Indian Journal of Anaesthesia最新文献

Central neuraxial anaesthesia is the preferred approach for caesarean deliveries leading to less frequent use of general anaesthesia. The 2025 guidelines for managing general anaesthesia in obstetrics recommend rapid sequence induction and intubation for parturients requiring general anaesthesia for caesarean delivery. If the initial intubation attempt fails, the team should "Call for help for difficult airway" (Code D) and prioritise oxygenation (SpO₂ > 95%). Tracheal intubation may be attempted by a more experienced operator after re-optimising position and considering alternate airway devices. The primary anaesthesia team can opt for a 2^nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation is critical. If satisfactory oxygenation is achieved with 2^nd generation SGA or FM, the decision to continue will depend upon maternal and fetal condition. If satisfactory ventilation cannot be maintained with 2^nd generation SGA or FM following failed tracheal intubation, the team declares "complete ventilation failure" and proceeds to surgical cricothyroidotomy. Should maternal cardiac arrest occur, proceed to "resuscitative hysterotomy" to improve chances of saving mother and baby. Post-resuscitation care should continue in the ICU to return the parturient to normalcy. Parturients may have a physiologically difficult airway in addition to anatomical reasons for airway difficulty. Specific steps to deal with associated pathophysiological changes constitute an important aspect of airway management in obstetrics. If a difficult airway is encountered, an "Airway Alert Card" must be given to the parturient and her responsible relatives to avoid similar life-threatening situations in future.

The All India Difficult Airway Association (AIDAA) guidelines for 2025 regarding the extubation of "at-risk airways" following anaesthesia emphasise the importance of recognising, preparing for, and executing a planned extubation procedure for these potentially vulnerable airways. AIDAA has reviewed its previous extubation guidelines and developed a new algorithm based on the latest evidence, a Delphi survey, and expert opinions to incorporate necessary changes for patients with "at-risk airways", ultimately aiming to achieve successful extubation. This is articulated through a four-pronged strategy known as SAFE: S-Stratify Risk, A-Assemble and Anticipate, F-Facilitate Extubation, and E-Evaluate and Escalate. This stepwise approach is designed to enhance patient safety during the extubation process. The guidelines emphasise the significance of peri-extubation oxygen (PerEOx) supplementation. Furthermore, it is crucial to quantitatively assess recovery from neuromuscular blockade prior to extubation. A three-limb approach to extubation has been devised to address specific situations: Limb 1 focuses on suppressing the haemodynamic response during extubation in scenarios that require such control but do not pose a risk to the airway, Limb 2 involves a staged sequential extubation, and Limb 3 addresses the need for delayed extubation. Patients at higher risk of airway compromise, collapse, or dependence on the tube may benefit from a staged sequential extubation or delayed extubation strategy rather than a one-step extubation approach. The current guidelines also propose management plans for certain unusual situations, such as a stuck tracheal tube and unexpected extubation failure.

Background and aims: The endotracheal tube (ETT) is commonly used in mechanically ventilated patients to allow for proper ventilation and prevent aspiration of gastropharyngeal contents. Adequate sealing pressures are required to prevent aspiration while being low enough to maintain adequate perfusion of the tracheal mucosa. Multiple techniques exist for inflation of the endotracheal cuff. This study evaluated and compared four different cuff inflation techniques with the primary objective of measuring the volume of air needed to create an effective seal.

Methods: After ethical approval and trial registration, 240 patients scheduled for surgery under general endotracheal tube anaesthesia were enroled, and 228 patients were randomised into four groups (n = 57 per group). The ETT cuff was inflated with air according to the designated group. The techniques were compared for the volume of air required to achieve an adequate seal, cuff pressure post-intubation and just before extubation, cuff-related complications of sore throat, hoarseness of voice, and cough after extubation.

Results: The manual palpation technique had the highest cuff volume, 5.7 mL [interquartile range (IQR): 5.6-5.8], and cuff pressure after inflation, 29.5 (IQR: 29.1-29.9, cmH₂O), whereas the pressure-volume loop (PVL) method had the lowest values [4.3 (IQR: 4.2-4.3) mL; 23.0 (IQR 22.7-23.4) cmH₂O] (P < 0.001). Before extubation, Group 4 (manual palpation) again recorded the highest cuff pressure [31.3 (IQR: 30.9-31.8) cmH₂O] and cuff volume [6.0 (IQR: 5.9-6.1) mL], while the PVL group had the lowest values [24.9 (IQR: 24.6-25.2) cmH₂O; 4.6 (IQR: 4.6-4.7) mL] (P < 0.001).

Conclusion: Cuff inflation guided by the PVL method effectively maintained ETT cuff pressures and volumes within acceptable limits.

The All India Difficult Airway Association 2025 Adult guideline provides guidance for the management of an unanticipated difficult airway under general anaesthesia. The American Heart Association (AHA) Class of Recommendation and Level of Evidence was used. In addition, for interventions where the evidence was absent or weak, a Delphi process among airway experts was convened to generate expert consensus statements. The most significant difference from the 2016 guidelines is providing guidance for a failed supraglottic airway (SGA) insertion, tracheal intubation, face mask ventilation, or other strategies commonly used as part of the primary airway plan under general anaesthesia, not restricting to a failed intubation. Airway assessment should be routinely performed to identify an anatomical as well as the physiologically difficult airway. Peri-intubation oxygenation with pre-oxygenation and apnoeic oxygen with nasal oxygen (10-15 L/min) or high-flow nasal oxygen increases the safe apnoea time. Videolaryngoscopy and adjuncts such as stylets and bougies improve first pass intubation success. Tracheal tube position should be confirmed by waveform capnography. If the primary airway plan fails, activate 'Code D' as the hospital emergency code to call for help. Airway rescue should then be attempted with any of the three devices (tracheal tube, SGA, or face mask), and switching promptly between them as needed, with no hierarchy, until effective ventilation and adequate oxygen saturation (SpO₂) are achieved. Optimise patient position, ensure neuromuscular blockade, and consider changing the tools, technique, or operator. Allow up to three failed attempts with these devices provided the SpO₂ remains ≥95%. Complete ventilation failure (ventilation using a tracheal tube, SGA, and face mask have all failed, even if oxygenation may be maintained) is the trigger to perform an emergency cricothyroidotomy, preferably by a surgical approach. Team debriefing, team support, patient and family counselling, and documentation are paramount after encountering an unanticipated difficult airway.

The All India Difficult Airway Association (AIDAA) guidelines provide a structured framework to ensure safe and effective airway management, with a key emphasis on preparation, timely assistance, and proper documentation. To support these essential elements, AIDAA has introduced a standardised Difficult Airway Cart (DAC), the declaration of "Code D" for summoning trained help, and a dedicated Difficult Airway Alert document for difficult airway management scenarios. Recognising that airway management extends beyond operating theatres, the proposed DAC also suggests a minimal but essential "carry kit." Timely, specific, and reasoned calls for help are encouraged through "Code D" to ensure appropriate personnel respond promptly. Post-event documentation is considered essential, not only for institutional records but also for providing an alert document for future reference. AIDAA's updated recommendations integrate these elements-DAC, Code D, and structured documentation-to improve safety, preparedness, and successful airway management.

Background and aims: Despite the benefits of Enhanced Recovery After Surgery (ERAS) guidelines, there are still hesitations in implementing them. In this study, we compared the ERAS guideline-based multimodal analgesia protocol (ERAS-MMA) with patient-controlled morphine analgesia (PCA-Morphine) for single-level lumbar fusion surgeries. The primary objective was the length of hospital stay. The secondary objectives were the postoperative mobilisation time, time to start oral feeds, pain scores, complications, and re-admissions.

Methods: This is a double-blinded, randomised controlled study, conducted on 60 participants who were randomised into two groups. Group T received the ERAS-MMA, and Group C received PCA-Morphine. An unpaired t-test was used to compare the continuous variables. The Mann-Whitney U test was used to compare discrete data. Regression analysis was used to identify the true effect of ERAS-MMA on the length of stay.

Results: The difference in the mean length of the hospital stay was significant [Group T vs Group C, 4226.02 (Standard Deviation (SD): 522.21) min vs 7144.12 (SD: 592.11) min), P < 0.001]. Multiple linear regression model analysis showed that ERAS-MMA reduced the stay duration by 2 days (B = - 2871.8, P < 0.001) compared to the control group. Postoperative pain, opioid consumption, time to initiate oral feeds, time to mobilisation, and complications were less in Group T. There were no re-admissions in either group.

Conclusion: Implementing ERAS-MMA for patients undergoing single-level spine fusion surgery significantly contributes to lesser hospital length of stay, faster time to oral feeding and mobilisation, lower opioid use with better pain scores, and reduced complications.

Background and aims: Endotracheal intubation (ETI) in the intensive care unit (ICU) carries significant risks. Peri-intubation care bundles have been shown to reduce severe complications associated with ETI, but they are not routinely implemented due to equipment, drug shortages, and changes in local policies. Therefore, we developed an intubation bundle and assessed its impact on complications.

Methods: This study was carried out over 18 months with adult patients requiring ETI in the ICU. The intubation practices and complication rates were evaluated during the pre-implementation phase (Phase I). The ETI bundle was developed based on an analysis of these complications and existing guidelines, and the ICU team was trained on its application. Afterwards, complications during ETI were documented in the post-implementation phase to evaluate the impact of the intubation bundle (Phase II). P values < 0.05 were considered statistically significant.

Results: The number of patients with major complications decreased significantly after the introduction of the bundle (45% vs 29%, P < 0.001). Critical haemodynamic instability (HI) was the primary complication, and the use of a bundle was associated with a significant reduction (39% vs 19%, P < 0.001). Additionally, by implementing the bundle led to significant improvements in intubation practices, such as airway assessment by the MACOCHA score, optimisation of patient positioning, and the presence of two intubators.

Conclusion: Our study demonstrates that implementing an intubation bundle in ICU settings makes ETI practices safer by decreasing the incidence of life-threatening complications.