due to multiple fenestrations in tricuspid leaflet only tricuspid and mitral valves were replaced. Patient was extubated next day with uneventful recovery

Comparison of Landmark Versus ECG-Guided Technique for Correct Insertion of Central Venous Catheter in Paediatric Patients Undergoing Cardiothoracic Surgery

Background: Central venous catheters are inserted in internal jugular vein during cardiac surgeries in all patients. However, the length of the catheter should be correctly estimated and the tip of the CVC should be correctly placed to avoid various complications.  The primary objective of this study is to compare anatomical landmark technique versus using ECG-guided technique for the correct insertion length of the Central Venous Catheter. Methods: Prospective, randomized, interventional study was conducted on 72 patients of <12 years age. Patients were randomly allotted to two groups of 36 patients each (landmark and ECG). After induction, CVC cannulation was performed using either of the techniques in right IJV in all patients. Correct position of CVC was checked by obtaining post operative chest X rays in all patients. CVC tip position within 0.5cm above/below or at carina was considered as correct position. Using student t-tests and Chi square-tests analyses were performed. Results: In landmark group, CVC was positioned correctly in 22(61.11%) out of 36 patients as compared to 33 (91.67%) in the ECG group, (P = 0.006). The mean depth of CVC insertion was 9.05±1.66 and 8.26±1.41 in the landmark and ECG group respectively (P= 0.032). The landmark group had 12 (33.33%) patients with complications during the procedure, as compared to 3(8.33%) in the ECG-guided group, (P = 0.020). Conclusion: ECG-guided CVC insertion, a simple bedside technique was found more accurate with lesser complications for CVC tip placement than the landmark technique. ECG-guided CVC placement is therefore relatively more accurate, efficient, and safe

Comparison of Intubating Conditions on the basis of Neuromuscular Monitoring versus Clinical Assessment Guided Tracheal Intubation: A Randomized Interventional Study

Background: Laryngoscopy and endotracheal intubation have been associated with marked hemodynamic responses and hazards. This study was undertaken with the purpose to compare the intubating conditions when the suitable time for intubation was judged by either clinical assessment or train-of-four monitoring. Methods: 60 patients without any difficult airway predictors, posted for surgery under general anaesthesia, were randomised into two groups. In Group A patients, the trachea was intubated after train of four counts became zero in adductor pollicis muscle, whereas in Group B patients, intubation was done after clinically judging jaw muscle relaxation. The primary objective was to compare Intubating conditions and mean duration of time between the administration of a neuromuscular blocker and endotracheal intubation. The secondary objectives included number of attempts, changes in hemodynamic parameters. Results were analysed by the Analysis of variance and chi-square tests. Results: In all Group A patients excellent and good intubating conditions were observed, whereas 25 out of 30 patients (83%) in Group B showed excellent and good intubation conditions. The mean time required for intubation was significantly longer in Group A compared to Group B (369 ± 79 s vs. 191 ± 5 s). HR and mean arterial pressure were significantly higher in Group B as compared to Group A after laryngoscopy and tracheal intubation (P < 0.05). Conclusion: Better intubating conditions and more haemodynamic stability are seen after attaining complete relaxation of laryngeal muscles, as detected by neuromuscular monitoring of adductor pollicis muscle.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Anesthetic management of descending thoracic aortobifemoral bypass for aortoiliac occlusive disease: Our experience

Background: Complete obstruction of the abdominal aorta at the renal artery level is a difficult surgical problem. Aortic clamping and declamping can lead to profound haemodynamic changes, myocardial infarction, ventricular failure or even death may result. These complications are important challenges in anesthetic management of these patients. Methods :0 Between August, 2010 and April, 2012, descending thoracic aorta to femoral artery bypass grafting was used to revascularize lower limbs in 11 patients in our institute. The anesthetic management of these patients is described here. Epidural catheter placement was done in T 5-6 or T 6-7 space for post operative pain relief. Induction was done by, Inj. Glycopyrolate 0.2 mg, Inj. Fentanyl 5 μg/kg., Inj. Pentothal sodium 5 mg/kg, Inj. Rocuronium 0.9 mg/kg, IPPV done. Left sided double lumen tube was inserted, Maintenance of Anesthesia was done by O 2 + N 2 O (30:70). Increments of Vecuronium and Fentanyl were given Monitoring of Heart rate, arterial pressure, central venous pressure were continuously displayed. The available pharmacological agents were used when there is deviation of more than 15% from base line. Results: In our study, inspite of measures taken to control rise in blood pressure during aortic cross clamping, a rise of 90 mm of Hg in one patient and 60-80 mm of Hg in four patients was observed, which was managed by sodium nitropruside infusion. At the end of surgery seven patients were extubated on the operation table. In remaining four patients DLT was replaced by single lumen endotracheal tube and were shifted to ICU on IPPV. They weaned off gradually in 3-5 hours. In our series blood loss was 400 ml to 1000 ml. There was no mortality in the first 24 hours. Postoperative bleeding was reported in one case which was re-explored and stood well. Conclusion: The anesthetic technique during aortic surgery is directed at minimizing the hemodynamic effects of cross clamping in order to maintain the myocardial oxygen supply demand ratio

Emergence and Recovery Characteristics of Desflurane versus Sevoflurane in Morbidly Obese Adult Patients Undergoing Abdominal Surgery

Background: Early and complete recovery after general anesthesia is desirable in all patients, more so in the morbidly obese patients. All volatile anesthetics accumulate, over time, in adipose tissue. Such accumulation may delay recovery from anesthesia. The new fluorinated agents have markedly improved the quality and the time required for recovery compared with the older inhaled anesthetics. Aim: This study was done to compare the maintenance and recovery characteristics of Sevoflurane versus Desflurane in morbidly obese patient, Method: Fifty morbidly obese patients (BMI &gt; 35kg/ meter square) requiring Abdominal surgery were randomly allocated to 2 groups (25 patients in each group)Group A received 1 MAC target concentration of Desflurane and GROUP B received 1MAC target concentration of Sevoflurane in oxygen for maintenance. EtCO2 (end-tidal carbon dioxide) was maintained between 30-40mm Hg. The MAP and HR were targeted to maintain within ± 20% of the baseline values throughout intra operative period. Results: Early recovery parameters were achieved statistically significantly(p&lt;0.05) faster in Desflurane group in comparison to Sevoflurane group. Time for response to eye opening was earlier by 1.41 minutes, time for hand grip was faster by 1.61 minutes, time for tracheal extubation was significantly faster by 2.21 minutes in Desflurane group than Sevoflurane group. Time to state his/her own name and name of village were also significantly faster in Desflurane group by 2.76 minutes and 2.76 minutes respectively. Intermediate recovery (the time to discharge the patient from the PACU) was comparable between two groups. (p&gt;0.05). Conclusion: In morbidly obese patients, using 1 MAC end-tidal concentration, we found that the time to emergence and early recovery from prolonged anaesthesia with Desflurane is shorter than with Sevoflurane anaesthesia

Awake orotracheal fibre-optic intubation: Comparison of two different doses of dexmedetomidine on intubation conditions in patients undergoing cervical spine surgery

Background and Aims: Awake fibre-optic intubation (AFOI) is an integral part of anaesthetic management of difficult airways. Conscious sedation is essential to assist AFOI. This study compared two different doses of dexmedetomidine in combination with topical spray and airway blocks for awake orotracheal fibre-optic intubation in patients undergoing elective cervical spine surgery with rigid cervical collar in situ. Methods: A randomized, prospective, comparative study design was conducted in sixty patients divided into two groups: Group (L) (n = 30) patients received low dose of dexmedetomidine (0.5 μg/kg) along with airway blocks and Group (H) (n = 30) patients received standard dose of dexmedetomidine (1 μg/kg) along with airway blocks. Both the groups received dexmedetomidine infusion over 10 min followed by airway block. Quantitative data were analysed by applying Student's t-test whereas qualitative data were analysed with Chi-square test. The objectives were to compare patients' Observer's Assessment of Alertness/Sedation scale (OAA/S) as primary outcome and other variables such as endoscopy, intubation condition, tolerance and haemodynamic stability among low and standard doses of dexmedetomidine. Results: Group H had more favourable OAA/S score than that of Group L, but endoscopy and intubation time, patient tolerance, vocal cord and limb movement and satisfaction score did not differ significantly between the groups. There were no significant haemodynamic differences between the two groups. Conclusion: The 0.5 μg/kg dose of dexmedetomidine was found optimal and effective in combination with topical spray and airway blocks for awake orotracheal fibre-optic intubation for patients undergoing elective cervical spine surgery

Impact of Pressure Control Ventilation and Volume Control Ventilation on oxygenation, pulmonary mechanics and haemodynamics during One Lung Ventilation in patients undergoing thoracic surgery: Arandomised controlled crossover study

Backgroud: Anaesthesia for thoracic surgery is nowadays performed with one lung ventilation (OLV) using volume control ventilation (VCV). Mechanical characteristics of pressure control ventilation (PCV) are thought to allow more homogenous distribution and improve oxygenation and reduce airway pressure so decrease chances of airway trauma and acute lung injury (ALI). This study was aimed to evaluate impact of two lung ventilation strategy (PCV/VCV) on oxygenation, pulmonary mechanics and haemodynamics during one lung ventilation in patient undergoing thoracic surgery.Method: After institutional ethical committee clearance this randomised single blind crossover study includes 30 patients of ASA I,II,III for elective thoracic surgery, using OLV and minimum duration of surgery of one hour were included in this study. Divided in two groups A and B using VCV first then PCV and vice versa. Haemodynamic parameters, ABG analysis and respiratory parameters were recorded, data collected and analysed by IBM SPSS statistics version 20.Results: Demographic, haemodynamic and ABG parameters were comparable in both groups higher Ppeak during VCV than PCV (p=0.004). Ppeak during OLV with VCV was significantly higher than during two lung ventilation (TLV) before starting OLV and end of the study (p&lt;0.05). Higher dynamic compliance in OLV – PCV group than OLV – VCV group (p&lt;0.001). Conclusion: PCV s a better ventilation mode than VCV in OLV with respect to reducing the incidence of barotrauma and ALI in patient undergoing elective thoracic surgery. Both modes are equivalent with respect to arterial oxygenation