Laryngomalacia

Laryngomalacia is the most common cause of stridor in neonates and infants. In laryngomalacia, there is a supraglottic collapse of the larynx during inspiration leading to obstruction and thus resulting in stridor. The exact etiology of laryngomalacia is still unknown. The neurological basis is one of the leading theories explaining the etiology. Laryngomalacia in most of the patients resolves with conservative management by two years of age. In severe cases of laryngomalacia or when symptoms are persistent beyond two years of age, such cases need surgical management in the form of supraglottoplasty. Flexible fibreoptic laryngoscopy is the gold standard for the diagnosis of laryngomalacia. Various classifications have been proposed to classify laryngomalacia, although considering dynamic airway changes might be the most acceptable basis for classification. Supraglottoplasty has higher success and a low complication rate

Accuracy of Sonographic Airway Parameters in Difficult Laryngoscopy Prediction: A Prospective Observational Cohort Study from Central India

Objective:Though airway ultrasonography (USG) is used to assess difficult laryngoscopy (DL), there is still ambiguity about approach followed and parameters assessed. There is need of a simple, stepwise sonographic assessment with clearly defined parameters for DL prediction. The primary objective of this study was to find diagnostic accuracy of sonographic parameters measured by a stepwise Airway-USG in DL prediction (DLP).Methods:This prospective, observational cohort study was done in 217 elective surgical adult patients administered general anaesthesia with tracheal intubation using conventional laryngoscopy from 1st May 2019 to 31st July 2020, after ethical approval. A sagittal Airway-USG was done using 2-6 Hz transducer in three steps specifying probe placement and head position. Demographic, clinical and Airway-USG measurements were noted. Correlation of the clinical/sonographic parameters was made with Cormack-Lehane score on DL. After receiver operating characteristic curve plotting, the sensitivity, specificity, positive predictive value, negative predictive value (NPV) of DL was calculated for each parameter using open-epi software.Results:DL was observed in 19/217 patients. Airway-USG parameters of skin to epiglottis distance >2.45 cm, hyomental distance with head extension 3.93 cm and maximum skin to tongue distance >5.45 cm were statistically significant in predicting DL. DLP score with presence of >3 positive parameters showed 98% specificity, 98% NPV and 96% diagnostic accuracy to predict DL.Conclusion:DLP score derived from Airway-USG may be used as a screening and diagnostic tool for DL

Spinal Shock: Clinical Pearls

Spinal shock is a clinical manifestation following injury to the spinal cord resulting from multiple mechanisms. It is a complex phenomenon with flaccid paralysis, absent anal wink, and bulbocavernosus reflex. Management strategy for such patients includes rapid evaluation and treatment strategies to minimize the impact of secondary spinal cord injury. The advanced trauma life support (ATLS) guidelines provide the basis for rapid assessment and stabilization of A (Airway), B (Breathing), and C (Circulation) before dealing with the neurological deficits under the primary survey. The emergence of better radiological investigations has been pivotal in categorizing spinal syndromes and reaching a precise diagnosis. Early initiation of treatment measures results in better neurological and functional recovery with minimal residual deficits. The role of steroids in spinal shock has been a highly debated topic, and the timing of surgery is variable, intending to eliminate the secondary injury. Clinical differentiation between neurogenic and hypovolemic shock is vital, enhancing the quality of care with realistic outcome expectations

Alpha 2 agonist dexmedetomidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block

Background: Regional anesthesia is a recommended technique for upper limb surgeries with better postoperative profile. Alpha-2 agonists are added to local anesthetic agents to extend the duration of nerve blocks. We evaluated the effect of combining dexmedetomidine with bupivacaine with respect to duration of motor and sensory block and duration of analgesia. Materials and Methods: Sixty patients posted for upper limb surgeries were enrolled for a prospective, randomized, study. Patients were divided into two groups, the control group B and the study group BD. In group B (n = 30), 30 ml of 0.325% bupivacaine + normal saline; and in group BD (n = 30), 30 ml of 0.325% bupivacaine +1μg/kg dexmedetomidine given ultrasound guided supraclavicular brachial plexus block. Results: The onset times for sensory and motor blocks were significantly shorter in BD than B group (p < 0.05), while the duration of sensory and motor blocks was significantly longer in BD group. The duration of analgesia was significantly longer in BD group than B group (p < 0.0001). SBP and DBP levels in BD group were significantly lower than in B group 20 min after block (p < 0.001). Bradycardia was observed in two patients in the group BD. Conclusion: Dexmedetomidine added as an adjuvant to bupivacaine for supraclavicular brachial plexus block significantly shortens the onset time and prolongs the duration of sensory and motor blocks and duration of analgesia. Patients in group BD were adequately sedated with no adverse effects except bradycardia in two patients

Study of the effect of intrathecal dexmedetomidine as an adjuvant in spinal anesthesia for Gynecological Surgery

Background: A randomized controlled study was designed to investigate the effects of addition of dexmetomedine to hyperbaric bupivacaine 0.5% for spinal anaesthesia in patients undergoing gynaecological surgeries, in terms of vital parameters, onset and duration of sensory andmotor block, intra and post operative pain and adverse effects. Methods: Sixty adult ASA Grade I and II patients were randomly divided equally in to dexmetomedine and control group. Control group received intrathecal 3.0 ml of 0.5% hyperbaric bupivacaine with 0.5 ml of normal saline and dexmetomedine group received identical volume of intrathecal dexmetomedine 5 μg with hyperbaric bupivacaine. Results: Mean time for post operative analgesia was significantly longer in dexmetomedine group (9.6 hours) than in the control group (3.55 hours). (p-value<0.01). Heart rate and blood pressure compared at 30 minute and 45 minute intervalswere significantly less in dexmetomedine group. (p-value< 0.05). Bradycardia and hypotension did not require any therapeutic intervention. Dexmetomedine group patients were found to be more sedated than control group. Conclusion: Adding dexmetomedine 5 μg to intrathecal bupivacaine prolongs the duration of spinal anaesthesia and analgesia. It is safe and is likely to be as effective as higher doses of bupivacaine without severe adverse effect

The analgesic efficacy of ultrasound-guided erector spinae plane block versus ultrasound-guided caudal epidural block for abdominal surgery in pediatric patients – A patient and assessor-blind, randomized controlled study

Background: Literature on the efficacy and safety of erector spinae plane block (ESPB) in pediatric patients is limited. Hence, we aimed to compare ESPB versus caudal epidural block (CEB) in children undergoing abdominal surgery. Methods: In this patient and assessor-blind study, fifty-two ASA I-II patients, between 1 to 9 years of age, were randomized into groups of 26 each. ESPB group received unilateral or bilateral ultrasound (USG)-guided ESPB with 0.5 ml/kg of 0.25% bupivacaine per side. CEB group received USG-guided CEB with 1 ml/kg of 0.25% bupivacaine. The primary objective was to estimate the proportion of patients requiring postoperative rescue analgesia. The secondary objectives were to assess postoperative Face, Legs, Activity, Cry and Consolability (FLACC) scale scores, duration of analgesia, and consumption of rescue analgesic drugs. Results: More patients in the ESPB group (88.4%), compared to the CEB group (42.3%), required rescue analgesics (P value <0.001). FLACC scores in the ESPB group, though satisfactory, were inferior, to the CEB group. The duration of postoperative analgesia was shorter in the ESPB group by 9.54 h (95% CI: 4.51 to 14.57 h, P value <0.001). The median (IQR) consumption of rescue paracetamol was significantly higher in the ESPB group (20 mg/kg (10,20) compared to the CEB group (0.0 mg/kg (0.0,10) P value <0.001)). No adverse effects were reported. Conclusion: In children undergoing abdominal surgery, both ESPB and CEB were safe and efficacious. CEB provided a longer duration and better quality of analgesia. ESPB may be considered when CEB is contraindicated or difficult

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)