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   Table of Contents - Current issue
Coverpage
January-April 2022
Volume 5 | Issue 1
Page Nos. 1-62

Online since Tuesday, April 5, 2022

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EDITORIAL  

Role of airway societies in improving airway management p. 1
Venkateswaran Ramkumar, Barry McGuire, Sheila Nainan Myatra, Massimiliano Sorbello, Felipe Urdaneta, Jigeeshu V Divatia
DOI:10.4103/arwy.arwy_6_22  
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SPECIAL ARTICLES Top

Anaesthetic considerations in rhino-orbito-cerebral mucormycosis p. 4
Hemlata Kapoor, Mohan Kumar Terdal, Sanjiv Badhwar, Faizan Rahmani
DOI:10.4103/arwy.arwy_56_21  
Rhino-orbito-cerebral mucormycosis is a serious infection that can complicate the course of coronavirus disease 2019 (COVID-19). Surgical debridement of infected/necrotic tissue along with antifungal co-medication constitutes the mainstay of treatment. Amphotericin B can produce electrolyte imbalance and nephrotoxicity. The lungs and other organs can be affected to various extents by COVID-19 infection. Both mask ventilation and intubation can be difficult in these patients. Meticulous preoperative evaluation and optimisation, followed by a carefully planned anaesthetic aimed at maintaining haemodynamic stability, often spells success.
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Strategic airway management in an independent anaesthetic practice – Hurdles and possible solutions Highly accessed article p. 9
Sathyajith Karanth Airody, Ananda Bangera
DOI:10.4103/arwy.arwy_54_21  
Airway management in an independent anaesthetic practice, often with limited resources, is always challenging. Comprehensive situational awareness, detailed airway evaluation, strategic planning and efficient execution of the plan are essential components of care. Equally important is the willingness to back out if the situation demands. Although the placement of a definitive airway device is necessary for the safe conduct of anaesthesia, prevention of hypoxia and secondary insults takes priority at times of crisis and all attempts should be channelled to achieve this at all costs. The practicing anaesthesiologist must always be prepared with an airway kit for dealing with emergencies and also train support staff in managing a difficult or failed airway.
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ORIGINAL ARTICLES Top

Changes in modified Mallampati class in patients undergoing percutaneous nephrolithotomy in prone position – A prospective observational study p. 13
Priyanka Mishra, Bhavna Gupta, Prakash Chandra, Ajit Kumar
DOI:10.4103/arwy.arwy_43_21  
Objective: Assessment and evaluation of changes in modified Mallampati class (MMC) in patients undergoing percutaneous nephrolithotomy (PCNL) in the prone position. Patients and Methods: Seventy-one patients undergoing PCNL in prone position who satisfied inclusion criteria were studied and their MMC was assessed preoperatively. The MMC was assessed immediately after surgery and 6 h, 12 h and 24 h postoperatively. The number of attempts for successful intubation, duration of surgery, the quantity of intraoperative fluids and irrigation fluids used, and blood loss was recorded to identify any significant correlation with changes in MMC. Results: MMC changed in 17 patients (23.9%) with the grade increasing by one in all the patients. Among the 17 patients who showed a change in MMC, 8 patients returned to baseline within 6 h, 6 patients at 12 h and the remaining 3 patients at 24 h. Conclusion: MMC worsened by one grade in almost one-quarter of the patients undergoing PCNL in the prone position. This change in MMC had no clinically significant correlation with the number of attempts for successful intubation, duration of surgery, quantity of intraoperative fluids and irrigation fluids used, and blood loss.
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Inhaled nitric oxide therapy for pulmonary arterial hypertension of newborn: Eight-year experience of a level IIIB unit p. 19
Vishnu Anand, Femitha Pournami, Ajai Kumar Prithvi, Anand Nandakumar, Jyothi Prabhakar, Naveen Jain
DOI:10.4103/arwy.arwy_57_21  
Background: Inhaled nitric oxide (iNO) has been in use for several decades now in neonates with hypoxic respiratory failure (HRF) associated with pulmonary hypertension (PH). Its requirement is uncommon, and is considered as an advanced form of support that is not widely available. Analysis of outcomes in specific settings, notably from low-middle income countries, is crucial. Objectives: To evaluate the patient profile and outcomes of neonates treated with iNO in our Level IIIB unit. Methods: This retrospective observational study describes the clinical diagnosis, management strategies and short-term outcomes of all neonates who received iNO in the years between 2013 and 2021. Details were retrieved from Electronic Medical Records and systematically analysed. Observation: Of 35 infants who received iNO during the study period, 31 (88.6%) were >34 weeks. The median and interquartile range (IQR) of oxygenation index at which iNO was started was 28 (20,33). The median (IQR) duration of iNO therapy was 48 (23,95) hours. Overall, 18 neonates (51.4%) survived till hospital discharge. Therapeutic response was best observed in infants with HRF secondary to meconium aspiration syndrome or congenital pneumonia (100% survival). Though the benefits of iNO use in congenital diaphragmatic hernia and bronchopulmonary dysplasia associated with PH are debatable, its use continues as a rescue measure. Conclusion: iNO is used in severe HRF associated with PH in neonates and can improve survival rates in select patient profiles without any major adverse outcomes.
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Correlation of tracheal size with body mass index – Retrospective computerised tomographic evaluation p. 25
Kalyani Anand Sathe, Hrishikesh Kale, Harshal Wagh, Barton Branstetter
DOI:10.4103/arwy.arwy_55_21  
Introduction: A question often asked in the anaesthetic room is 'What size endotracheal tube (ETT) should be used for this patient?' In the recent past, it has become common for anaesthesiologists to use ETTs 1–2 mm smaller than the expected tracheal size. However, it is difficult to gauge the appropriate size of ETT in obese patients. Aim: This study aimed to establish the baseline dimensions of the normal adult trachea and determine whether body mass index (BMI) affects cervical tracheal size. Patients and Methods: A total of 179 patients were included in the study. All imaging was performed on a 64-slice Lightspeed scanner (GE Healthcare) using collimation of 1.25 mm or 2.5 mm. Two axial levels were identified: the first tracheal ring and the most superior segment of the substernal trachea (i.e., the thoracic inlet). The diameter of the trachea in the anteroposterior (AP) and transverse (Trans) dimensions, as well as the cross-sectional area (using freehand region of interest tool) were measured at both the identified levels. The BMI was calculated from weight and height or taken directly from the clinical notes when available. To test the null hypothesis of no association between BMI and tracheal size, Pearson correlation coefficients along with 95% confidence interval were computed. Results: No trends or statistically significant associations were found between BMI and tracheal size on computerised tomography using AP, transverse and cross-sectional area measurements. Conclusion: Our study suggests that there is no link between BMI and tracheal size.
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Comparison of oxygen delivery methods during monitored anaesthesia care for flexible endoscopy procedures p. 30
Shivangi Harish Agrawal, Birva Khara
DOI:10.4103/arwy.arwy_61_21  
Introduction: Endoscopic procedures are usually performed under monitored anaesthesia care. Hypoxia could occur due to the sedative effects of drugs used during flexible endoscopic procedures and sharing of airway between endoscopist and anaesthesiologist. Administration of oxygen could reduce the incidence of hypoxia. Aims and Objectives: We aimed to study whether delivery of oxygen through nasal prongs or through a T-piece without an after-burner connected to a nasopharyngeal airway could reduce the incidence of hypoxia during monitored anaesthesia care for flexible endoscopic procedures. While our primary objective was to compare the incidence of hypoxia (oxygen saturation [SpO2] < 90% lasting for at least 15 s), our secondary objectives were to compare the level of sedation and incidence of adverse events. Patients and Methods: Sixty six patients (33 in each group) aged between 18 and 80 years were randomly allocated to one of two groups to receive oxygen through nasal prongs or through a T-piece without an after-burner connected to a nasopharyngeal airway. Drug requirement, SpO2 and adverse events were monitored pre-procedure and every 5 min thereafter till the end of the procedure. Results: There was no statistically significant difference in the mean SpO2 (P > 0.05), but the incidence of hypoxia was less in patients receiving oxygen through nasal prongs as compared to patients receiving oxygen through a T-piece without an after-burner connected to a nasopharyngeal airway (P < 0.05). Adverse events were found to be comparable between two groups. Conclusion: During flexible endoscopy under monitored anaesthesia care, oxygen delivery through nasal prongs results in a lower incidence of hypoxia as compared to oxygen delivery through a T-piece without an after-burner connected to a nasopharyngeal airway.
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CASE REPORTS Top

Videolaryngoscope-guided awake tracheal intubation in a patient with invasive medullary thyroid carcinoma causing subglottic airway obstruction p. 36
Ram Singh, Madhusmita Baruah, Brajesh Kumar Ratre, Vinod Kumar
DOI:10.4103/arwy.arwy_50_21  
Head-and-neck tumours are associated with a difficult airway due to the involvement of airway structures and infiltration into surrounding tissues. In clinical practice, awake tracheal intubation (ATI) is mainly performed with a fibreoptic bronchoscope. Videolaryngoscope-guided ATI has been proven to be equally effective in terms of patient comfort, safety profile and success rate. It also takes lesser time as compared to fibreoptic bronchoscopy provided adequate airway topicalisation is done and sedation carefully titrated with a suitable sedative. Formulating a good plan with team members, psychological preparation of the patient and choosing the right technique facilitated successful ATI in our patient with an anticipated difficult airway.
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Airway challenges posed by tongue injuries following neurosurgical procedures in prone position p. 40
Amruta Mihir Kulkarni, Vijay L Shetty
DOI:10.4103/arwy.arwy_53_21  
Safe patient position is an important aspect of anaesthesia care. Prone position during neurosurgery may be associated with airway oedema or complications such as tongue injuries or swelling. Prevention of such morbidities with proper planning, meticulous positioning, continuous vigilance, early diagnosis and aggressive treatment are crucial. We describe the perioperative events of three patients who presented with tongue-related morbidity following neurosurgical procedures in the prone position where one developed tongue haematoma and other two had macroglossia in the postoperative period. The patient with haematoma was asymptomatic and required no intervention apart from reassurance about the self-resolving nature of haematoma. Two patients with macroglossia were kept intubated, nursed in head-up position and administered intravenous steroids and local antidesiccants. One patient required tracheostomy while the other could be extubated 48 h postoperatively. Vigilance, prompt diagnosis and appropriate management improved overall outcome.
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Anaesthetic management of a child with Beckwith-Wiedemann syndrome posted for tongue reduction surgery - A case report and review of literature p. 45
Reena, Abhinay Jayanthi, Amrita Rath, Vineet Mishra, Ashutosh Vikram
DOI:10.4103/arwy.arwy_62_21  
Beckwith-Wiedemann syndrome (BWS) is a complex overgrowth syndrome. Affected children require surgeries for various reasons such as correction of macroglossia, abdominal wall defects, cleft palate or neoplasms. Anaesthesiologists often face problems in the form of a difficult airway, associated congenital heart disease causing haemodynamic compromise and hypoglycaemia, especially during the neonatal period. We discuss the management of a child with BWS scheduled to undergo tongue reduction surgery for macroglossia.
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Arrow injury through the floor of the mouth – How to proceed p. 50
Pavan Kumar Dammalapati, Chaitali Sen Dasgupta, Soumi Das
DOI:10.4103/arwy.arwy_60_21  
Although traditional arrow injuries are relatively rare nowadays, we occasionally come across such injuries being reported from remote areas. With the increase in recreational activities with modern arrows in the contemporary era, we should expect arrow injuries even in the urban population. Arrow injuries are managed in a similar manner to other penetrating injuries. Although arrow injuries in different parts of the body have been reported, arrow injury through the floor of the mouth is relatively rare. We describe a case of arrow injury where the arrow entered the floor of the mouth and emerged through the side of the neck posing difficulty in positioning, ventilation and intubation. Proximity to important structures in the neck also contributed to the rarity of this presentation.
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Electromyography endotracheal tube – Road to safety for thyroid surgery p. 54
Tina Khurana, Rejitha Chandrasekharan, Mohandeep Kaur, Shruti Sharma
DOI:10.4103/arwy.arwy_3_22  
Thyroidectomy is one among the most commonly performed endocrine surgeries. Iatrogenic injury of the recurrent laryngeal nerve (RLN) is of major concern in thyroid surgery. We report the case of a 37-year-old female with papillary carcinoma of thyroid posted for total thyroidectomy. Although direct identification of the nerve is considered as the gold standard, we discuss the intraoperative monitoring of RLN using electromyography endotracheal tube and its anaesthetic considerations.
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Gnana laryngeal airway device – A case series of our experience at a tertiary care cancer hospital p. 57
Suparna Mitra, Debashis DebRoy, Joy Mitra, Jyotsna Goswami
DOI:10.4103/arwy.arwy_4_22  
Gnana laryngeal airway (GLA) is a supraglottic airway device with capability of hypopharyngeal suctioning for removing oral secretions. It is easy to insert and is an effective means of airway management. We present a case series of 32 patients in whom GLA was used as a primary device to manage the airway after induction of general anaesthesia for breast surgeries, intracavitary application of brachytherapy and cystoscopy. The GLA was found to be easy to insert in a short time.
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LETTER TO EDITOR Top

Anaesthesia in a patient with seckel syndrome - Plan for contingencies p. 61
Sujata Shivlal Rawlani, M Dave Nandini
DOI:10.4103/arwy.arwy_1_22  
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NAC 2022 Top

13TH NATIONAL AIRWAY CONFERENCE  
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AIRWAY FELLOWSHIP Top

Airway Fellowship  
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AIRWAY FLIER Top

Airway Flier  
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