Journal of Anaesthesiology, Clinical Pharmacology最新文献

Background and aims: Difficult airway management is a critical skill requiring quick decision-making and effective team coordination. However, healthcare workers often lack real-life experience due to rarity of such instances. The aim of this study was to evaluate the effectiveness of simulation-based training for difficult airway management on real teams.

Material and methods: A prospective quasi-experimental study was conducted with 24 participants divided into six teams, each comprising three resident doctors and one staff nurse. An initial baseline simulation (S0) was conducted, followed by didactic sessions and skill training. Subsequent simulation sessions were carried out two weeks after the skill training (S1) and again six months later (S2). The primary objective was to evaluate the improvement in skills of real teams by comparing checklist scores. Simultaneously, retention of these skills and behaviour changes in real-world clinical practice were also assessed. Data were analyzed using descriptive and inferential statistics.

Results: Notable improvement in team performance was observed during post-skill training simulations compared to baseline, as demonstrated by a significant increase in technical and non-technical skill scores [mean (SD): 26.7 (6.3) at S0 to 67.8 (7.3) at S1; P < 0.001]. Critical airway management skills, including time to call for help, deliberation time, and cricothyroidotomy time, also showed significant improvement. Skill retention was observed at the six-month simulation session [mean (SD) at S2 66.8 (4.1); P = 0.7]. Participants and observers reported increased confidence and situational awareness in real-world settings.

Conclusions: This single-institute multi-professional team training resulted in significant improvement and retention of technical and non-technical skills of real teams in managing difficult airway.

Background and aims: Left head rotation (LeHeR) maneuver improves the glottic view in patients with difficult airway. We aimed to assess whether rotating the head to the left side to 45° improved Cormack-Lehane (CL) glottic view during direct laryngoscopy compared to the classic sniffing position. Ease of intubation in the LeHeR position, number of attempts, time taken for intubation, and hemodynamic changes were also assessed.

Material and methods: This prospective, observational study was performed in 130 surgical patients aged 18-70 years, of American Society of Anesthesiologists Physical Status 1 and 2. Patients with CL grade 1 on initial direct laryngoscopy and those with restricted mouth opening were excluded. Following induction and neuromuscular blockade, direct laryngoscopy was initially attempted with the patient's head in sniffing position and CL grade was documented. Then, the head of the patient was rotated 45° to the left side, glottic view was graded, and the trachea was intubated.

Results: Of the patients, 76.9% showed improvement in CL grade in the LeHeR position. Significantly higher percentage of patients had CL grade 1-2B in the LeHeR position compared to that in sniffing position (95.38% vs. 73.8%). Intubation was performed in the LeHeR position in 73.8%, 26.2% patients were intubated in a supine position, and 20% required bougie for intubation. Mean heart rate remained comparable with baseline values throughout the study period. Compared to baseline values, mean blood pressure values were significantly lower.

Conclusions: LeHeR to 45° improved the glottic view during direct laryngoscopy compared to the classic sniffing position. Intubation was easy with good first-attempt success without desaturation or adverse hemodynamic effects.

Lung transplantation is considered the curative treatment of end-stage lung disease. Severe chronic obstructive pulmonary disease (COPD), interstitial lung disease, cystic fibrosis, idiopathic and secondary pulmonary artery hypertension are the main indications for lung transplantation. It can either be a single lung transplant as in COPD or pulmonary fibrosis or a bilateral sequential lung transplant as in suppurative lung disease (bronchiectasis, cystic fibrosis) and severe pulmonary hypertension. If cardiac decompensation is associated with the end-stage lung disease, combined heart-lung transplantation can be considered. Anesthesiologists have a significant role to play in the multidisciplinary assessment of the recipient before fitness for listing, pretransplantation bridging by extracorporeal life support (ECLS), anesthetic management during organ retrieval and implantation, implementation of the complex perioperative protocols, and management of one-lung anesthesia. Titration of intraoperative anticoagulation, hemodynamic management, close liaison with the perfusionist during cardiopulmonary bypass or extracorporeal membrane oxygenation, and performing transesophageal echocardiography also fall under the shared responsibility of the anesthesiologist. As part of the core team, anesthesiologists also actively take part in the postoperative care protocols, ventilatory and hemodynamic management, maintaining ECLS, immunosuppressant administration, pain management, and proactive management of complications. After half a century since its inception, lung transplantation is still considered a very high-risk procedure with significant perioperative morbidity and mortality. Because of its complexity, not too many centers are doing it worldwide. Till now, in our center, we have conducted 15 bilateral sequential lung transplants. Although we did not list any recipient from pulmonary hypertension point of view, most of our patients showed very high pulmonary pressures when measured by the pulmonary artery (PA) catheter intraoperatively, some even showing >100 mmHg. The article is a culmination of our experience and knowledge gained so far on this challenging procedure. We hope that in the near future, many centers will start their lung transplantation program and our article will be helpful in formulating protocols as per the available resources in our country.

Background and aims: The main aim of this study was to evaluate the efficacy of real-time intraoperative transesophageal echocardiography (TEE) in guiding the central venous catheter (CVC) tip placement at the superior vena cava (SVC)-right pulmonary artery (RPA) junction.

Materials and methods: One hundred patients aged between 18 and 65 years undergoing elective cardiac surgery were enrolled in the study. In the operation room, under ultrasound guidance, right internal jugular vein was punctured and CVC was inserted. The primary outcome was to determine the accuracy of placing the CVC tip under TEE guidance at the SVC-RPA junction by intraoperative surgical palpation and to correlate between the preoperative chest radiograph-predicted CVC depth and the TEE-guided placement of CVC depth. The secondary outcomes were to evaluate the position of CVC tip in relation to the carina in postoperative chest radiograph and the incidence of complications.

Results: A total of 98 patients were included in the analysis. The CVC tip was palpable by the surgeon intraoperatively at the SVC-RPA junction in 76 patients (77.6%). A significant direct correlation was observed between the predicted preoperative CVC depth and TEE-guided placement of CVC depth (r = 0.7441, P < 0.0001). In the postoperative chest radiograph, 78 (79.5%) patients had the CVC tip positioned above the carina. Twenty-nine patients had atrial ectopics and six patients had ventricular ectopics during CVC insertion.

Conclusions: TEE-guided SVC-RPA junction is an accurate landmark for the intraoperative positioning of CVC tip in the extra-pericardial portion of SVC to prevent life-threatening cardiac complications.

Background and aims: Postoperative pain management in open live donor hepatectomy is vital. This study aimed to compare postoperative analgesia provided by intrathecal morphine (ITM) and epidural in open live donor hepatectomy.

Material and methods: Patients were divided into two groups. In the epidural (EPI) group, a bolus dose of 0.125% levobupivacaine (5-6 mL) with 3 mg of preservative-free morphine (diluted in 5 mL of 0.9% normal saline) was injected. In the postoperative period, infusion of levobupivacaine 0.125% at a rate of 5-8 mL/hour was continued for 3 days. In the intrathecal group (ITM), 0.3 mg morphine with 1.5 mL of 0.5% bupivacaine heavy was injected. General anesthesia was administered. Postoperatively, both groups received intravenous fentanyl patient-controlled analgesia. Numerical rating score (NRS) scores were recorded at 0, 2, 4, 12, 24, 36, 48, and 72 hours postoperatively. Data were analyzed using the Student t-test, Mann-Whitney U test, and Fisher's exact test. P < 0.05 was considered significant.

Results: A total of 60 patients were enrolled. The postoperative fentanyl consumption for the first 24 hours was significantly higher in the EPI group compared to the ITM group (162.5 mcg vs. 75 mcg, respectively; P = 0.023). NRS up to 12 hours in the postoperative period at rest, on movement, and for shoulder pain were significantly lower in the ITM group compared to the EPI group (P = 0.000).

Conclusions: ITM significantly decreased fentanyl consumption in the first 24 hours when compared to the epidural group in patients undergoing open donor hepatectomy.