Anaesthesiologist's service begins as a general physician, goes on as an investigator cum data analyser leading to the architectural planning of a forthcoming surgical event, but only after articulately convincing the subject along with his kith and kin. In the era of rapid developments in the field of medicine which includes relevant developments in anaesthetic care, an adequate work environment has to be provided to the anaesthesia team so that all anaesthetic procedures can be carried out safely and efficiently and an optimal workflow can be established in the operating room environment. Such ecological state demands an updated knowledge and ergonomics to aid him. Unfortunately, ergonomics is an area of anaesthesia that has received little attention and should be addressed through more education and training for workplace well-ness. Hence, an attempt is made to discuss few aspects on ergonomics for the interface between anaesthesiologist-machine-patient systems regarded as human-machine-system.

Background and Aims: Several devices enabling double-lumen tube (DLT) placement for thoracic surgeries are available, but there are no studies for D-blade video laryngoscope-guided DLT insertion. We compared the CMac D-blade videolaryngoscope™ and the Macintosh laryngoscope for DLT endobronchial intubation using parameters of time and attempts required for intubation, glottic view, incidence of complications and haemodynamic changes. Methods: Prospective, parallel group, randomised controlled clinical trial where sixty American Society of Anesthesiologists I and II patients aged 18-80 years scheduled for thoracic surgeries entailing DLT placement were randomly allocated in two groups based on the laryngoscopic device used for endobronchial intubation. Data were subjected to statistical analysis SPSS (version 17), the paired and Student's t-test for equality of means. Nominal categorical data between the groups were compared using Chi-squared test or Fisher's exact test as appropriate. P ˂ 0.05 was considered statistically significant. Results: Time required for intubation was comparable (37.41 ± 18.80 s in Group-M and 32.27 ± 11.13 s in Group-D). Number of attempts and incidence of complications (trauma, DLT cuff rupture, oesophageal intubation) was greater in the Macintosh group, except malpositioning into the wrong bronchus (easily rectified fibre-optic bronchoscopically), which was greater with the D-blade. Greater haemodynamic changes were observed during Macintosh laryngoscopy. Conclusion: D-blade videolaryngoscope™ is a useful alternative to the standard Macintosh laryngoscope for routine DLT insertion.

Background and Aims: Oropharyngeal colonisation followed by aspiration of contaminated secretions is the major cause for ventilator-associated pneumonia (VAP). Pooled secretions present in the sub-glottic area above inflated endotracheal tube cuff may be aspirated into the lower airways. It was hypothesised that intermittent suctioning of sub-glottic secretions would prevent VAP. Methods: Group I (n = 50) patients were intubated with HiLo Evac™ endotracheal (ET) tube with facility for sub-glottic suctioning, and Group II (n = 50) patients were intubated with HiLo Contour™ ET tube without such facility. In the Group I, sub-glottic suctioning was performed every 2 h. Incidence of VAP, mean ventilator days, Intensive Care Unit (ICU) stay and mortality were compared. Qualitative variables were reported as percentages and were compared by Chi-square test or unpaired two-tailed, Fisher's exact test, as appropriate, to analyse the significance of difference between the two groups. Results: The two groups were similar with respect to demographic characteristics. VAP was seen in 6% of patients in Group I and 22% of patients in Group II (P = 0.021). Both early- and late-onset VAPs were significantly reduced in Group I. Both ventilator days (8.0 vs. 6.45; P = 0.001) and ICU stay (8.33 vs. 6.33; P = 0.001) on the day of onset of VAP were significantly more in the Group I. Total ventilator days were significantly less (6.52 vs. 8.32; P = 0.006) with lower incidence of mortality (36% vs. 48%; P = 0.224) in the Group I. Conclusion: Intermittent sub-glottic suctioning reduces the incidence of VAP including late-onset VAP.

Background and Aims: Insufficient illumination of the oral cavity during endotracheal intubation may result in suboptimal conditions. Consequently, suboptimal illumination and laryngoscopy may lead to potential unwanted trauma to soft tissues of the pharyngeal mucosa. We investigated illumination of the oral cavity by different videolaryngoscopes (VLS) in a manikin model. Methods: We measured light intensity from the mouth opening of a Laerdal intubation trainer comparing different direct and indirect VLS at three occasions, resembling optimal to less-than-optimal intubation conditions; at the photographer's dark room, in an operating theatre and outdoors in bright sunlight. Results: Substantial differences in luminance were detected between VLS. The use of LED light significantly improved light production. All VLS produced substantial higher luminance values in a well-luminated environment compared to the dark photographer's room. The experiments outside-in bright sunlight-were interfered with by direct sunlight penetration through the synthetic material of the manikin, making correct measurement of luminance in the oropharynx invalid. Conclusion: Illumination of the oral cavity differs widely among direct and indirect VLS. The clinician should be aware of the possibility of suboptimal illumination of the oral cavity and the potential risk this poses for the patient.

Background and Aims: The conventional techniques of epidural space (EDS) identification based on loss of resistance (LOR) have a higher chance of complications, patchy analgesia and epidural failure, which can be minimised by objective confirmation of space before catheter placement. Acoustic puncture assist device (APAD) technique objectively confirms EDS, thus enhancing success, with lesser complications. This study was planned with the objective to evaluate the APAD technique and compare it to LOR technique for EDS identification and its correlation with ultrasound guided EDS depth. Methods: In this prospective study, the lumbar vertebral spaces were scanned by the ultrasound for measuring depth of the EDS and later correlated with procedural depth measured by either of the technique (APAD or LOR). The data were subjected to descriptive statistics; the concordance correlation coefficient and Bland-Altman analysis with 95% confidence limits. Results: Acoustic dip in pitch and descent in pressure tracing on EDS localisation was observed among the patients of APAD group. Analysis of concordance correlation between the ultrasonography (USG) depth and APAD or LOR depth was significant (r ≥ 0.97 in both groups). Bland-Altman analysis revealed a mean difference of 0.171cm in group APAD and 0.154 cm in group LOR. The 95% limits of agreement for the difference between the two measurements were − 0.569 and 0.226 cm in APAD and − 0.530 to 0.222 cm in LOR group. Conclusion: We found APAD to be a precise tool for objective localisation of the EDS, co-relating well with the pre-procedural USG depth of EDS.

Background and Aims: GlideScope video laryngoscope (GVL) and intubating laryngeal mask airway (I-LMA) may be used to facilitate intubation and secure the airway in patients with normal and abnormal airways. The aim of this study was to evaluate whether (GVL) and (I-LMA) facilitate and improve the tracheal intubation success rate and could be learned and performed easily by paramedic students when compared with Macintosh direct laryngoscopy (DL). Methods: This study was a prospective, randomised crossover trial that included 100 paramedic students. Macintosh DL, I-LMA and GVL were tested in both normal and difficult airway scenarios. Each participant was allowed up to three intubation attempts with each device, in each scenario. The time required to perform tracheal intubation, the success rate, number of intubation attempts and of optimisation manoeuvres and the severity of dental trauma were recorded. Statistical analysis was performed using Chi-square, one-way ANOVA, or Kruskal-Wallis test as appropriate, followed by post hoc test. Results: GVL and I-LMA required less time to successfully perform tracheal intubation, showed a greater success rate of intubation, reduced the number of intubation attempts and optimization manoeuvres required and reduced the severity of dental trauma compared to Macintosh DL in both normal and difficult airway scenarios. Conclusion: GVL and I-LMA provide better airway management than Macintosh DL in both normal and difficult airway scenarios.

Background and Aims: Air-Q intubating laryngeal mask airway (ILA) is used as a supraglottic airway device and as a conduit for endotracheal intubation. This study aims to assess the efficacy of the Air-Q ILA regarding ease of insertion, adequacy of ventilation, rate of successful intubation, haemodynamic response and airway morbidity. Methods: Sixty patients presenting for elective surgery at our Medical College Hospital were selected. Following adequate premedication, baseline vital parameters, pulse rate and blood pressure were recorded. Air-Q size 3.5 for patients 50-70 kg and size 4.5 for 70-100 kg was selected. After achieving adequate intubating conditions, Air-Q ILA was introduced. Confirming adequate ventilation, appropriate sized endotracheal tube was advanced through the Air-Q blindly to intubate the trachea. Placement of the endotracheal tube in trachea was confirmed. Results: Air-Q ILA was successfully inserted in 88.3% of patients in first attempt and 11.7% patients in second attempt. Ventilation was adequate in 100% of patients. Intubation was successful in 76.7% of patients with Air-Q ILA. 23.3% of patients were intubated by direct laryngoscopy following failure with two attempts using Air-Q ILA. Post-intubation the change in heart rate was statistically significant (P < 0.0001). 10% of patients were noted to have a sore throat and 5% of patients had mild airway trauma. Conclusion: Air-Q ILA is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation. It benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway.

Pompe disease (PD) is a type II glycogen storage disease, characterised by abnormal glycogen deposition, mainly in heart and skeletal muscles, leading to progressive loss of muscle function. The infantile variety is associated with severe hypertrophic cardiomyopathy and generally do not reach adulthood. The juvenile variety presents with progressive muscle weakness and respiratory failure. Anaesthetic management concerns in the patient reported here were mainly due to respiratory failure, myopathy and sensitivity to muscle relaxants and significant haemodynamic changes perioperatively. We successfully managed a 13-year-old girl with juvenile PD on respiratory support scheduled for thoracolumbar kyphoscoliosis corrective surgery. Ketamine and dexmedetomidine were used for induction of anaesthesia and maintenance. Muscle relaxants were diligently avoided in this case.

Cerebral venous thrombosis (CVT) is a rare complication of lumbar puncture. Occasionally, the clinical picture of CVT may mimic post-dural puncture headache (PDPH) resulting in delayed diagnosis. A case of PDPH progressing to CVT is presented and the pathophysiology, diagnostic challenges and management options discussed in this article.