Comparison of upper lip bite test with Mallampati test in the prediction of difficult intubation at a tertiary care hospital of Pakistan

Objective: To determine the accuracy of the Upper lip bite test and Mallampati test in predicting difficult endotracheal intubation.Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, a tertiary care facility in Karachi, Pakistan. Between June 1,2007 and May 31, 2008, 324 adult patients undergoing elective surgeries requiring general anaesthesia with endotracheal intubations were enrolled. Pre-operatively upper lip bite test and Mallampati test were performed for the assessment of airway by a specifically trained observer. Laryngoscopic view was rated by using Cormack and Lehane laryngoscopic grading once the patient was fully anaesthetised using standard anaesthesia technique. Completed data sheets were analysed using SPSS version 10. McNemar test and rank correlation coefficient were used to compare the upper lip bite test and the Mallampati test.Results: Of the 324 patients, 56 (17.3%) were classified as cases of difficult intubation. Upper lip bite test showed significantly higher accuracy, positive predictive value and negative predictive value than the Mallampati test. Comparison of specificity, however, did not reveal any significant difference between the two tests.CONCLUSION: Upper lip bite test is an acceptable alternative as a single test to predict difficult intubation in addition to other tests of airway assessment for the prediction of difficult intubation

Emergency airway management of a patient with tracheal stenosis

We are presenting a case of a 26 year old healthy male, who came with gradual worsening of dyspnoea following prolonged intubation and ventilation, after a road traffic accident five months back. On arrival in ER, he was hypoxaemic with severe respiratory distress. He was transferred to the operation room (OR) for emergency tracheostomy. During the transfer, he was placed in an upright position with oxygen at 15 L/M. In the OR, anaesthesia was induced with sevoflurane gradually. Direct laryngoscopy was done which revealed normal vocal cords. A size 4.00 mm ID endotracheal tube was impossible to pass more than 1-2 cm distal to vocal cords. Due to a large leak, size 8 tube was passed below the cords and cuff was inflated slightly to reduce air leak. Oxygen saturation dropped to 95-96% and surgeon was asked to start tracheostomy. Findings included an almost complete subglottic stenosis, 2 cm below the vocal cords. A tracheostomy tube was inserted below the stenotic lesion which was followed by direct laryngoscopy

Effectiveness of premature epidural catheter termination as a quality indicator in a developing country

Background And Objective: Premature epidural catheter termination in the postoperative period is a common cause of epidural analgesia failure. The incidence varies from 5.7 to 13%. A higher incidence of unplanned epidural catheter termination was observed in our hospital. We took this as a quality improvement project, monitored the causes and applied remedial measures at the same time to reduce the incidence. Method: An audit was conducted by the Acute Pain Service between January 2004 and December 2007 to find the incidence and different causes of accidental epidural catheter pullout. Different strategies were applied simultaneously to counter the identified causes. A predesigned pro forma was used for audit while remedial measures included change in practice, counselling of the person responsible, group teaching and reinforcement of epidural care policy. Results: The overall incidence of premature epidural termination was 3.9% during a 4-year period with a higher incidence in 2004 (5.59%), which was reduced in later years. The main reason for premature epidural catheter removal was mishandling of the catheter and filter (64%). The most common site for catheter disconnection was found to be at the filter end of the catheter (54.7%), although 39 (61%) epidural catheters were removed by the Acute Pain Service following disconnection or breakage to avoid danger of infection. Conclusion: Identification of premature epidural catheter termination as a quality indicator and continuous quality improvement efforts later on proved to be a useful approach in reducing the incidence. The present audit also helped to quantify the improvement in the quality of care

Haemodynamic response of intravenous tramadol and intravenous morphine during laryngoscopy and endotracheal intubation

Objective: To compare the haemodynamic response of equipotent analgesic doses of morphine and tramadol to laryngoscopy and endotracheal intubation.Methods: A randomized double blind study of eighty ASA 1 and ASA II patients, age 18-50 years for elective surgery requiring endotracheal intubation was conducted. Forty patients were selected for each group, M (morphine) and T (tramadol). All patients received study drug three minutes prior to induction of anaesthesiaResults: Mean heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) between the groups and within the groups from base line and from preintubation period was significantly (p\u3c0.05)different at different time intervals.. When compared from base line maximum increase in heart rate in group M and T was 11.86% and 28.92% and maximum decrease was 12.08% and 1.43% respectively. Mean maximum increase in SBP was 8.06% in group T. Decrease was 18%and 10.48% in group M and T respectively. Maximum increase and decrease in DBP and MAP follow the same pattern and increase in blood pressures remained below 15% of the baseline value.CONCLUSION: Morphine is a better drug as compared to tramadol for attenuation of laryngoscopy and endotracheal intubation response