SummaryRemifentanil is increasingly being used as the primary agent to provide sedation during awake fibreoptic nasal intubation. In this observational study, we aimed to determine the optimal effect site concentration of remifentanil, using a target controlled infusion based on the Minto pharmacological model, to provide optimal safe intubation conditions without the use of other sedatives ⁄ premedication and ⁄ or spray-as-you-go local anaesthesia. Twenty patients with anticipated difficult airway participated in the study. Good intubating conditions were achieved in all patients with mean (SD) effect site concentration of 6.3 (3.87) ng.ml )1 of remifentanil recorded at nasal endoscopy and 8.06 (3.52) ng.ml )1 during tracheal intubation. No serious adverse event occurred during any of these procedures. These preliminary findings suggest that this is a feasible and safe technique for awake fibreoptic nasal intubation.
Congenital diaphragmatic hernia (CDH) is a defect in the dome of diaphragm, more often in left and posterior-lateral that permits the herniation of abdominal contents into the thorax. Treatment requires stabilization prior to surgical correction. The best hospital series report 80-100% survival. The objective of the study was to present the experience regarding management of selected respiratory stable cases of CDH in non intensive care setup. Retrospective case series analysis was conducted on total 17 stable acyanotic patients with or without oxygen support and left sided defect were planned for surgical correction. Surgery was done per abdominally through left subcostal incision. In postoperative ward, patients received oxygen with nasal cannula and assisted ventilation with artificial manual breathing unit (AMBU) bag through ETT (endotracheal tube) if required. Patients vital parameters; pulse, respiration, oxygenation (SpO2) and hydration were monitored throughout postoperative period. Oral feeding was started after bowel movement on 2nd or 3rd postoperative day. Plain X-ray of the thorax and abdomen was repeated on 4th or 5th postoperative day to asses lung expansion. Postoperative follow up was given at one week and one month after discharge. The age of the patients ranged from 2 days to 2 year 6 months and the mean (SD) age and body weight was 1.2 (0.6) and 5.0 (1.2), respectively. The male/female and vaginal/cesarean delivery ratios were 12:5 and 10:7, respectively. Associated congenital anomalies found were 3 (17.7%): 1 (5.9%) cleft lip and palate, 1 (5.9%) undescended testes and 1 (5.9%) hypospadias. Respiratory distress was found in 15 (88.2%) patients and 2 (11.8%) patients with recurrent abdominal distension and vomiting. One baby needed assisted ventilation with endotracheal tube and AMBU bag for 24 hours postoperatively. One case with pneumothorax required chest drain for 5 days. All other patients had good lung expansion, correction of mediastinal shifting and no evidence of any pleural effusion. All babies tolerated feeding well postoperatively after bowel movement. Survival rate was 100%. The higher survival rate among the more mature babies suggests natural selection of those with minimal respiratory impairment. In our short series survival was 100% where surgical correction was made on selective 17 cases of left sided CDH in a non intensive care setup.Mediscope Vol. 3, No. 1: January 2016, Pages 16-21
Spinal anaesthesia in children evolved more than hundred years ago and gaining considerable popularity worldwide. In our setups in Bangladesh, this technique has not gained popularity yet but over the past few years this technique has been practiced in some centers. The objective of the present study was to observe the efficacy and safety of spinal anaesthesia under sedation in children scheduled for infra-umbilical surgical procedures. In this study, 67 children of age ranging from 2 to 10 years of either sex, with American Society of Anaesthesioloists physical status I and II, undergoing infra-umbilical surgeries were included. Spinal anaesthesia was administered with Quincke 27 gauge needles between L4L5 or L5-S1 interspace in the lateral position under sedation with ketamine and midazolam. Heart rate, mean arterial blood pressure and oxygen saturation (SpO2) were monitored throughout perioperative period. Complications of sedation and spinal anaesthesia were recorded and managed accordingly. Among 67 children, male and female were 62 (92.5%) and 5(7.5%), respectively. The mean (SD) age, body weight, American Society of Anaesthesiologists physical status I and II was 5.2 (2.1) years, 15.5 (4.8) kg, 60 (89.6%) and 7 (10.5%), respectively. Successful spinal anaesthesia was done in all cases. The incidences of side effects of sedation were transient apnoea 1 (1.5%), desaturation (SpO2<93%) 3 (4.5%), stridor 1 (1.5%), laryngospasm 1 (1.5%) and agitation 4 (6.0%). Side effects were transient, self limiting and managed conservatively. Complications of spinal anaesthesia were hypotension 2 (3.0%), bradycardia 1 (1.5%), shivering 1 (1.5%), nausea and vomiting 1 (1.5%) and backache 1 (1.5%). The complications were minor and managed accordingly. There were no serious adverse events reported in any child. The mean (SD) operation time and recovery time from anaesthesia was 49.2 (8.4) minutes and 91.2 (9.2) minutes, respectively. Spinal anaesthesia under sedation with ketamine and midazolam is safe and effective technique for paediatric infraumbilical surgery.Mediscope Vol. 4, No. 1: Jan 2017, Page 18-24
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