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

Antiulcer Potential of the Ethanolic Extract of Aerva Persica Merrill Root in Rats

AbstractThe ethanol extract of the roots of Aerva persica (Burm f) Merrill (Amaranthaceae) was investigated to determine its antiulcer and in vivo antioxidant activities in albino Wistar rats. Ulcers were induced by ethanol and pylorus ligation. The extract was administered at the dose of 200mg/kg orally, p.o. for 15 consecutive days. The ulcer index of the ethanol extract was found to be significantly reduced compared with control animals. The effect was also assessed by determining the free acidity, pepsin activity, total carbohydrate (TC), and protein content (PK) in control, standard, and test group animals. The in vivo antioxidant activity was evaluated by determining the reduced glutathione level (GSH) and malondialdehyde (MDA) level in the tissue homogenates. The results reveal the significant reduction in the level of malondialdehyde and the increase in the level of reduced glutathione in the rats that received the ethanolic extract. Furthermore, histopathological studies have shown that pretreatment with the ethanolic extract of the roots of A persica reduces (100%) ethanol- and pylorus ligation-induced hemorrhagic necrosis in rats

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 Practitioner’s Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel

Aim To develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner’s toolkit for insulin motivation in the management of diabetes mellitus (DM). Background Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization. Review Results After review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy. Conclusions In the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals

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

Numerična analiza sistema dvostopenjskega ejektorja-difuzorja na osnovi konstantne hitrosti sprememb kinetične energije

Supersonic ejector energy flow devices are extensively used in various applications, such as pumping, mixing, compression, etc. The conventional single-stage ejector (SSE) design approaches are inefficient for modelling an efficient ejector because of their inefficiency in minimizing mixing losses in the mixing chamber, thermodynamic shock in constant area diffuser, and utilization of redundant discharged momentum at the exit of the first stage. The physics-based single-stage ejector design has better solutions because it minimizes irreversibility due to thermodynamic shocks. The present study utilizes the constant rate of a kinetic energy change physics-based approach to design a two-stage ejector (TSE) for water vapour. The computational fluid dynamics (CFD) tool ANSYS-Fluent has been utilized to predict flow characteristics. The performance of the ejector-diffuser system has also been compared with a single-stage ejector. It is found that the performance of TSE is 70 % higher than that of the performance of SSE

An unanticipated difficult airway in Lesch–Nyhan syndrome

An 11-year-old boy with Lesch–Nyhan syndrome presented to the emergency for fixation of a fractured femur. During induction of general anesthesia, unexpected difficult intubation was encountered with a 6.5-mm ID endotracheal tube and successively smaller tubes, also failing to pass 1 cm beyond the vocal cords. Intubation was finally achieved with a 4.5-mm ID tube. The surgery was completed uneventfully. A tracheal diverticulum was found in the computerized tomography (CT) scan performed postoperatively to account for this unexpected difficult intubation. This case highlights the anesthetic concerns in Lesch-Nyhan syndrome and also reports the rare occurrence of a tracheal diverticulum associated with it

A prospective randomized study for comparison of onset time of intubation and intubating conditions using rocuronium with priming and without priming

Background: Rocuronium, a non-depolarizing neuromuscular blocking agent, with priming, can be used as an alternative to succinylcholine for rapid sequence intubation because it produces rapid onset of intubation with comparable intubating conditions. We aimed to compare the onset time of intubation and intubating conditions using rocuronium with priming and without priming. Methods: Sixty adult patients of either sex, aged 18-60 years, ASA grade I and II, scheduled for various elective surgeries under general anaesthesia were randomly allocated into two groups (30 patients in each group). Group P received 0.06 mg/kg of rocuronium as priming dose and Group C received normal saline as placebo before induction. The patients in both groups received fentanyl 1.5 µg/kg and induced with propofol 2.5 mg/kg. The intubating dose of rocuronium 0.54 mg/kg for Group P and 0.6 mg/kg for Group C were given after 3 min of priming. The time interval between the intubating dose and the loss of T1 of TOF stimuli was considered as the onset time of intubation and Cooper’s scoring system was used to compare the intubating conditions. Results: The onset time of intubation was significantly shorter (P &lt;0.05) in group P (54.87 ± 3.75 sec) than group C (94.37 ± 3.52 sec). Intubating conditions were found to be excellent in both the groups with no any adverse effects. Conclusion: Rocuronium (0.6 mg/kg) with priming provides rapid onset time of intubation (&lt;60 sec) along with excellent intubating conditions without any adverse effects which may be particularly useful for rapid sequence intubation and where succinylcholine is contraindicated