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  Access statistics : Table of Contents
   2016| December  | Volume 60 | Issue 12  
    Online since December 9, 2016

 
 
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GUIDELINES
All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults
Sheila Nainan Myatra, Amit Shah, Pankaj Kundra, Apeksh Patwa, Venkateswaran Ramkumar, Jigeeshu Vasishtha Divatia, Ubaradka S Raveendra, Sumalatha Radhakrishna Shetty, Syed Moied Ahmed, Jeson Rajan Doctor, Dilip K Pawar, Singaravelu Ramesh, Sabyasachi Das, Rakesh Garg
December 2016, 60(12):885-898
DOI:10.4103/0019-5049.195481  PMID:28003690
The All India Difficult Airway Association (AIDAA) guidelines for management of the unanticipated difficult airway in adults provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in adults. They have been developed based on the available evidence; wherever robust evidence was lacking, or to suit the needs and situation in India, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. We recommend optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful. Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available. We recommend no more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95%. Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended. If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation. Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes 'complete ventilation failure', and emergency cricothyroidotomy should be performed. Patient counselling, documentation and standard reporting of the airway difficulty using a 'difficult airway alert form' must be done. In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.
  44,343 9,984 6
All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics
Venkateswaran Ramkumar, Ekambaram Dinesh, Sumalatha Radhakrishna Shetty, Amit Shah, Pankaj Kundra, Sabyasachi Das, Sheila Nainan Myatra, Syed Moied Ahmed, Jigeeshu Vasishtha Divatia, Apeksh Patwa, Rakesh Garg, Ubaradka S Raveendra, Jeson Rajan Doctor, Dilip K Pawar, Singaravelu Ramesh
December 2016, 60(12):899-905
DOI:10.4103/0019-5049.195482  PMID:28003691
The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus). Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA). Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H 2 O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD) or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO 2 should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.
  36,831 4,129 -
All India Difficult Airway Association 2016 guidelines for the management of anticipated difficult extubation
Pankaj Kundra, Rakesh Garg, Apeksh Patwa, Syed Moied Ahmed, Venkateswaran Ramkumar, Amit Shah, Jigeeshu Vasishtha Divatia, Sumalatha Radhakrishna Shetty, Ubaradka S Raveendra, Jeson R Doctor, Dilip K Pawar, Ramesh Singaravelu, Sabyasachi Das, Sheila Nainan Myatra
December 2016, 60(12):915-921
DOI:10.4103/0019-5049.195484  PMID:28003693
Extubation has an important role in optimal patient recovery in the perioperative period. The All India Difficult Airway Association (AIDAA) reiterates that extubation is as important as intubation and requires proper planning. AIDAA has formulated an algorithm based on the current evidence, member survey and expert opinion to incorporate all patients of difficult extubation for a successful extubation. The algorithm is not designed for a routine extubation in a normal airway without any associated comorbidity. Extubation remains an elective procedure, and hence, patient assessment including concerns related to airway needs to be done and an extubation strategy must be planned before extubation. Extubation planning would broadly be dependent on preventing reflex responses (haemodynamic and cardiovascular), presence of difficult airway at initial airway management, delayed recovery after the surgical intervention or airway difficulty due to pre-existing diseases. At times, maintaining a patent airway may become difficult either due to direct handling during initial airway management or due to surgical intervention. This also mandates a careful planning before extubation to avoid extubation failure. Certain long-standing diseases such as goitre or presence of obesity and obstructive sleep apnoea may have increased chances of airway collapse. These patients require planned extubation strategies for extubation. This would avoid airway collapse leading to airway obstruction and its sequelae. AIDAA suggests that the extubation plan would be based on assessment of the airway. Patients requiring suppression of haemodynamic responses would require awake extubation with pharmacological attenuation or extubation under deep anaesthesia using supraglottic devices as bridge. Patients with difficult airway (before surgery or after surgical intervention) or delayed recovery or difficulty due to pre-existing diseases would require step-wise approach. Oxygen supplementation should continue throughout the extubation procedure. A systematic approach as briefed in the algorithm needs to be complemented with good clinical judgement for an uneventful extubation.
  12,748 3,645 -
All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in Paediatrics
Dilip K Pawar, Jeson Rajan Doctor, Ubaradka S Raveendra, Singaravelu Ramesh, Sumalatha Radhakrishna Shetty, Jigeeshu Vasishtha Divatia, Sheila Nainan Myatra, Amit Shah, Rakesh Garg, Pankaj Kundra, Apeksh Patwa, Syed Moied Ahmed, Sabyasachi Das, Venkateswaran Ramkumar
December 2016, 60(12):906-914
DOI:10.4103/0019-5049.195483  PMID:28003692
The All India Difficult Airway Association guidelines for the management of the unanticipated difficult tracheal intubation in paediatrics are developed to provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in children between 1 and 12 years of age. The incidence of unanticipated difficult airway in normal children is relatively rare. The recommendations for the management of difficult airway in children are mostly derived from extrapolation of adult data because of non-availability of proven evidence on the management of difficult airway in children. Children have a narrow margin of safety and mismanagement of the difficult airway can lead to disastrous consequences. In our country, a systematic approach to airway management in children is lacking, thus having a guideline would be beneficial. This is a sincere effort to protocolise airway management in children, using the best available evidence and consensus opinion put together to make airway management for children as safe as possible in our country.
  11,218 3,319 2
The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit
Sheila Nainan Myatra, Syed Moied Ahmed, Pankaj Kundra, Rakesh Garg, Venkateswaran Ramkumar, Apeksh Patwa, Amit Shah, Ubaradka S Raveendra, Sumalatha Radhakrishna Shetty, Jeson Rajan Doctor, Dilip K Pawar, Singaravelu Ramesh, Sabyasachi Das, Jigeeshu Vasishtha Divatia
December 2016, 60(12):922-930
DOI:10.4103/0019-5049.195485  PMID:28003694
Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.
  9,042 2,845 3
GUEST EDITORIAL
Airway management guidelines: A safe passage to India
Venkateswaran Ramkumar, Jigeeshu Vasishtha Divatia
December 2016, 60(12):883-884
DOI:10.4103/0019-5049.195480  PMID:28003689
  3,112 3,162 1
EDITORIAL
The Indian Journal of Anaesthesia: The timeline never ceases
S Bala Bhaskar
December 2016, 60(12):881-882
DOI:10.4103/0019-5049.195479  PMID:28003688
  1,913 4,013 -
ORIGINAL ARTICLES
Comparison of caudal and intravenous dexamethasone as adjuvants for caudal epidural block: A double blinded randomised controlled trial
Bharath Srinivasan, Rakesh Karnawat, Sadik Mohammed, Bharat Chaudhary, Anil Ratnawat, Sunil Kumar Kothari
December 2016, 60(12):948-954
DOI:10.4103/0019-5049.195489  PMID:28003698
Background and Aims: Dexamethasone has a powerful anti-inflammatory action with significant analgesic benefits. The aim of this study was to compare the efficacy of dexamethasone administered through intravenous (IV) and caudal route on post-operative analgesia in paediatric inguinal herniotomy patients. Methods: One hundred and five paediatric patients undergoing inguinal herniotomy were included and divided into three groups. Each patient received a single caudal dose of ropivacaine 0.15%, 1.5 mL/kg combined with either corresponding volume of normal saline (Group 1) or caudal dexamethasone 0.1 mg/kg (Group 2) or IV dexamethasone 0.5 mg/kg (Group 3). Baseline, intra- and post-operative haemodynamic parameters, pain scores, time to rescue analgesia, total analgesic consumption and adverse effects were evaluated for 24 h after surgery. Unpaired Student's t-test and analysis of variance were applied for quantitative data and Chi-square test for qualitative data. Time to first analgesic administration was analysed by Kaplan-Meier survival analysis and log-rank test. Results: Duration of analgesia was significantly longer (P < 0.001), and total consumption of analgesics was significantly lower (P < 0.001) in Group II and III compared to Group I. The incidence of nausea and vomiting was higher in Group I (31.4%) compared to Group II and III (8.6%). Conclusions: Addition of dexamethasone both caudally or intravenously as an adjuvant to caudal 0.15% ropivacaine significantly reduced the intensity of post-operative pain and prolonged the duration of post-operative analgesia with the significant advantage of caudal over IV route.
  2,609 634 -
Comparative randomised study of GlideScope® video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation
Essam Abd El-Halim Mahran, Mohamed Elsayed Hassan
December 2016, 60(12):936-938
DOI:10.4103/0019-5049.195487  PMID:28003696
Background and Aims: Awake flexible fibre-optic bronchoscope (FFS) is the standard method of intubation in difficult airway in oral cancer patients. We decided to evaluate GlideScope® video laryngoscope (GL) for intubation as compared to the standard FFS for nasal intubation in such patients. Methods: After the ethical committee approval, we included 54 oropharyngeal cancer patients divided randomly into two equal groups: Group G and Group F. After pre-medication and pre-oxygenation, awake nasal intubation was performed using GL in Group G and FFS in Group F. In both groups, we compared intubation time in seconds (mean ± standard deviation) (primary outcome), success rate of the first intubation attempt, percentage of Cormack and Lehane glottic score and incidence of complications. We assumed that GL could be a suitable alternative for the standard FFS in nasal intubation of patients with oropharyngeal cancer. Success rate of the first attempt and Cormack and Lehane glottic score were compared using Chi-square test. Results: Intubation time in seconds was significantly shorter in Group G (70.85 ± 8.88 S) than in Group F (90.26 ± 9.41 S) with (P < 0.001). The success rate of the first attempt intubation was slightly higher in Group G (81.5%) than Group F (78.8%). Cormack and Lehane glottic Score I and II showed insignificant difference between both Group G (92.6%) and Group F (96.3%). We detected three cases of sore throat in each group. Conclusion: GlideScope® could be a suitable alternative to FFS in nasal intubation of oropharyngeal cancer patients.
  2,154 468 -
Anaesthesia for foetoscopic Laser ablation- a retrospective study
Vaishali Kumbhar, M Radhika, Parameswara Gundappa, Jayashree Simha, Prathima Radhakrishnan
December 2016, 60(12):931-935
DOI:10.4103/0019-5049.195486  PMID:28003695
Background and Aims: Twin pregnancy with monochorionic placenta may be associated with arteriovenous vascular anastomosis of the placental vessels resulting in twin-to-twin transfusion syndrome (TTTS) and twin reversed arterial perfusion syndrome (TRAP). Foetoscopic LASER ablation (FLA) is the treatment of choice in reducing foetal mortality related to this. Methods: A retrospective review of medical records of 41 FLA procedures for TTTS and TRAP were analysed for anaesthetic management. Thirty-four patients received subarachnoid block, three combined spinal-epidural block, three general anaesthesia and one local anaesthesia with sedation. Nitroglycerine 5 mg patch was used for tocolysis 1 h before the procedure and continued for 24-48 h postoperatively. Results: Bupivacaine was used in 34 patients, and ropivacaine in three patients. Mean dose of bupivacaine 0.5% was 2.43 ± 0.32 ml and ropivacaine 0.75% was 2.85 ± 0.19 ml. The mean duration of surgery was 117.07 ± 28 min. Mild hypotension occurred in all patients under spinal anaesthesia and was treated with vasopressors. The foetal outcome among all 41 patients were 13 delivered live twins, 15 had a single live baby with intrauterine death of other twin baby. In 12 patients, both babies were intrauterine death. One patient was lost for follow-up. Conclusion: Foetoscopic procedures can be done under central neuraxial block, however occasionally general anaesthesia may be required.
  2,130 359 -
Isoflurane versus sevoflurane with interscalene block for shoulder arthroscopic procedures: Value of process capability indices as an additional tool for data analysis
Thrivikrama Padur Tantry, Harish Karanth, Sunil P Shenoy, Shreekantha V Ayya, Pramal K Shetty, Karunakara K Adappa
December 2016, 60(12):939-947
DOI:10.4103/0019-5049.195488  PMID:28003697
Background and Aims : Hypotensive anaesthesia reduces intra-articular bleed and promotes visualisation during arthroscopy. The haemodynamic effects of inhalational agents isoflurane and sevoflurane were studied extensively, and both were found to reduce mean arterial pressures (MBP) to an equivalent magnitude. We investigated the relative ability of isoflurane vis-a-vis sevoflurane to maintain the target systolic blood pressure (SBP) in patients undergoing shoulder arthroscopic procedures. Methods: In a prospective randomised study, 59 patients in two groups of 30 and 29 patients each received concomitant general anaesthesia (1.2-1.5 MAC of isoflurane and sevoflurane) and interscalene brachial plexus block. Nitrous oxide was used in both groups. Intraoperatively, serial blood pressure recordings of SBP, diastolic blood pressure (DBP), MBP and heart rates were done at every 3 rd min intervals. The manipulations needed to achieve target SBP (T = 90 mmHg) for optimal arthroscopic visualisation and treat unacceptable hypotensive episodes were noted. Conventional statistical tests and process capability index (PCI) evaluation were both deployed for data analysis. Results: Lower mean SBP and DBPs were recorded for isoflurane patients as compared to sevoflurane (P < 0.05, for mean, maximum and minimum recordings). Higher mean heart rates were recorded for isoflurane (P < 0.05). PCIs indicated that isoflurane was superior to sevoflurane in the ease of achieving target SBP of 90 mmHg as well as maintaining blood pressures in the range of 80-100 mmHg. Conclusion: Isoflurane provides better intraoperative haemodynamic status vis-a-vis sevoflurane in patients undergoing shoulder arthroscopic surgery with preliminary interscalene blockade. The PCI can be a useful additional medical data analysis tool.
  1,960 334 -
CASE REPORT
An unusual presentation of autonomic dysreflexia in a patient with cold abscess of cervical spine for anterolateral decompression
Susmita Sarangi, Dipali Taneja, Bhavna Saxena
December 2016, 60(12):955-957
DOI:10.4103/0019-5049.195490  PMID:28003699
A young female having complaints of quadriparesis along with bladder and bowel involvement, diagnosed to have osseous destruction of C 4 , C 6 , C 7 , T 2 vertebral bodies with pre- and para-vertebral abscess, was taken up for anterolateral decompression and fusion of cervical spine. She presented with anxiety, agitation, sweating and headache and was in hypertensive crisis which was refractory to antihypertensives, anxiolytics and analgesics but showed a reasonable response to intravenous dexmedetomidine and finally responded dramatically to rectal evacuation. Autonomic dysreflexia was suspected with stimulus arising from distended rectum as all other causes of hypertension were ruled out.
  1,841 344 -
BRIEF COMMUNICATION
'Can't ventilate' during surgery: Nightmare for anaesthesiologist
Preety Mittal Roy, Sangeeta Khanna, Yatin Mehta, AZ Khan
December 2016, 60(12):958-959
DOI:10.4103/0019-5049.195501  PMID:28003700
  1,601 461 -
LETTERS TO EDITOR
Airway management in a child with partial mandibulo-maxillary fusion
Kiran Patel, Vrushali Ponde
December 2016, 60(12):961-963
DOI:10.4103/0019-5049.195503  PMID:28003702
  1,753 240 -
Halothane: I am still there
Pooja Bihani, Deepak Choudhary, Pradeep Kumar Bhatia, Sadik Mohammed
December 2016, 60(12):965-966
DOI:10.4103/0019-5049.195505  PMID:28003704
  1,578 401 -
Evaluation of paranasal sinuses on available computed tomography in head and neck cancer patients: An assessment tool for nasotracheal intubation
Raghu Sudarshan Thota, Jeson R Doctor
December 2016, 60(12):960-961
DOI:10.4103/0019-5049.195502  PMID:28003701
  1,326 211 -
Difficulty in diagnosing physical damage to the airway tube of the ProSeal laryngeal mask airway
Kaur Jasvinder, Goneppanavar Umesh
December 2016, 60(12):963-964
DOI:10.4103/0019-5049.195504  PMID:28003703
  1,229 208 -
ERRATUM
Erratum: Overcoming airway challenges with the C MAC® video laryngoscope in a child with Goldenhar syndrome

December 2016, 60(12):967-967
DOI:10.4103/0019-5049.195506  PMID:28003705
  1,114 186 -