Anaesthetic management in a case of large plunging ranula with difficult airway: A case report

AbstractPlunging ranula is a mucous retention cyst found on the floor of mouth which arises from the submandibular and sublingual salivary glands extending to lateral aspect of neck, which may often cause potential airway obstruction leading to difficulty in airway management. A forty year old female patient was admitted to our hospital with large, painless swelling in the floor of mouth extending to the lateral part of body of mandible and neck. This intraoral swelling distorted the normal airway anatomy thus making airway management difficult as the patient was planned for excision of swelling under general anaesthesia. So we present a case of successful management of a difficult airway by using awake fibre optic intubation in a patient posted for excision of a large plunging ranula under general anaesthesia

COMPARISON OF PREDICTORS OF DIFFICULT INTUBATION

Context: Unanticipated difficult laryngoscopy and tracheal intubation always remain a primary concern for an anaesthesiologist as the failure to maintain a patent airway during induction of anaesthesia may lead to anaesthesia related morbidity and mortality. Aims: The aim of our study was to predict difficult intubation and to identify best predictor(s) among them and also to compare the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of various airway parameters.Airway parameters taken in our study were Modified Mallampati Classification (MMT), Thyromental Distance (TMD), Sternomental Distance (SMD), Interincisor Gap (IIG), Upper Lip Bite Test (ULBT), Degree of Neck Extension (DNE), Anterior Subluxation of Mandible (ASM) and Protruding Teeth (PT). Methods and Material: 350 patients of ASA Grade 1 and 2 scheduled for various elective surgeries under general anaesthesia were included in our study and were assessed preoperatively for different airway parameters. Intraoperatively all patients were classified as difficult and easy intubation group according to Cormack and Lehane laryngoscopic view. Clinical data of each test was collected, tabulated and analyzed to obtain the sensitivity, specificity, positive predictive value and negative predictive value. Results: The upper lip bite test had the highest sensitivity (80%); Anterior subluxation of mandible had highest specificity (99.06%) and both of above were most accurate tests. The overall incidence of difficult intubation was 8.57%. Conclusion: Upper lip bite test was the best predictor of difficult intubation and it should be included as a routine test along with Modified mallampati test in preanaesthetic evaluation

COMPARISON OF PREDICTORS OF DIFFICULT INTUBATION

Context: Unanticipated difficult laryngoscopy and tracheal intubation always remain a primary concern for an anaesthesiologist as the failure to maintain a patent airway during induction of anaesthesia may lead to anaesthesia related morbidity and mortality. Aims: The aim of our study was to predict difficult intubation and to identify best predictor(s) among them and also to compare the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of various airway parameters.Airway parameters taken in our study were Modified Mallampati Classification (MMT), Thyromental Distance (TMD), Sternomental Distance (SMD), Interincisor Gap (IIG), Upper Lip Bite Test (ULBT), Degree of Neck Extension (DNE), Anterior Subluxation of Mandible (ASM) and Protruding Teeth (PT). Methods and Material: 350 patients of ASA Grade 1 and 2 scheduled for various elective surgeries under general anaesthesia were included in our study and were assessed preoperatively for different airway parameters. Intraoperatively all patients were classified as difficult and easy intubation group according to Cormack and Lehane laryngoscopic view. Clinical data of each test was collected, tabulated and analyzed to obtain the sensitivity, specificity, positive predictive value and negative predictive value. Results: The upper lip bite test had the highest sensitivity (80%); Anterior subluxation of mandible had highest specificity (99.06%) and both of above were most accurate tests. The overall incidence of difficult intubation was 8.57%. Conclusion: Upper lip bite test was the best predictor of difficult intubation and it should be included as a routine test along with Modified mallampati test in preanaesthetic evaluation

A comparative study between ProSeal laryngeal mask airway and endotracheal tube for ease of insertion and haemodynamic changes in patients undergoing laparoscopic cholecystectomy under general anaesthesia

Background: The endotracheal tube is considered a gold standard for providing a safe and effective glottic seal, especially for laparoscopic procedures under general anaesthesia. However, haemodynamic pressor responses associated with its use might be detrimental. The ProSeal LMA minimizes this response without compromising the airway with lesser incidence of complications. The aim of this study was to compare ProSeal LMA and Endotracheal tube with respect to intra-operative haemodynamic responses and ease of insertion of device and nasogastric tube in patients undergoing laparoscopic surgeries under general anaesthesia.Methods: This prospective randomized study was conducted on sixty patients, aged 20-60 years; of ASA grade 1 or 2, 30 in each group, posted for laparoscopic cholecystectomy under general anaesthesia. After induction with propofol and neuromuscular blockade with rocuronium, PLMA or ETT was inserted. The haemodynamic responses and insertion time of device and nasogastric tube were noted. Postoperative complications, if any were also noted.Results: The mean time of insertion of PLMA was 37.40±16.09 seconds and for intubation (ETT) was 31.17±20.89 seconds which was statistically not significant (P >0.05). The mean time of insertion of nasogastric tube was 18.84±6.84 seconds in PLMA group and 73.00±71.06 seconds in the ETT group which was highly significant, (P 0.05).Conclusions: ProSeal LMA proved to be a suitable alternative to endotracheal tube for airway management with stable haemodynamics in patients undergoing laparoscopic cholecystectomy under general anaesthesia

A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block

Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A (n = 25) received ultrasound guided FNB and Group B (n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable (P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) (P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) (P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB

Pre-emptive Analgesic Efficacy of Low Dose Ketamine versus Magnesium Sulfate in Patients undergoing Major Abdominal Surgeries under General Anaesthesia: A Randomised Clinical Study

Introduction: Pre-emptive analgesia has been proposed to result in better pain management, reduced analgesic consumption, and improved patient satisfaction. Aim: To evaluate pre-emptive analgesic efficacy of intravenous ketamine and intravenous magnesium sulfate in patients undergoing major abdominal surgeries under general anaesthesia by administering it 10 minutes before the incision. Materials and Methods: This randomised, double-blind, clinical study, was conducted in JLN Medical College, Ajmer, Rajasthan, India, from November 2019 to November 2020. The study included 100 patients, aged 18-60 years of American Society of Anaesthesiologist (ASA) physical status I and II were randomly allocated into two groups. Group K (n=50) received intravenous (i.v.) ketamine infusion 0.3 mg/kg in 100 mL normal saline over 10 minutes. Group M (n=50) received i.v. magnesium sulfate (MgSO4) infusion 30 mg/kg in 100 mL normal saline over 10 minutes. The duration of analgesia, total amount of rescue analgesic consumed in 24 hours, haemodynamics, and side-effects were noted. The quantitative data was presented as mean±standard deviation and were compared by student’s t-test. Results: Duration of analgesia was significantly prolonged in group K (67.96±9.20 min) as compared to group M (30.60±6.44 min) (p-value <0.001). The total dose of rescue analgesic consumption in 24 hours was lesser in group K (1180±388.09) as compared to group M (1280±453.56) (p-value=0.236). Haemodynamics and side-effect profile were comparable in the two groups. Conclusion: In major abdominal surgeries under general anaesthesia, patients getting ketamine had longer duration of analgesia compared to magnesium sulfate, had an improved quality of recovery after surgery and less serious adverse events in the Postanaesthesia Care Unit (PACU). Ketamine reduces the need for intraoperative opioids and could suppress the pressure response to endotracheal intubation

A comparative clinical study of intrathecal bupivacaine 2.5 mg with dexmedetomidine 5 μg versus intrathecal bupivacaine 2.5 mg with fentanyl 25 μg on the duration of labor analgesia using combined spinal epidural technique

Context: Adjuvants may be added to decrease motor blockade caused by intrathecal bupivacaine and prolong labor analgesia. Aim: To study the effect of intrathecal dexmedetomidine versus fentanyl when added to bupivacaine on the duration of labor analgesia, progress of labor, block characteristics, and side effects. Settings and Design: A prospective, randomized double-blind study. Materials and Methods: Sixty parturients consenting for labor analgesia were divided into two groups. Group A (n = 30) received an intrathecal 0.5% hyperbaric bupivacaine 2.5 mg and dexmedetomidine 5 μg and Group B (n = 30) received an intrathecal 0.5% hyperbaric bupivacaine 2.5 mg and fentanyl 25 μg. Partogram, visual analog score, sensory and motor blockage, progress of labor, maternal hemodynamic variations, and fetal heart rate were noted. Statistical Analysis Used: Standard qualitative and quantitative tests were used to compare data (e.g., unpaired student t-test, ANOVA, Chi-square); P value of 0.05 was considered significant. Results: Duration of labor analgesia was significantly greater in Group A as compared to Group B (254.17 ± 4.75 min vs. 123.67 ± 6.01 min, P 0.05)

A comparison of postoperative analgesic efficacy of opioid-free anesthesia using intravenous paracetamol (15 mg/kg), lignocaine (2 mg/kg), and magnesium sulfate (20 mg/kg) versus standard opioid anesthesia using intravenous tramadol (2 mg/kg) for preemptive analgesia in abdominal surgeries under general anesthesia

INTRODUCTION: Pain is an unpleasant sensory and emotional experience and is considered the fifth vital sign. Opioid-free anesthesia (OFA) is a technique where no intraoperative systemic, neuraxial, or intracavitary opioids are administered during the anesthesia. The prescription misuse/overuse has generated an opioid crisis which has led to the need for OFA. In this study, we will investigate the 24-h postsurgical analgesia and analgesic consumption with the use of OFA versus opioid anesthesia (tramadol) in patients undergoing abdominal surgery under general anesthesia. METHODOLOGY: Sixty patients of the American Society of Anesthesiologists Grade I-II scheduled for various abdominal surgeries were randomly assigned into two groups, with 30 patients in each group. Group A (opioid-free group): received IV lignocaine (2 mg/kg), IV magnesium sulfate (20 mg/kg), and V paracetamol (15 mg/kg) in 100 ml NS. Group B (opioid group): received IV tramadol (2 mg/kg) in 100 ml NS. Hemodynamic parameters, postoperative analgesic consumption, duration of analgesia, and any adverse effects were recorded. RESULTS: A very significant difference was observed between the study groups for mean values of mean arterial pressure at the last stages of surgery, with hemodynamics more stable in the opioid-free group (P < 0.01). In terms of mean values of minimum alveolar concentration throughout the surgery, the opioid group showed more anesthetic-sparing effect (P < 0.05). In terms of postoperative pain scores between the groups, the opioid-free group experienced less pain (P < 0.01). There was no difference between the groups in postoperative analgesic consumption and duration of analgesia. More side effects were noted in the opioid group. CONCLUSION: This study concludes that avoiding opioid use by preemptive administration of intravenous paracetamol, lignocaine, and magnesium sulfate provides safe, effective, and satisfactory analgesia in patients undergoing various abdominal surgeries under general anesthesia

Effectiveness of norepinephrine versus phenylephrine intravenous boluses for the treatment of hypotension in elective lower-segment cesarean section under spinal anesthesia: A randomized controlled, double-blind study

Background and Aim: Hypotension following spinal anesthesia is a common adverse effect during caesarean sections, with potentially harmful consequences for both the mother and the fetus. While phenylephrine is the current first-line treatment for maternal spinal hypotension during obstetric anesthesia, norepinephrine has been proposed as a possible alternative due to its weaker β-agonist-mediated positive chronotropic action. However, there is a lack of comparative data on the safety and efficacy of these two drugs in obstetric anesthesia. This study aimed to compare the number of bolus doses of phenylephrine and norepinephrine required to treat hypotension after spinal anesthesia in lower segment caesarean sections, as well as to evaluate maternal and fetal outcomes in both groups, including complications. Materials and Method: A prospective double-blinded randomized controlled trial was conducted, The study included 60 term parturients between the ages of 18 and 40, who had singleton pregnancy and were categorized as American Society of Anaesthesiologists (ASA) physical class II, and who were scheduled for elective caesarean section under spinal anesthesia. the parturients were randomized into two groups: Group N and Group P. Group P patients received an intravenous dose of phenylephrine 100 μg, while Group N patients received an intravenous dose of 8 μg whenever the systolic arterial pressure dropped below 20% of the baseline.primary objective was number of intravenous drugs required to treat spinal hypotension, secondary objective were incidence of maternal and foetal Complications. The data was collected on a form and entered into Excel. Statistical analysis was done using Epi Info 7.2.1.0 for Windows. The Kolmogorov-Smirnov test was used to check normality. Mean and standard deviation or median and range were used to present numerical data, while frequency and percentage were used for categorical data. T-tests compared quantitative variables, and Chi-square tests compared categorical data. Two-tailed tests were used, and a P-value of <0.05 was considered significant. Result: The patient's demographic profile was comparable in both groups.T he number of bolus doses of study drug required to treat spinal hypotension was significantly lower in Group N versus P (1.50 ± 0.57 vs. 2.13 ± 0.73, p =0.001)Incidence of bradycardia was more in group P, but not statistically significant. Other maternal complications like bradycardia, hypertension, nausea, vomiting, shivering were comparable in both groups. Conclusions: According to our study, Intermittent boluses of norepinephrine were effective in the management of spinal-induced hypotension during caesarean section. Norepinephrine boluses can thus be considered as an alternative to phenylephrine boluses

Post-operative analgesic efficacy of 0.25% ropivacaine with dexmedetomidine versus dexamethasone as an adjuvant in bilateral superficial cervical plexus block for thyroidectomy under general anaesthesia - A comparative randomized clinical study

Background and Aims: The bilateral superficial cervical plexus block (BSCPB) is efficacious for post-operative analgesia in thyroid surgeries. We assessed the analgesic efficacy of dexmedetomidine and dexamethasone administered as adjuvants with 0.25 percent ropivacaine in BSCPB for thyroidectomy under general anaesthesia with regard to the duration of analgesia, total amount of rescue analgesic requirement, changes in intra- and post-operative haemodynamic parameters, VAS scores, and adverse events, if any. Methods: A prospective double-blind trial was planned with 80 adults undergoing thyroidectomy, randomized into two equal groups and given BSCPB with 20 ml 0.25% ropivacaine with adjuvants as either dexmedetomidine 50μg (group A) or dexamethasone 4mg (group B), 10 ml on each side, after the induction of general anaesthesia. Post-operative pain was monitored using the visual analog scale and the duration of analgesia was measured by time to first rescue analgesia. Post-operative haemodynamics and any adverse events were recorded. Results: The mean duration of analgesia was slightly prolonged in group A but statistically non-significant as compared to group B (1037 ± 97 vs. 1004 ± 122 minutes; P0.18). The post-operative median VAS scores and vital parameters were relatively comparable for both groups (P > 0.05) for the first 24h. There was a significant reduction in the incidence of PONV (P < 0.05) in group B. Conclusion: Although dexamethasone offers a slight advantage of decreased incidence of PONV, BSCPB using ropivacaine with either dexmedetomidine or dexamethasone as an adjuvant imparted adequate analgesia with stable haemodynamics and may be used as a pre-emptive analgesic technique in thyroid surgeries