Aspirated foreign body (FB),Point-of-care ultrasound (POCUS) of the upper airway

http://www.saudija.org/article.asp?issn=1658-354X;year=2019;volume=13;issue=1;spage=89;epage=90;aulast=Mohanty;type=3

Foreign bodies are common among the pediatric population. Plain radiograph AP view is the standard to diagnose and localize ingested or aspirated foreign body (FB). Most of the patients need either sedation or general anesthesia for FB removal depending on its position. Point-of-care ultrasound (POCUS) of the upper airway can be used for detection and also as a dynamic tool for monitoring the changes in the position of the FB during the attempt of its removal. It has been used for the localization and removal of soft tissue FB.^[1] Here, we present a case of use of POCUS for upper esophageal FB removal.

A 3-year-old male child, 11 kg, presented to the emergency department with a history of ingestion of FB. The plan was to remove it under general anesthesia. Chest X-ray AP view confirmed a radio-opaque FB. He was premedicated with injection glycopyorrolate 0.1 μg, fentanyl 2 μg/kg, and inj. midazolam 0.5 mg iv. Ventilation was assisted with 50% oxygen and sevoflurane. Inj attracurium 0.5 mg/kg was administered, and trachea was intubated with cuffed size 4 endotracheal tube. The SonoSite M-Turbo ultrasound machine with linear 13--6 MHz transducer was used to confirm the location of FB [Figure 1]. It was removed with the help of esophagoscope. Initially, it was visible but was lost during manipulation. There was a doubt of the passage of FB down in the esophagus, but the ultrasound was suggesting its presence in the upper esophagus. Esophagoscope was repositioned and the FB was removed in the fourth attempt with minimal trauma. It is not rare to detect the FB in preprocedure X-ray, but finding nothing during exploration under anesthesia.

Figure 1: Radio-opaque foreign body (yellow arrow) inside esophagus (ESO); CCA: Common carotid artery; IJA: Internal jugular vein Click here to view

We suggest the use of POCUS before or after anesthesia, depending on the co-operation of the patient posted for FB removal. It will also avoid unnecessary radiation exposure in the pediatric population.^[2] Further studies are needed to consider it as a part of FB management algorithm.  

Cannot intubate and cannot ventilate scenario in an infant for airway assessment

http://www.saudija.org/article.asp?issn=1658-354X;year=2019;volume=13;issue=1;spage=83;epage=84;aulast=Mahfouz

Cannot intubate and cannot ventilate scenario, in general, is rare, especially in infant age group, but results in calamitous events if it occurs. Here, we report the management of a case of cannot intubate and cannot ventilate in an infant with a history of stridor.

Case

A 6-month-old girl was brought by an ambulance to our tertiary care hospital with difficulty in breathing and severe stridor. It was decided to perform airway assessment by ENT surgeon to determine the possible causes of stridor due to failure of improvement despite maximum medications given by pediatrician. Preoperative assessment showed an infant with mixed stridor requiring about 4 L of oxygen to maintain oxygen saturation above 90%. Suprasternal and intercostal recessions with conducted sounds could be heard on the chest. Chest X-ray was normal. No premedication was given and she was shifted to the operation theatre.

Supraglottic airway assessment was done awake with topical anesthesia using flexible fiberoptic endoscope which was normal. Subglottic endoscopic examination was decided under general anesthesia. She was induced with sevoflurane to maintain spontaneous ventilation for dynamic airway assessment. The spontaneous ventilation was assisted with great difficulty after loss of consciousness. The ENT surgeon used pediatric rigid endoscope. It revealed subglottic mass occluding 90% of the area, and it was not possible to bypass the mass with the smallest endoscope available (size 2.7 mm) [Figure 1]. The infant started to desaturate after endoscopic manipulations with difficulty to ventilate. Intubation failed with the smallest tube size 2. Ventilation was tried but was not effective. The saturation and heart rate started to drop with the scenario of cannot intubate and cannot ventilate. Atropine was given and external cardiac massage started as saturation dropped to less than 50% and heart rate fell to less than 60 beats per minute. Emergency tracheostomy was done successfully in 7 min and saturation improved to 99%. Infant regained consciousness and spontaneous breathing. Computed tomography was done which revealed a small hypodense area measuring 0.5 cm in diameter in the region of glottis. LASER marsupialization of the subglottic cyst was done successfully after 2 days from emergency tracheostomy.

Figure 1: Subglottic mass obstructing 90% of the airway Click here to view

Unfortunately, there is no definitive algorithm to follow for difficult airway in case of patients aged less than 1 year of age. Difficult airway society (DAS) published algorithm of cannot intubate and cannot ventilate in a paralyzed anesthetized child aged 1–8 years in 2015.^[1]

In the present case, we skipped insertion of supraglottic devices, percutaneous transtracheal jet ventilation (PTJV), rigid bronchoscopy ventilation, and percutaneous cannula cricothyroidotomy (PCC) for different reasons. Supraglottic devices cannot be used due to distal mechanical obstruction. PTJV is relatively contraindicated due to near total airway obstruction below vocal cord.^[2] In addition to risk of serious complications such as air embolism, extensive cervical emphysema, pneumothorax, and damage to the esophagus occur if jet ventilation is tried with misplaced cannula.^[3]Rigid bronchoscopy ventilation was impossible as the smallest endoscope of size 2.7 mm could not bypass the mass. PCC is not easy in infants. Moreover, it is challenging to obtain a proper angle to insert PCC without the risk of perforation of posterior tracheal wall.^[4] Emergent tracheostomy should be considered as the first step if an ENT surgeon is available.^[5]

The management of cannot intubate, cannot ventilate scenario needs vast experience in airway assessment, unshaken confidence, with extreme cooperation between anesthetists and ENT surgeons.  

Difficult airway management and suspected malignant hyperthermia in a child with Cri Du Chat syndrome Amata AO - Saudi J Anaesth

http://www.saudija.org/article.asp?issn=1658-354X;year=2019;volume=13;issue=1;spage=81;epage=83;aulast=Amata

Cri du Chat Syndrome (CdCs) also known as Cat Cry syndrome, is a genetic disorder caused by the partial or total deletion of genetic material from the short arm of chromosome 5 (5p-, 5p minus syndrome) and was first described in 1963 by Lejeune et al.^[1] The phenotypic manifestations are variable and often affect multiple organ systems with the most common features being the characteristic high-pitched cat-like cry (hence the name), dysmorphic features, and mental retardation.^[2],[3] The reported incidence of CdCs is between 1 in 15,000 and 1 in 50,000 live births,^[2],[3] and the children often require surgery for correctable anomalies.^[3] Difficult airway management is a recognized challenge because of dysmorphic changes such as microcephaly, micrognathia, short neck, and the anatomical anomalies of the larynx.^[2],[3] However, there have not been any reports of increased risk or susceptibility to malignant hyperthermia (MH) with this condition. I present a child that developed airway management challenge and possible MH during anesthetic induction.

A 2-year 5-month, 9.5 kg African male child with bilateral congenital talipes equinovarus congenital talipes equinovarus (CTEV) otherwise known as clubfoot, was scheduled for bilateral posteromedial release operation after minimal improvement with the conservative serial splinting, stretching, and bracing treatment known as the Ponseti method.

During the preoperative anesthetic assessment on the day before surgery, the child was noted to have an unusual facies, and he could not walk or talk. He had a peculiar high pitched cry that sounded cat-like that the mother said had been present since birth. He was the third in a family of three children, and he had been hospitalized twice in the past year for aspiration pneumonia. He was small for age and had a global developmental delay with significant hypotonia, gross motor and speech impairment, and severe bilateral CTEV. He had a microcephalic head with a round face, hypertelorism, depressed broad nasal bridge, low set ears, and micrognathia (head circumference 48 cm, height 79 cm). Clinical examination of the cardiorespiratory system was unremarkable. Hematologic examination indicated hypochromic microcytic anemia and thrombocytosis (hemoglobin - 10.5 g/dl, platelets - 513 × 10⁹/L). Chest X-ray was unremarkable.

The anesthetic plan was to maintain the airway with a laryngeal mask airway (LMA) and perform a caudal epidural block for perioperative analgesia. On the operating table, routine monitors of noninvasive blood pressure (BP), electrocardiography, SpO₂, and temperature were applied, and anesthesia was induced inhalationally with sevoflurane and nitrous oxide in oxygen. An intravenous (iv) access was secured once the child was unconscious. After the adequate depth of anesthesia, a size 2.0 LMA was inserted but ventilation through it was ineffective and it was removed with a plan to reinsert it properly. Morphine 1 mg iv was given. When attempting to reinsert the LMA, the child was noticed to have suddenly developed generalized muscle rigidity including trismus and laryngospasm. Mask ventilation became very difficult and ineffective, and the mouth could not be opened to insert an oropharyngeal airway. Propofol 20 mg iv was given to facilitate jaw relaxation but had no effect. At this point, the patient's oxygen saturation had begun to rapidly decrease. Succinylcholine, 20 mg iv was given, but it also had no effect. Attempts at laryngoscopy were impossible as the teeth were tightly clenched. The pulse rate was now >195/min and the immediate preinduction temperature of 35.7°C had gone up to 37.7°C. The capnograph tracing that initially indicated hypercarbia had progressed to almost baseline because of inability to ventilate the lungs. At this stage, the sevoflurane and nitrous oxide were turned off, and the patient was maintained on 100% oxygen through bag and mask. We were about to perform an emergency cricothyroidotomy when we noticed that the child that had been apneic during this period started making some respiratory efforts that rapidly got better and the oxygen saturation progressively improved with assisted respiration. About 10 min after the commencement of the incident, the child was breathing adequately spontaneously with SpO₂ of 99%, and after close observation for about 15 min, he was transferred to the PACU for further monitoring. He was fully awake within 5 min of arrival in the PACU and was responding appropriately. The temperature and heart rate were still elevated (37.5°–377.7°C; 165–196/min) while his BP and oxygen saturation were normal during his 2 h stay in PACU. He was stable enough to be sent back to the high dependency unit of the ward and was closely observed by the ward doctor and reviewed by the pediatrician. The heart rate and temperature returned to preinduction levels about 4 h after the incident, and he was discharged from the hospital without any adverse effects or sequelae 96 h after the incident.

Children with CdCs have variable multiple phenotypical manifestations that predispose them to a greater likelihood of surgical intervention and also that have significant anesthetic implications.^[2],[3] Diagnosis is clinical with confirmation by molecular cytogenetic tests such as fluorescent in situhybridization. With increasing and widespread availability of cytogenetic studies, the anesthesia care provider is likely to see increasing numbers of patients with this relatively common chromosomal condition.^[2],[3] Up to two-thirds (75%) of patients with CdCs require general anesthesia for interventional procedures and parents felt that only about one-third (35%) of the anesthesiologists caring for their children were familiar with the condition.^[3]

Previous studies have reported an increased risk of airway difficulty and inability to intubate the trachea.^[2],[3] This is not surprising considering the orofacial anomalies these patients possess. MH risk or susceptibility has however not been associated with CdCs to our knowledge. We have a strong impression that our patient developed intraoperative MH because of the constellation of signs and symptoms. We initially assumed that the muscle rigidity and masseter spasm in a hypotonic child may have been opioid induced and/or due to a "light" plane of anesthesia, but when administration of propofol and then succinylcholine and maximum concentration of sevoflurane had no effect, coupled with the rapid development of hyperthermia, tachycardia, and hypercarbia, MH seemed the most likely diagnosis. In addition, discontinuation of the presumptive trigger, sevoflurane, led to improvement.

As early diagnosis and prompt treatment are vital in minimizing the high morbidity and mortality associated with MH, the diagnosis is usually clinical and requires a high index of suspicion and good clinical acumen.^[4] This is especially important in resource-poor environments where medical record keeping is poor and necessary monitoring and laboratory facilities are not readily available. A clinical standardized and validated grading scale has been developed to help determine if an MH event has occurred.^[5] The score ranges from 0 (almost never/very unlikely) to 6 (almost certain). Our patient scored 5, which indicates a "very likely" MH episode just short of the maximum 6, that indicates "almost certain" event in spite of our lack of relevant blood tests.

We did not use dantrolene, a specific drug indicated for MH because of nonavailability. However, patients have been shown to survive MH episodes even in the absence of dantrolene provided the diagnosis is considered early enough, and aggressive symptomatic treatment is carried out.^[6] We were unable to confirm a definite diagnosis of MH because of unavailability of the "gold standard" confirmatory in vitro contracture test^[4] however, pending future confirmatory studies it would be prudent to consider patients with CdCs as susceptible to MH and treated as such.  

Bronchial thermoplasty (BT) is an invasive procedure which carries a risk of coughing, wheezing, bronchospasm, and laryngospasm during and after the procedure.

Bronchial thermoplasty (BT) is an upcoming treatment for patients with asthma refractory to traditional pharmacotherapy

p. 78
Shilpi Agarwal, Wasimul Hoda, Saurbh Mittal, Karan Madan, Vijay Hadda, Anant Mohan, Sachidanand Jee Bharti
DOI:10.4103/sja.SJA_640_18  
Bronchial thermoplasty (BT) is an upcoming treatment for patients with asthma refractory to traditional pharmacotherapy. BT is an invasive procedure which carries a risk of coughing, wheezing, bronchospasm, and laryngospasm during and after the procedure. Some of these complications can be minimized using better anesthetic techniques during BT. We hereby report a case of a 63-year-old female with poorly controlled asthma posted for BT done under general anesthesia (GA) with supraglottic device. GA provides better working conditions for pulmonologists when compared with sedation. But still there is no consensus on what would be the ideal anesthetic technique for BT procedure. Till the time, considering anesthesiologist and pulmonologist's prospective, GA (total intravenous anesthesia) using supraglottic device would be a preferred choice for a safe and effective anesthetic strategy in BT.
https://plus.google.com/u/0/+AlexandrosGSfakianakis/posts/DbhmnVsxE6j

The use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided.Clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension

Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension p. 63

Hiroyuki Oshika, Yukihide Koyama, Yutaka Usuda, Tomio Andoh

DOI:10.4103/sja.SJA_367_18  

We report a case of intravenous ephedrine administration that abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension and who was subsequently diagnosed postoperatively as having bronchial asthma. A 54-year-old man who had childhood asthma was scheduled for laparoscopic cholecystectomy at our institution. The preanesthetic interview suggested full resolution of his childhood asthma. His capnogram showed an airway obstructive pattern immediately after the initiation of mechanical ventilation. However, after administration of ephedrine due to low blood pressure during surgery, his obstructive capnogram reverted to normal. On postoperative day 3, he was diagnosed as having bronchial asthma. Furthermore, we found that small airway obstruction as indicated in his preoperative pulmonary function test (PFT) had been overlooked. Two important points arise from this case. First, the use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided. Second, clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate

Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias

DOI:10.4103/sja.SJA_413_18  

Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of Postoperative acute kidney injury (AKI) : Hydroxyethyl starch (HES) solutions,Stroke volume variation-guided tetrastarch,Ringer's lactate

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate 

Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi

DOI:10.4103/sja.SJA_410_18  

Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. 

Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.

Mitral regurgitation (MR)

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography p. 134

N Chidambaram, GN Balaji, TS Subashini

DOI:10.4103/jncd.jncd_50_18  

Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures

Osteonecrosis and nonunion as complication of fracture neck femur p. 23

Rudra P. S. Thakur, Alok C Agrawal, Bikas K Sahoo, Vishal K Kujur

DOI:10.4103/jodp.JODP_14_18  

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Vascularity of femoral head

and its assessment after femoral neck fractures p. 1

Harshal Sakale, Alok C Agrawal, Bikram Keshri Kar, Bikas Sahoo, Sandeep K Yadav

DOI:10.4103/jodp.JODP_5_18  

Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Orthodontic Rehabilitation

http://www.orthodrehab.org/currentissue.asp?sabs=n

Complications of mini-implant anchorage A Sumathi Felicita International Journal of Orthodontic Rehabilitation 2018 9(4):133-133

Analysis of facial pattern among 12–16-year-old students in Lagos, Nigeria Olawande A Ajisafe, Babatunde O Ogunbanjo, Kikelomo O Adegbite, Afolabi Oyapero International Journal of Orthodontic Rehabilitation 2018 9(4):134-140 Background: Facial patterns or biotypes have been known to influence the treatment plan of orthodontic patients and analyze the facial patterns described by Ricketts. Determining the facial type is extremely important for orthodontic diagnosis and planning since the muscular and skeletal configuration of each facial type responds differently to the orthodontic treatment. Materials and Methods: A sample of 100 individuals was recruited by multistage sampling from three schools in Ikeja local government, Lagos State. Those aged between 12 and 16 years who met the inclusion criteria were enrolled in the study after obtaining informed consent and assent from the parents and participants. Lateral cephalometric radiographs were taken for all participants, and the final sample after analysis of the radiographs was 84. The error of the cephalometric method was assessed using the intraclass correlation coefficient. Facial axis angle (Ptm-Gn/Ba-N) was used to classify the facial pattern into brachyfacial (<87°), mesofacial (87°–93°), and dolichofacial (>93°) Results: Out of the 84 participants, 60 (71.4%) had mesofacial facial pattern which consisted of 27 (32.1%) males and 33 (39.3%) females. 10 (11.9%) had brachyfacial pattern out of which 9 (10.7%) were male and 1 (1.2%) was a female. This difference between the males and females in the brachyfacial pattern was statistically significant with a P value of 0.014 (P ≤ 0.05). 14 (16.67%) participants had dolichofacial pattern with 5 (6.0%) males and 9 (10.7%) females. Conclusion: The mesofacial pattern had the highest frequency among the facial pattern types studied in this Nigerian population and was found to be more predominant among females. The brachyfacial pattern was seen more frequently in males while the dolichofacial pattern was more prevalent among females. The facial pattern assessment should guide the orthodontist in the use of appropriate mechanics to achieve an overall balanced occlusion and facial profile following orthodontic treatment.

Norms for anterior–posterior assessment of jaw relationship in Maharashtra population Niyati B Potode, Twinkle D Bajaj, Amol A Verulkar, Swapnil B Wankhade, Ratndeep A Lohakpure, Jimmy K Sangatani International Journal of Orthodontic Rehabilitation 2018 9(4):141-144 Background: Regularly used parameters for anteroposterior assessment of jaw relationships are ANB angle and Wits appraisal, and recently, beta angle, Yen angle, and W angle are introduced. ANB angle depends on the cranial landmarks and is affected by various factors and often can be misleading. The Wits appraisal does not depend on cranial landmarks, but still has the problem of correctly identifying the functional occlusal plane, which can sometimes be impossible. To overcome these problems, a new measurement, beta angle, was developed at Tufts University. The present study was carried out on Maharashtra population to derive norms of beta angle. Materials and Methods: For selection of sample, the lateral cephalograms were selected from the available patient's records, and the sample was divided into three groups based on the ANB angle, Wits appraisal, and profile. Conclusion: The norms of beta angle are between 28.5° and 36.5° in skeletal Class I pattern, <28.5° in skeletal Class II pattern, and >36.5° in skeletal Class III pattern.

Evaluation of the effect of moisture and saliva on the shear bond strength of brackets bonded with conventional bonding system and moisture insensitive primer: An in vitro study I Girish Kumar, A Bhagyalakshmi, BM Shivalinga, N Raghunath International Journal of Orthodontic Rehabilitation 2018 9(4):145-154 Introduction: Bonding of orthodontic attachments with acid etching is the most commonly used orthodontic procedure. However, there are certain limitations with acid etching procedure like/moisture contamination, etching time, the concentration of adhesive, etc., Moisture insensitive primers (MIPs) were introduced to overcome these limitations. Objectives: The aim of this study is to compare the shear bond strength of orthodontic brackets bonded with a MIP (Transbond MIP, 3M Unitek) against a conventional primer (Transbond XT, 3M Unitek) when contaminated with saliva – in vitro study. Methodology: Sixty maxillary premolars extracted for orthodontic purpose or due to periodontal involvement with sound buccal surfaces were collected, cleaned thoroughly, and stored in 0.1% (wt/vol) thymol at room temperature for 2 weeks. Following materials were used: Transbond XT Light cure adhesive (3M unitek), Transbond XT primer (3m unitek), Transbond MIP primer (3M unitek), and Metal brackets (3M unitek). A commercially available artificial saliva (AQWET, CIPLA) was used for contamination purpose. Ivoclarbluephase N LED light curing unit were used for curing purpose. Results: Mean bond strength was well above the clinically acceptable bond strength values indicating the use of these hydrophilic bonding materials in contaminated environments (8.5 Mpa for Transbond XT and 9.25 Mpa for Transbond MIP). On comparison of bond strengths of MIP and XT when contaminated with saliva, statistically significant values were obtained with contamination with saliva after primer application. There was a statistically significant increase in the bond strength after primer application (P = 0.233) and before and after primer application (P = 0.027*). Transbond MIP can be used to achieve adequate bond strength in saliva contaminated condition. Conclusion: Under dry condition, the shear bond strength of conventional primer (TRANSBOND XT) was significantly increased when compared to MIP. Under wet conditions MIP (TRANSBOND MIP) showed the highest shear bond strength and hence can be considered as a material of choice in wet conditions.

An overview of evidence-based dentistry and randomized controlled trials: Importance in the current orthodontic research Jasleen Kaur, Harpreet Kaur, Shikha Virdi International Journal of Orthodontic Rehabilitation 2018 9(4):155-158 Evidence-based dentistry (EBD) was developed to help dental care professionals in incorporating the current, valid, and bias-free research into their clinical practice. It is equally important to review and critically appraise the evidence before its adoption into clinical decision-making. In orthodontics, as there are emerging innumerable appliances, materials, and treatment approaches, there is an urgent need to conduct new trials to determine their effectiveness. Recently, randomized controlled trials (RCTs) are considered as the most powerful and strongest research design for the comparison of various treatment interventions. This article gives a brief overview about EBD and RCTs and their importance in the field of orthodontics.

Orthodontic consideration with patients with bleeding disorders Vaidehi N Arekar, Pushpak Ladhe, Apurva Nikte, Pawankumar Dnyandeo Tekale International Journal of Orthodontic Rehabilitation 2018 9(4):159-162 Orthodontist must be aware of the impact of bleeding disorders on the management of orthodontic treatment. Initial recognition of a bleeding disorder, which may indicate the presence of a systemic pathologic process, may occur in dental practice. Patients should be queried about any previous unusual bleeding episode after surgery or injury, spontaneous bleeding, and easy or frequent bruising. The purpose of this paper is to review bleeding disorders and their effects on the delivery of orthodontic treatment.

Nutrition and orthodontics Jeevan M Khatri, Vijaymala D Kolhe International Journal of Orthodontic Rehabilitation 2018 9(4):163-167 Orthodontic patients avoid many types of food, particularly fruits, raw vegetables, and other hard and tough foods, as they cannot chew these properly because of pressure sensitivity of the teeth in the initial 3–5 days period after routine. As a result, such individuals consume significantly less proteins and other key nutrients, fiber, calcium, nonhem iron, and some vitamins. This article presents an overview of the relationship between diet and orthodontic treatment. The nutritional guidelines to obtain good oral and general health in orthodontic patients are discussed.

Treatment of Class II division 1 malocclusion using forsus fatigue-resistant device S B V Ramana Reddy, Venkata Naga Sravanthi Jonnalagadda International Journal of Orthodontic Rehabilitation 2018 9(4):168-172 Functional orthopedic appliances are mostly used to treat Class II malocclusion originated from mandibular retrusion. Removable or fixed functional appliances are available to advance the mandible. Fixed appliances can be treated in tandem with multibarcket therapy, thus making it a single-phase treatment. The major disadvantage of fixed functional appliances is proclination of lower anterior teeth. To reduce this proclination, miniplates or miniimplants are being used; negative torque is added to the lower incisors. Despite these additions, the proclination could not be eliminated but minimized. This case report documents the successful treatment of skeletal Class II in late stages of puberty using forsus fatigue resistance appliance with soldered hooks placed distal to the lower canines.

Orthopaedic Diseases and Traumatology

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Vascularity of femoral head and its assessment after femoral neck fractures Harshal Sakale, Alok C Agrawal, Bikram Keshri Kar, Bikas Sahoo, Sandeep K Yadav Journal of Orthopaedic Diseases and Traumatology 2018 1(1):1-4 Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Classification of fracture neck of femur Bikas Sahoo, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Sandeep K Yadav, Sameer Mittal Journal of Orthopaedic Diseases and Traumatology 2018 1(1):5-7 There are numerous classification systems for fracture neck of femur in adults. A fracture classification is proposed either for taxonomical purpose, characterization, guiding intervention, or predicting outcomes of intervention. The classifications described in this chapter are needed to decide on choice of implant, stability, acceptability of reduction, vascularity and long term prognosis.

Early management of fracture neck of femur Abhishek Jain, Alok C Agrawal, Bikas K Sahoo, Sandeep K Yadav, Bikram Keshri Kar, Harshal S Sakale Journal of Orthopaedic Diseases and Traumatology 2018 1(1):8-10 Femoral neck fracture is considered a medical emergency as an early fixation helps in getting an accurate reduction, preservation of blood supply, removal of tamponade within the capsule, and early mobilization. This article deals with the science of early management of femoral neck fractures.

Pediatric fracture neck of femur Sandeep K Yadav, Alok C Agrawal, Bikram Keshri Kar, Harshal S Sakale, Bikas Sahoo, Rahul K Chandan Journal of Orthopaedic Diseases and Traumatology 2018 1(1):11-14 The incidence of hip fractures in children about 1% of total pediatric fractures. The most common cause is a high-energy trauma, such as motor vehicle accidents and falls from a height. In old cases, magnetic resonance imaging (MRI) may be needed to assess the vascularity of femoral head. Hip fractures can have deep impact on the development of hip. Vascularity of femoral head plays a vital role in the management of femoral neck fracture. The paper deals with the cited complications related to femoral neck fracture like avascular necrosis (AVN), nonunion, mal-union, and premature closure of the proximal femoral physis, leading to leg length discrepancy.

Delayed diagnosed femoral neck fractures Bikram K Kar, Alok C Agrawal, Sandeep K Yadav, Harshal Sakale, Bikas Sahoo Journal of Orthopaedic Diseases and Traumatology 2018 1(1):15-20 Treatment of displaced femoral neck fractures includes internal fixation with/without graft supplementation or internal fixation plus osteotomy or arthroplasty. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in patients with displaced femoral neck fractures who present delayed, treated either by internal fixation or arthroplasty. The purpose of our study was to summarize the management protocol of fracture of neck of femur when they present at different duration and at different stage.

Neglected fracture neck of femur: Our experience Alok C Agrawal Journal of Orthopaedic Diseases and Traumatology 2018 1(1):21-22 Fracture neck of femur continues to be neglected in rural India. Several salvage options tried in the past are now out of local interest in favor of some sort of arthroplasty. Although the long-term viability of this policy is not known, only the future will guide to a definite path.

Osteonecrosis and nonunion as complication of fracture neck femur Rudra P. S. Thakur, Alok C Agrawal, Bikas K Sahoo, Vishal K Kujur Journal of Orthopaedic Diseases and Traumatology 2018 1(1):23-28 Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Failure of fixation of fracture neck of femur and remedies for management Sameer Mittal, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Bikas Sahoo, Sandeep K Yadav Journal of Orthopaedic Diseases and Traumatology 2018 1(1):29-32 Failure of fixation is common complication of fracture neck of femur, more common in displaced fractures than in undisplaced fractures. Early diagnosis and treatment of fixation failure is very important for good outcome. Physiological age of patient, status of the hip joint, viability of the femoral head, and presence of occult infection are the factors that should be considered before deciding the suitable salvage procedure. In patients younger than 50 years, preservation of the femoral head is preferred as salvage treatment. Hemiarthroplasty or total hip arthroplasty is the choice of salvage for femoral neck fracture nonunions in physiologically older patients.

Do we need internal fixation devices for giant cell tumors around knee joint? An outcome study Ritesh Runu, Vidya Sagar, Ashutosh Kumar, Arnab Sinha, Santosh Kumar Journal of Orthopaedic Diseases and Traumatology 2018 1(1):33-37 Introduction: Giant cell tumors around the knee joint are the most common aggressive benign tumors. Several limb sparing and limb ablation surgeries are practiced with varying level of success. Here we present an original outcome study conducted on 14 patients with giant cell tumor around the knee joint, treated with intralesional curettage, bone grafting and bone cementing with or without internal fixation. Material and Methods: This is a retrospective study carried out in an institutional set up. Fourteen patients were operated and Internal fixation was used in five cases. the patients were followed up for 2 years minimum. Results: Total fourteen patients were treated with giant cell tumors around knee joint. Phenol cauterization showed reduced recurrence compared to no phenol cauterization. Collapse was noted in cases done with curettage and only cementing or only bone grafting. plating group showed no collapse. No collapse was noted in cases with subchondral bone more than 5 mm. Conclusion: For giant cell tumor, campannaci grade III, internal fixation is suggested if subchondral bone is less than 5 mm and articular involvement is more than 50%.

Dome osteotomy in cubitus varus: Our results Ashutosh Kumar, Vidya Sagar, Pawan Kumar, Deepak Kumar, Ritesh Runu, Gaurav Khemka Journal of Orthopaedic Diseases and Traumatology 2018 1(1):38-42 Introduction: Cubitus varus (gunstock deformity) is the most common complication of supracondylar fracture of the humerus. Several osteotomies and various fixation techniques are described for its correction. The most commonly used is the lateral closing-wedge osteotomy, also known as French osteotomy with variable results. Persistent lateral condyle prominence leads to cosmetically unacceptable appearance and poor patient satisfaction. To avoid this problem, dome osteotomy is performed. We have evaluated results of dome osteotomy in our population. Material and Methods: This was a retrospective study carried out in our institute. Ten patients with cubitus varus treated by dome osteotomy were evaluated at 24 months. All patients were operated by triceps-splitting approach. Pre- and postoperative carrying angle of elbow, range of motion, and lateral condyle prominence index were compared according to Banerjee criteria. Results: Ten patients with average age of 9.1 years were followed up for 2 years. Mean gap between injury and surgery was 15 months. Postoperative improvement in carrying angle and lateral condylar prominence index was significant. One case developed ulnar neuropraxia, which recovered fully within 2 weeks. Pin tract infection was seen in three cases and skin infections in two cases. Conclusion: Dome osteotomy is a technically demanding surgery. The functional and cosmetic correction is better compared to that for French osteotomy.

Noncommunicable Diseases

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Noncommunicable diseases surveillance in India: Moving toward a more comprehensive approach Jai Prakash Narain, KR Thankappan International Journal of Noncommunicable Diseases 2018 3(4):111-114

Diabetic care delivery with package of essential noncommunicable diseases interventions protocol in rural Nepal: A district hospital-based study Pawan Agrawal, Priyanka Gupta, Bikash Gauchan, Biplav Shrestha International Journal of Noncommunicable Diseases 2018 3(4):115-119 Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization's Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow-up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty-six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow-up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions.

Health professionals' perspectives on factors needed to implement nutrition strategy: A questionnaire validation study Reem Saleh Al Gurg, Mohammed Alameddine, Amar Hassan Khamis International Journal of Noncommunicable Diseases 2018 3(4):120-125 Background: Noncommunicable diseases (NCDs) increasingly recognized as a serious, worldwide public health concern. According to the WHO, NCDs are currently responsible for two-thirds of global deaths annually. Nutritional food and unhealthy diet are contributing to an immense portion of NCDs. Exploring the role of nutrition in healthcare delivery with a particular focus on the United Arab Emirates (UAE) context is also aligned with the UAE Government's Vision 2021. Aim: To develop a reliable and valid questionnaire that helps to assess the agreement about factors needed to implement a nutrition strategy in the UAE. Materials and Methods: One hundred and sixty-one health professionals were invited to respond to a questionnaire assessing agreement with factors needed to implement a nutrition strategy. The questionnaire consisted of 11 factors, each containing four items that made a total of 44 items assessed on a 7-point Likert scale (1 strongly disagree to 7 strongly agree). The questionnaire was evaluated using factor analysis, and Cronbach's alpha was used to test the internal consistency of the responses of participants. Ethical approval was given by the Chair of Humanities and Health Sciences Research Ethics Panel (UAE). Results: The questionnaire was validated by an expert panel. A factor analysis was carried out through responses of the health professional and revealed that the 11 factors are included in the questionnaire; only one item from the factor of resources and enablement was excluded: the exclusion of the item “hospital uses the lifespan approach in nutrition interventions” due to singularity and insufficient load of the variance extracted. Conclusion: The study concluded that the questionnaire was valid and reliable on its form of 43 items divided into 11 factors to assess the agreement toward factors needed to implement a nutrition strategy in the UAE.

Effectiveness of "percutaneous coronary intervention care program" on selected variables among patients undergoing percutaneous coronary intervention Poonam Sharma, Sandhya Ghai, Manoj Kumar Rohit, Monika Dutta International Journal of Noncommunicable Diseases 2018 3(4):126-133 Objective: The study was conducted to assess the effectiveness of “percutaneous coronary intervention (PCI) care program” among patients undergoing PCI. Subjects and Methods: A quasi-experimental design was adopted, and purposive sampling technique was used to enroll the patients in the experimental and control groups. Different tools were used to collect the data, which include numerical pain and comfort rating scale, Barthel Index for activities of daily living, assessment for the presence of vascular complications, modified CADEQ-SV questionnaire, State-Trait Anxiety Inventory scale, self-structured satisfaction scale, and PCI manual. Results: There was a significant decrease observed in state anxiety (P < 0.001), pain level at 12 h (P = 0.03), discomfort within 12 h (P < 0.001) and 24 h (P = 0.002), improving knowledge regarding coronary artery disease (CAD) (P < 0.001), and activities of daily living as well as significant increase in satisfaction level (P < 0.001) among patients undergoing PCI in the experimental group than the control group. Conclusion: The study concluded that this program was effective in reducing anxiety, pain, and discomfort and increased satisfaction level, knowledge regarding CAD, and independence in self-care activities for PCI patients.

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography N Chidambaram, GN Balaji, TS Subashini International Journal of Noncommunicable Diseases 2018 3(4):134-138 Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Decoding increasing prevalence of noncommunicable diseases Alok K S Thakur International Journal of Noncommunicable Diseases 2018 3(4):139-144 Background: In recent times, noncommunicable diseases (NCDs) have attained epidemic status in India and several other countries. Globally, each year, NCDs cause premature deaths of nearly 40 million people younger than 60 years accounting for 70% of all deaths; 80% of these premature deaths are reportedly in the low- and middle-income countries. Many studies have reported increasing prevalence of NCDs such as type 2 diabetes, coronary and pulmonary diseases, and cancer. Incidentally, all these studies besides discussing environmental pollution have grossly ignored dietary profiling of affected populace despite the fact that several studies have established a direct correlation between food quality and good health. Objective: Besides pollutants, an attempt is made to analyze mathematically effects of dietary changes over the last four decades on constantly increasing prevalence of NCDs at cellular level. A relationship seems to exist between increasing prevalence of NCD and large-scale consumption of synthetic salt. Conclusions: Elimination of essential trace elements and micro- and macro-minerals in regular diet through synthetic salt fortified with iodine alone appears to cause more harm than benefits associated with iodization of salt than pollutants. Regular intake of essential trace elements is necessary for normal functioning of many fundamental functions of the body such as Na-K pump, electron–proton transport, biochemistry, and thermodynamics. An attempt has been made to study effects of salt constituents used in food at the most fundamental cellular level by means of disturbances in body electrolyte through heat and ion transport mechanism that is fundamental to various underlying processes in human body. Interestingly, almost all the families who switched over to unprocessed rock salt from synthetic iodized salt reported improvement in general health and reported reduction in medical visits.

Anaesthesia

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Erector spinae plane block: New block with great expectations Can Aksu, Yavuz Gürkan Saudi Journal of Anaesthesia 2019 13(1):1-2

Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly Maria João M. Lima, Daniela F M Cristelo, Joana B Mourão Saudi Journal of Anaesthesia 2019 13(1):3-8 Background: Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a validated instrument used to predict morbidity. The aim of our study was to evaluate the performance of the POSSUM score system on predicting perioperative frailty and quality of life (QOL) in elderly surgical patients. Patients and Methods: An observational prospective study was conducted during 3 months. POSSUM was used to determine operative morbidity risk. Patients with a POSSUM score ≥26 were considered as having a high POSSUM (PHP). WHODAS 2.0, EuroQOL-5 dimensions (EQ-5D), Charlson score, and the Clinical Frailty Scale were used to assess the QOL and frailty. Chi-square, Fisher's exact, or Mann–Whitney tests were used for comparisons. Results: Two hundred and thirty-five patients were included. Median age was 69 years; 58% were ASA I/II and 42% ASA III/IV. Frailty was present in 53 patients (23%). Median POSSUM score was 26. Patients PHP were older (median age 71 vs. 68, P = 0.008), more frequently ASA III/IV (P = 0.001), had higher median Charlson scores (7 vs. 5, P = 0.006) and were more frail (49% vs. 26%, P < 0.001). PHP presented more problems in EQ-5D dimensions preoperatively (mobility: 59% vs 41%, P = 0.008; care: 41% vs. 25%, P = 0.013; activity: 52% vs. 32%, P = 0.002; pain: 59% vs. 45%, P = 0.041) but not anxiety (P = 0.137). Three months after surgery, PHP patients presented more problems in mobility: 63% vs. 38%, P < 0.001; care: 48% vs. 31%, P = 0.009; activity: 58% vs. 44%, P = 0.036; pain 59% vs. 37%, P = 0.001 and anxiety: 54% vs. 50%, P = 0.025. Conclusions: Patients PHP were frailer and had worse perioperative QOL.

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi Saudi Journal of Anaesthesia 2019 13(1):9-15 Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.

The quality of life and satisfaction rate of patients with upper limb hyperhidrosis before and after bilateral endoscopic thoracic sympathectomy Waseem M Hajjar, Sami A Al-Nassar, Heba M Al-Sharif, Dana M Al-Olayet, Wejdan S Al-Otiebi, Alanoud A Al-Huqayl, Adnan W Hajjar Saudi Journal of Anaesthesia 2019 13(1):16-22 Background: Hyperhidrosis is a functional disorder identified by excessive sweating. Its incidence is approximately 1% in any population. Bilateral endoscopic thoracic sympathectomy (BETS) intervention is the definitive treatment of choice for palmar and axillary hyperhidrosis. Aims and Objectives: The purpose of this study is to evaluate and compare the quality of life (QOL) and satisfaction rate of patients with upper limb hyperhidrosis before and after BETS surgery and the influence of compensatory hyperhidrosis (CH) on patients' QOL after surgery. Settings and Design: This study is a cross-sectional study designed to generate longitudinal data. Subjects and Methods: This study is a cross-sectional study designed to generate longitudinal data pre- and postbilateral BETS prospectively. This study was conducted in the surgery department of University Hospital in Riyadh, Saudi Arabia. Hundred patients with upper limb hyperhidrosis who underwent BETS from 2014 to 2017 were included. A modified and validated QOL questionnaire for hyperhidrosis was completed by the patients themselves in order to compare the QOL for patients both before and after BETS. Patients' satisfaction and the occurrence of CH were obtained postoperatively. Statistical Analysis Used: Data were analyzed using the SPSS® statistical package for social studies, version 22.0 (SPSS 22; IBM Corp., New York, NY, USA) for Windows®. Results: A total of 100 patients completed the questionnaire; 94% of patients had a positive QOL outcome after the surgery. The mean decrease in QOL scores was −42.0 points toward better QOL. The site of sweating had a significant effect on the patients' QOL before and after the surgery (P value < 0.001). Moreover, 76% of patients reported a high satisfaction rate. Conclusion: Primary hyperhidrosis can negatively impair patients' QOL in different domains. BETS showed to be an effective option for improving the QOL of patients and it provided both short- and long-term effectiveness in treating upper limb hyperhidrosis. CH did not interfere with the rate of patient satisfaction or their QOL postoperatively.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias Saudi Journal of Anaesthesia 2019 13(1):23-27 Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study Eman Ramadan Salama, Doaa El Amrousy Saudi Journal of Anaesthesia 2019 13(1):28-34 Background and Objective: Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia. Materials and Methods: Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded. Results: TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5–28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8–32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45–100 and median = 82.4, range 10–100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt. Conclusion: In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

Comparative evaluation of two approaches of infraclavicular brachial plexus block for upper-limb surgeries Chandni Sinha, Neeraj Kumar, Amarjeet Kumar, Ajeet Kumar, Anup Kumar Saudi Journal of Anaesthesia 2019 13(1):35-39 Background: Infraclavicular approach is a common technique of brachial plexus block. The main difficulty of ultrasound guided technique is in needle visualization due to deep location of the cords. Hebbard et al described a retroclavicular approach wherein the needle was inserted posteriorly to the clavicle. Materials and Methods: In this prospective randomized controlled study, we have compared the classical technique with the retroclavicular approach in terms of needle visibility, block success rate, number of needle passes, block performance time, procedure-related pain, complications, patient and operator comfort and satisfaction. Results: The rate of block success was similar in both the groups. The needle tip and shaft visibility was more in the retroclavicular group (P < 0.05). The number of needle passes was also less in the retroclavicular group. Time for the block procedure was less in retroclavicular group when compared to the classical coracoid group. The patients reported less pain in retroclavicular group (P < 0.05). Discussion: Retroclavicular approach is a feasible option of infraclavicular brachial plexus block in Indian Subpopulation in terms of needle visibility and block success rate.

Respiratory mechanics with volume-controlled auto-flow ventilation mode in cardiac surgery* Murat Arslan, Elvan Öçmen, Seden Duru, Belkis Şaşmaz, Şule Özbılgın, Hasan Hepağuşlar Saudi Journal of Anaesthesia 2019 13(1):40-45 Aim: We aimed to investigate the changes in respiratory mechanics in adult patients undergoing open heart surgery (OHS) while using volume-controlled auto-flow (VCAF) ventilation mode. Materials and Methods: After obtaining ethics committee's approval and informed consent, 30 patients (17 males and 13 females; mean age: 57.3 ± 17.0 years; mean weight; 74.9 ± 13.6 kg) scheduled for OHS were enrolled. Mechanical ventilation was carried out using VCAF mode (VT: 5–8 mL/kg, I/E: 1/2, 10 ± 2 fr/min). Values of dynamic compliance (Cdyn) and resistance (R) were obtained at six time points (TPs). Normally distributed variables were analyzed with repeated measure of analysis of variance and Bonferroni tests. For abnormally distributed variables, Friedman variance analysis and Wilcoxon signed-rank tests were used. Values were expressed as mean ± standard deviation. P value <0.05 was considered significant. Results: Cdyn (mL/mbar) and R (mbar/L/s) values were as follows – (1) before sternotomy (S): 49.9 ± 17.1 and 7.8 ± 3.6; (2) after S: 56.7 ± 18.3 and 7.1 ± 3.7; (3) after S and after sternal retractor placement: 48.7 ± 16.1 and 8.3 ± 4.4; (4) after weaning from cardiopulmonary bypass and following decannulation while retractor was in place: 49.6 ± 16.5 and 8.1 ± 4.0; (5) after retractor removal: 56.5 ± 19.6 and 7.4 ± 3.7; and (6) after sternal closure: 43.1 ± 14.2 and 9.6 ± 9.1, respectively. Significant differences were observed in Cdynand R between; first and second TPs, second and third TPs, fourth and fifth TPs, and fifth and sixth TPs. Also, significant difference in Cdynwas found between first and sixth TPs, but it was not found in R. Conclusion: Cdyndecreases, but R remains the same in cardiac surgical patients when mechanical ventilation is performed with VCAF ventilation mode. Additionally, Cdynis negatively affected by the presence of sternal retractor and the sternal closure in OHS.

Outcome prediction with physiological and operative severity score for the enumeration of mortality and morbidity score system in elderly patients submitted to elective surgery Diana F Torres Lima, Daniela Cristelo, Pedro Reis, Fernando Abelha, Joana Mourão Saudi Journal of Anaesthesia 2019 13(1):46-51 Context: Elderly patients have a higher risk of complications and 30-day mortality than younger patients. Population is aging and this is an emergent preoccupation. Aims: The aim of this study was to evaluate the performance of Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) system on 30-day mortality in elderly patients submitted to elective surgery. Additionally, the correlation of WHODAS 2.0 and Clinical Frailty Score (CFS) with mortality was evaluated. Settings and Design: An observational prospective study was conducted between May and July 2017. Methods and Material: Patients submitted to elective orthopedic, gynecologic, urologic, vascular, plastic, and general surgery were included. Exclusion criteria were as follows: age <60 years old; inability to give informed consent; emergency/urgency surgery, inability to understand Portuguese; patients admitted in the ICU after surgery. POSSUM was used to estimate postoperative mortality risk. WHODAS 2.0 and CFS were used to assess quality of life and health status. Mortality was evaluated during hospital stay and 30 days after surgery. area under the receiver operating characteristic (AUROC) was analyzed to test the discrimination of P-POSSUM, WHODAS 2.0 and CFS scale. Statistical Analysis Used: Statistical analysis was done using the SPSS Software (version 24.0). Results: POSSUM-predicted mortality was 3.0% with a standardized mortality ratio = 0.87; 95% CI 0.62–0.93; and a good calibration (H–L: P = 0.646); however, the AUROC was poor (0.563). We identified an association between mortality and a higher CFS grade (P = 0.000 and AUROC = 0.859) and a higher WHODAS 2.0 score (P = 0.000 and AUROC = 0.808). Conclusions: WHODAS and CFS appear to be a better assessment tolls for predicting postoperative mortality with a good discrimination comparing with P-POSSUM system.

Comparative study of mid-thoracic spinal versus epidural anesthesia for open nephrectomy in patients with obstructive/restrictive lung disease: A randomized controlled study Nazmy Edward Seif, Ahmed Mohamed ELbadawy Saudi Journal of Anaesthesia 2019 13(1):52-59 Background: The aim of this randomized controlled study is to compare the safety and efficacy of thoracic spinal versus thoracic epidural anesthesia for open nephrectomy in patients with obstructive/restrictive lung disease. Methods: Sixty patients with mild to moderate chronic obstructive/restrictive lung disease undergoing open nephrectomy were randomized into two groups, 30 patients each. The thoracic spinal group (TSA) group received ultrasound guided mid-thoracic spinal anesthesia, and the thoracic epidural group (TEA) group received thoracic epidural anesthesia. All blocks were performed at the T7-T8. Hemodynamics, visual analogue scale score, sensory and motor block profile as well as any adverse events, and patient satisfaction were all reported. Results: Both blocks were successfully performed and were effective for surgery in all patients, with the exception of only one patient in TSA group who needed to receive general anesthesia even after IV midazolam because of extreme anxiety and was excluded from the study analysis. The sensory block ranges were quiet close, with T2-T5 for the TSA group and T3-T6 for the TEA group as the upper level and L3-L5 as the same lower level. The values for the onset time and the duration of sensory and motor blocks were lower in TSA group. There were no statistically significant differences existed in intraoperative VAS, and hemodynamics between the two groups. Postoperative adverse effects were negligible and insignificant, with no case reporting any neurological sequel. Conclusion: Ultrasound guided thoracic spinal anesthesia can be performed safely and effectively for open nephrectomy in patients with obstructive/restrictive lung disease with the potential for an early ambulation and great patient satisfaction.