Central Journal of ISA

Rashid Manzoor Khan ¹, Maher Al-Bahrani ², Naresh Kaul ¹

Affiliations
1 Department of Anaesthesia & ICU, Khoula Hospital, Muscat, OM
2 Department of Anaesthesia & ICU, Royal Hospital, Muscat, OM

Abstract

The objective of this review article is to increase awareness of the potential benefit from prophylactically placing an intravenous catheter or central venous catheter transtracheally or through cricothyroid membrane. This may serve as a temporary life saving route for oxygenation or jet ventilation in cases of anticipated difficult airway in the adult patients being undertaken under general anaesthesia and who have a high likelihood of ending in Cannot Intubate; Cannot Oxygenate (CICO) situation.Patients with severe difficult airway are at greatest risk of developing hypoxia especially where the patient despite best counseling denies awake airway management. In these patients, there is a high probability of ending in a CICO situation necessitating urgent cricothyroidotomy, trans-tracheal jet ventilation or other forms of surgical airway. Unfortunately, performing these procedures in precarious situation is not easy. Historically, literature is full of reports of successful trans-tracheal jet ventilation via needle or catheter when faced with CICO situation. However, last two decades have seen case reports and case series of prophylactic placement of intravenous catheter or central venous catheter in patients with predicted difficult airway in anticipation of failed intubation and oxygenation. All these reports favour taking this step as a planned 'Safe Exit Strategy' in the management of predicted difficult airway patient as it offers assurance of excellent oxygenation if the need arises. However, shortcomings have been reported with the use of catheters but fortunately taking simple appropriate measures can circumvent most of them. All these have been discussed with evidence to support the recommendations for this practice.

Keywords

Anticipated Difficult Airway Management, Cannot Intubate, Cannot Oxygenate, Cannula Cricothyrotomy.

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Mohammed Rabea Karama Al-Tamimi ¹, Abdullah Mohammed Al-Jadidi ¹, Amani Khalifa Hamood Al-Dhuli ², Rashid Manzoor Khan ¹, Naresh Kaul ³

Affiliations
1 Department of Anesthesia and ICU, Khoula Hospital, Muscat, OM
2 Oman Medical Specialty Board, Muscat, OM
3 Department of Anesthesia and ICU, Khoula Hospital, OM

Abstract

Preformed Ring, Adair and Elwyn (RAE) tracheal tubes are generally preferred for tracheal intubation in patients undergoing cleft lip and palate repair. Till date, only few sporadic cases in literature have been reported where oral Airtraq optical laryngoscope has been used to perform tracheal intubation with RAE tracheal tube in these children. In this study we hypothesize that using a pre shaped styleted RAE endotracheal tube with nasal Airtraq (without a side channel) would be easier to direct the tracheal tube towards the glottis than with an oral Airtraq resulting in reduced intubation time and increased success rate. Following approval by Hospital Ethical Issues committee, 30 ASA I and II patients between 1-24 months of age with cleft lip and palate undergoing repair of either cleft lip or palate were included in this study. Patients were randomized into two groups of 15 patients each as per sealed envelope. Tracheal intubation was performed by senior anesthetists who were well experienced in visualizing the glottic view on its dedicated video screen and intubation with oral or nasal Airtraq. Mean time to perform tracheal intubation using Nasal Airtraq was over 50% faster than when using Oral Airtraq. Nasal Airtraq ensures 100% successful intubation in the first attempt as compared to 60% with Oral Airtraq. In conclusion, Nasal Airtraq aided tracheal intubation is superior to Oral Airtraq in patients with cleft lip and palate that gives nearly 100% successful tracheal intubation in the first attempt with no evidence of soft tissue trauma.

Keywords

Airtraq Optical Laryngoscope, Cleft Lip and Palate Repair, Tracheal Intubation.

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Hassan Hamed Khalfan Al-Salmi ¹, Nikhil Madhukant Gosalia ², Rashid Manzoor Khan ², Naresh Kaul ², Fathiya Ali Abdallah Al Shamsi ³

Affiliations
1 Department of Anaesthesia, Nizwa Hospital, Nizwa, OM
2 Department of Anesthesia and ICU, Khoula Hospital, Muscat, OM
3 5^th Year Anesthesia Resident, Oman Medical Specialty Board, Muscat, OM

Abstract

The ideal time for intravenous cannulation following inhalational induction with sevoflurane in children is debatable. Loss of eyelash reflex or centralization of eyeballs has been recommended to assess adequate depth for painless cannulation but occasional patient may still respond to pain. Trapezius Squeeze Test (TST) elicits toe/body movement if the patient feels pain while being induced with sevoflurane. We tested the hypothesis that the loss of response to TST under sevoflurane anesthesia would give an accurate optimal time for pain-free intravenous cannulation.

37 patients between the age ranges of 1 to 8 years of either gender weighing 8-20 kg undergoing minor day care surgery were included in the study. Patients were randomly assigned to Group I (eyeball centralization), Group II (loss of eye lash reflex + 3.5 min), and Group III (Unresponsive to TST). All children were induced with a gradually increasing concentration of sevoflurane. After one minute of induction, the study indicators (eyeballs centralizing effect, loss of eye lash reflex + 3.5 min or negative response to TST) were checked every 15 s till the end point of the indicator had been reached. A person not associated with the study performed intravenous cannulation and noted movement, if any.

None of the TST group patients (Group III) showed any motor response to cannulation (0%). In contrast, 7.1% and 16.7% of Group I and II patients demonstrated some motor response respectively. Grade-3 response to the cannulation in the form of movement of the limb or head and neck accompanied with coughing and/or laryngospasm was not observed in any patient.

Keywords

Induction of Anesthesia, Pediatric Anesthesia, Sevoflurane, Venous Cannulation.

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