Anaesthesia

Prediction of endotracheal tube size in children by predicting subglottic diameter using ultrasonographic measurement versus traditional formulas Shubhi Singh, Parul Jindal, Priya Ramakrishnan, Shailendra Raghuvanshi Saudi Journal of Anaesthesia 2019 13(2):93-99 Background: Paediatric airway assessment remains the most challenging task before the anaesthesiologists. Recent advancement in ultrasonography techniques should now allow for accurate and descriptive evaluation of paediatric airway. To compare calculated external diameters of the endotracheal tube from physical indices of traditional formulas and predetermined by ultrasound. Materials and Methods: 100 subjects of either sex between 12-60 months of age, undergoing various elective surgeries under general anaesthesia requiring endotracheal intubation were enrolled in the study. The transverse diameter was measured at the level of cricoids cartilage by ultrasonography. The tracheal tube was considered best fit if air leak was satisfactory at 15-20 cm H2O of airway pressure. The obtained values were compared with the values of endotracheal tube size calculated by various age, height, weight based formulas and diameter of right and left little finger. The correlation of size of Endotracheal tube by different modalities was done and Pearson's correlation coefficient was obtained. Results: According to Pearson's correlation there was a moderate correlation of best fit Endotracheal tube with endotracheal tube size by age based formula (r = 0.743), body length based formula (r = 0.683), right little finger based formula (r = 0.587), left little finger based formula (r = 0.587) and multivariate formula (r = 0.741). There was a strong correlation with ultrasonography (r = 0.943). Conclusion: Ultrasonography is a reliable method of estimation of subglottic diameter and for prediction of endotracheal tube size in children.

Postoperative analgesia with ropivacaine and dexmedetomidine for ultrasound-guided fascia iliaca compartment block after arthroscopic knee surgery Ying Li, Jun Geng, Laiyou Wen, Jianqing Chen, Zhen Wu Saudi Journal of Anaesthesia 2019 13(2):100-105 Objective: The objective of this study is to evaluate the postoperative analgesic effect of a combination of ropivacaine and dexmedetomidine for ultrasound-guided fascia iliaca compartment block (FICB) after knee arthroscopy. Materials and Methods: Forty patients scheduled for knee arthroscopy were randomized to receive either 30 ml of 0.25% ropivacaine alone (Group A, n = 20) or combined with dexmedetomidine 1 μg/kg (Group B, n = 20). Pain intensity was evaluated using the visual analogue scale (VAS), at rest and during activity at 4, 6, 8, 12, and 24 h after surgery. Level of consciousness was evaluated using the Ramsay sedation score. Time to first analgesic request after surgery, the dose of analgesic used in the first 24 h after surgery, variation of heart rate, and adverse reactions were also recorded. Results: VAS scores at 6 and 12 h after surgery were significantly lower in Group B compared to Group A (P < 0.05). No significant difference was observed in the Ramsay sedation score or time to first analgesic request after surgery (P > 0.05). The total dose of analgesic used in the first 24 h after surgery was higher in Group A than in Group B. The incidence of bradycardia was higher in Group B compared to Group A. No adverse reactions were observed in either group. Conclusion: FICB with a combination of ropivacaine and dexmedetomidine resulted in significant reduction of VAS scores with lower postoperative analgesic requirement after arthroscopic knee surgery. No adverse reactions or complications were noted except for lower heart rate in Group B patients.

Knowledge of patients on safe medication use in relation to nonsteroidal anti-inflammatory drugs Salmeen D Babelghaith, Mohamed N Alarifi, Syed Wajid, Tariq M Alhawassi, Sara K Alqahtani, Sultan M Alghadeer Saudi Journal of Anaesthesia 2019 13(2):106-111 Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed and used medications that are used as analgesic, antipyretic, or anti-inflammatory agents, but have a high risk of adverse effects. Objective: The main purpose of this study is to evaluate the knowledge of patients toward the risks and safe usage of NSAIDs. Methods: A descriptive cross-sectional study was conducted among patients who attended orthopedic clinics at King Khalid University Hospital in Riyadh, Saudi Arabia, during December 2017 to February 2018. A self-administered questionnaire comprising three sections [sociodemographic information, patients' knowledge of NSAIDs, and the attitude toward receiving information about NSAIDs' adverse drug reactions (ADRs)] was used. The attitude was measured with a 5-point Likert scale. Results: The mean duration of NSAIDs usage was 7.3 ± 6.9 years. Only 45% of the respondents used NSAIDs daily, while 38% said they only used NSAIDs as needed. Nearly one-quarter of patients (25.5%) were counseled by a healthcare provider on the risks of NSAIDs. Almost 94% and 90.5% of the study subjects agreed that physicians and pharmacists, respectively, should play an essential role in providing information regarding ADRs to their patients. More than half of the respondents claimed that information about ADRs might lead them to discontinue their medicines. More than one-third of respondents stated that their healthcare setting provided them with insufficient knowledge of ADRs. Conclusion: Counseling of patients may diminish potentially inappropriate use and increase risk awareness. Healthcare providers can improve their role in identifying and counseling patients on NSAIDs.

Role of academic anesthesiology department in introducing patient safety module into medical school curriculum: 5 years-experience at King Abdulaziz University, Saudi Arabia Abeer A Arab Saudi Journal of Anaesthesia 2019 13(2):112-118 Background: Medical schools' curricula face increasing number of must to add-on components. Although the World Health Organization has emphasized integrating teaching patient safety and quality improvement in medical curricula, only few medical schools have responded and included these topics in their curricula. Objective: This article aimed to describe the process of foundation and integration of patient safety module led by academic anaesthesiology department at King Abdulaziz's Faculty of Medicine. It also describes the main achievements and the most important challenges faced during implementation of this module during the last 5 academic years to guide other aspiring academic anaesthesiology departments in other medical schools for them to replicate the success. Methods and Subjects: Patient safety module was designed to be interprofessional and multidisciplinary module that depends on evidence-based approach to patient safety. It was offered during the 6th year medical study started in 2011–2012 as part of an integrated, hybrid, system-based curriculum at King Abdulaziz's Faculty of Medicine. The mode was delivered through interactive lecture (15% of the module contact hours), e-learning (15%), and practical sessions (70%). Student's assessment during the module included written exams and presentation of a patient safety advocacy project on group base. Results: The module committee continuously assessed the outcome measures of the module that included results of student's assessment, student's satisfaction, as well as student's self-reported learning of the module outcome. The module committee continuously revised the module in the light of these outcomes. Conclusion: Today medical school curricula aspire to graduate market-place ready safe and efficient future physicians. This requires implementation of effective programs that help students to recognize and show appropriate clinical and patient safety skills early and continuously in their professional education.

Dexmedetomidine versus fentanyl added to bupivacaine for epidural analgesia in combination with general anesthesia for elective lumbar disc operations: A prospective, randomized double-blinded study Amin Mohammed Alansary, Marwa Ahmed Khairy Elbeialy Saudi Journal of Anaesthesia 2019 13(2):119-125 Background: The literature on drugs used for combined general anesthesia and epidural analgesia (CGE) in lumbar operations is scarce. The purpose of the study was to compare the addition of either dexmedetomidine or fentanyl to bupivacaine for epidural analgesia in combination with general anesthesia with regard to efficacy and adverse events in such operations. Materials and Methods: This prospective, randomized, double-blinded study was conducted on 80 patients who were scheduled for an elective lumbar disc operation, age 20–65 years, of either sex and American Society of Anesthesiologists physical status I or II. They were randomly allocated into one of the two groups – group bupivacaine-dexmedetomidine (BD) (n = 40): patients who received CGE with 15 mL of bupivacaine 0.20% plus 50 μg of dexmedetomidine and group bupivacaine-fentanyl (BF) (n = 40): patients who received CGE with 15 mL of bupivacaine 0.20% plus 50 μg fentanyl. The primary outcome was time to first analgesic requirement, whereas the secondary outcomes were the total opioid consumption and pain scores during the first 24 h. The incidence of adverse postoperative (PO) effects related to the study drugs, such as sedation, nausea and vomiting, pruritus, shivering, and respiratory depression, was also documented. Results: Patients in the BD group experienced a significantly prolonged pain-free period, lower total opioid consumption, and lower pain scores than patients in the BF group (P < 0.001). Patients in the BD group showed a significantly lower intraoperative heart rate and mean blood pressure (P < 0.001). Regarding adverse events, there were greater PO sedation scores (P < 0.001) and less frequent episodes of PO nausea and vomiting in the BD group. In addition, patients in the BD group showed less pruritis and shivering. There were no reported cases of respiratory depression in either group. Conclusion: CGE with bupivacaine plus dexmedetomidine provided better PO pain control than bupivacaine plus fentanyl, with fewer adverse events overall.

A prospective study to evaluate the efficacy of ultrasound-guided ganglion impar block in patients with chronic perineal pain Anju Ghai, Priti Jangra, Sarthak Wadhera, Nandita Kad, RK Karwasra, Ankur Sahu, Rajmala Jaiswal Saudi Journal of Anaesthesia 2019 13(2):126-130 Background: The blockade of the ganglion impar has been described to relieve the intractable perineal pain of sympathetic origin in patients with coccydynia. Chronic perineal pain (CPP) has been effectively managed by ganglion impar block. The feasibility, safety, and efficacy of ultrasound (US)-guided ganglion impar block by transsacrococcygeal approach was analyzed in the present study. Methods: A total of 15 patients with CPP were administered US-guided ganglion impar block using out of plane approach. Patients were followed for VAS and quality of life using Karnofsky performance status (KS), Linear Analog Scale Assessment (LASA), and constipation score up to 2 months at different time intervals. Time required to perform the procedure, number of attempts, and any complications were also noted. Results: The mean time required to perform the procedure was 7.67 ± 1.23 min. There were no adverse events. All the patients had significant pain relief during 2 month follow-up (P < 0.05 compared to baseline VAS). The KS and LASA score improved post block which was statistically significant. The dose of nonsteroidal anti-inflammatory drugs (NSAIDS) decreased from preblock state with statistically significant difference, while the difference in dose of tramadol and morphine was statistically insignificant. Conclusion: US-guided ganglion impar block is technically feasible and safe technique. USG can be used to locate sacrococcygeal junction (SCJ) and facilitate the performance of ganglion impar block. The efficacy and safety of the US-guided ganglion impar blockades needs a proper evaluation in the randomized controlled trials.

Cytoreductive onco-surgery with combined hyperthermic intraperitoneal chemotherapy and hyperthermic intrathoracic chemotherapy: Perioperative challenges Rohini Dattatri, Rakesh Garg, Mukur Dipi Ray Saudi Journal of Anaesthesia 2019 13(2):131-135 Cytoreductive surgeries (CRSs) are the common management modality for advanced cancers. The perioperative period is impacted by major surgical resection and its associated effects. The surgical morbidity is further enhanced when the resection of abdominal and thoracic cavity is required simultaneously. It is added on by the effects of hyperthermic intraperitoneal chemotherapy (HIPEC) and hyperthermic intrathoracic chemotherapy (HITHOC). These procedures are technically challenging with potential for high perioperative morbidity and mortality. We report a case of 56-year-old female diagnosed with carcinoma ovary with pleural metastases and malignant right pleural effusion and scheduled for CRS with HIPEC together with HITHOC.

Giant meningoencephalocele with Arnold-Chiari type III malformation and anaesthetic challenges: A rare case report Veena Ganeriwal, Paulomi Dey, Rupali Bawage, Baburao Gore Saudi Journal of Anaesthesia 2019 13(2):136-139 Meningoencephalocele means protrusion or herniation of brain (neural) tissue along with meninges through a defect in the cranium into a swelling filled with cerebrospinal fluid (CSF). It is very rarely associated with Arnold-Chiari type III (ACM type III). Size, location and type of content of the swelling determine the surgical as well as anaesthetic problems. The most common challenges faced by anaesthesiologist in managing these patients are related to positioning of head and prevention of rupture of swelling, airway management, fluid and blood loss and maintenance of body temperature. In order to manage huge meningoencephalocele, you need a well-planned approach amongst anaesthesiologist and surgeon.

Anesthetic management of separation of conjoint twins: Challenges and limitations Choudhary Deepak, Sharma Vandana, Bhatia Pradeep, Kothari Nikhil Saudi Journal of Anaesthesia 2019 13(2):140-143 A conjoint twin is a rare congenital anomaly. The separation of conjoint twins presents a unique challenge to anesthesiologists. We report the anesthetic management of successful separation of thoraco-omphalopagus conjoint twins, along with challenges and limitations that we faced in perioperative period. We highlight the importance of a multidisciplinary approach, proper preoperative planning, and perioperative vigilance regarding monitoring and complication.

Unexpected difficult airway caused by prior wide neck surgery Daeseok Oh Saudi Journal of Anaesthesia 2019 13(2):144-145