Neonatal & Paediatric Point Of Care Ultrasound (Pocus): A Novel Standard Practice

An ever expanding branch of applications have been developed for ultrasound, including its goal directed use at the bedside, often called point-of-care ultrasound (POCUS). ). Although neonatologist-performed functional echocardiography has been at the frontline of the worldwide growth of POCUS, a rapidly growing body of evidence has also demonstrated the importance of non-cardiac applications, including guidance of placement of central catheterisation and lumbar puncture, endotracheal tube localisation as well as rapid estimation of the brain, lungs, bladder and bowel. Ultrasonography has become a pivotal adjunct to the care of neonates in the neonatal intensive care unit (NICU); but a full appreciation for its diagnostic capabilities in the NICU is lacking.(2) Ultrasonography (USG) is no longer the exclusive domain of radiologists and cardiologists. With appropriate training, clinician performed ultrasound (CPU) is now practised widely in obstetrics, emergency medicine and adult intensive care .In many developed countries,it is standard practice in neonatology. (3) In this review, we will discuss neonatal & pediatric point of care ultrasound (POCUS) as a novel standard practice & its clinical application for assessment of the head, heart, lung, gut, bladder, for vascular line localization & for endotracheal tube placement. As new applications and adoption of point-of-care ultrasound continues to gain acceptance in paediatric and neonatal medicine throughout the world, a rapidly growing body of evidence suggests that the result will be faster, safer and more successful diagnosis and treatment of our patients.

DETERMINANTS OF ORAL ENDOTRACHEAL TUBE PLACEMENT: A CROSS SECTIONAL STUDY

Introduction: Finding the best depth of endotracheal tube (ET) placement has been a challenge because of the complications caused due to its malposition. Aims: To nd the best depth of placement of oral ET in Indian adult patients. Methods And Design: This study was conducted in 125 ASA I and II patients requiring general anaesthesia and orotracheal intubation. Methods: After placing the ET with the designated black mark at vocal cords, various airway distances were measured from the right angle of mouth using a bre optic bronchoscope. Statistical Analysis: Mean (SD) and median (range) of various parameters and Pearson correlation coefcient was calculated. Results: The mean lip-carina distance, i.e., total airway length was 23.52±1.72 cm and 22.11±1.26 cm in males and females, respectively. With black mark of ET between vocal cords, the mean ET tip-carina distance of 4.19±1.60 cm in males and 2.78±1.52 cm females was found to be less than the recommended safe distance. Conclusions: Height has the best correlation to lip to carina distance. Fixing the tube at recommended distances in both male and female will lead to carinal stimulation or endobronchial placement in many Indian patients. The formula “(Height in cm/7) -2.5.” gives us an idea about the approximate depth of ET placement.

Upright (45°) Versus Supine Position for Intubation in Intracranial Bleed Patients

Objective: To find out the effective method of endotracheal intubation among patients of intracranial bleed. Methods: A quasi experimental research was performed at emergency department of Ziauddin University Hospital Karachi. 236 intracranial bleed patients were selected by consecutive sampling, half of them were intubated at upright position (45°) and remaining half at supine position. Patients of musculoskeletal deformities, ischemic stroke and previously intubated were excluded. Success or failure of endotracheal tube was confirmed by measuring oxygen saturation and audible breath sounds on chest. Results: Success rate of endotracheal placement (p-value <0.001) was high in upright position 115 (97.5%) as compared to supine position 90 (76.3%). Similarly, endotracheal tube placement attempts (p-value <0.001) and completion time (p-value <0.001) was low in upright position 1.1 ± 0.4 and 62.9 ± 24.9 sec as compared to supine position 1.5 ± 0.9 and 90.2 ± 67.9 sec. Conclusion: Endotracheal intubation of intracranial bleed patient at upright position is more successful, effective, less painful in terms of number of attempts and less time consuming as compared to supine position.

CASE OF VACTERLASSOCIATION WITHOUT THE "V AND L": ANAESTHETIC CHALLENGES

Aim & Objective: To highlight the importance of anesthetic management in a small neonate with cleft lip, cleft palate, single kidney, atrial septal defect, posted for trachea-oesophageal stula repair. Case description:Afemale baby born at 35 weeks of gestation to a 23-year-old primigravida mother by caesarean section in view of foetal distress with breech presentation .Baby had difculty in breathing and froathing from mouth. Cleft lip and cleft palate was present. Anasogastric tube was not going beyond 11 cm per oral route. Chest x ray showed coiling of tube in upper esophagus.F/S/O Type C Tracheo esophageal stula. . Plain Xray abdomen showed presence of bowel gas. Ultrasonography of the abdomen showed right renal agenesis. The left kidney was normal. Echocardiography showed presence of atrial septal defect with left to right shunt, tiny patent ductusarteriosus, mild pulmonary arterial hypertension, mild tricuspid regurgitation. Based on the presence of tracheoesophagealstula, atrialseptal defect, unilateral renal agenesis and absence of features, suggestive of alternative diagnosis infant, meet criteria of vacteral association. Discussion: VACTERL is a cluster of congenital malformations based on the non-random association of various congenital malformations in a single patient. Here “V” denotes vertebral defects or vascular anomalies (single umbilical artery), “A” anal atresia, “C” cardiac abnormalities, “TE” tracheoesophageal stula, “R"renal (kidney) abnormalities and “L” for limb anomalies) Diagnosis of VACTERL association is done only when at least three of the above mentioned congenital malformations are identied in a patient. Although 80% of these cases have vertebral defects, our case is unique as patient does not have one of the commonest occuring association i.e., vertebral anomalies. The other highlight of this case is although reports say that VACTERL babies with ipsilateral renal disorder have the same side limb defects, our case has a renal anomaly with no limb anomaly. Conclusion: Anaesthetic challenges were difcult airway, endotracheal tube placement, low respiratory reserve, small maximum allowable blood loss, long duration of surgery, risk of hypothermia, aspiratedlungs, risk of right to left shunt, difculty in securing intravenous line and intra arterialline. this case needs continuous monitoring of ECG, invasive blood.

THE SENSITIVITY, SPECIFICITY AND ACCURACY OF STATIC METHOD OF ULTRASONOGRAPHY TO CONFIRM ENDOTRACHEAL INTUBATION IN EMERGENCY DEPARTMENT.

Aims and objectives: This study aims to assess the diagnostic accuracy and timeliness of ultrasonography by static method only for identication of Endotracheal tube (ET Tube) placement in the trachea in emergency settings vs existing clinical methods. Material and Methods: This prospective study was carried out in the emergency room from October 2018 till the end of March 2019. The ultrasonography was performed in 120 emergency patients only after the intubation had been completed ie, static phase. A linear probe was used over the neck to identify the predened signs of ET intubation. Residents who perform ultrasound examination ll a form after assessment of each patient. Results: It was found that Tracheal Intubation-USG Sensitivity was 99.1, Specicity was 91.7, Positive Predictive Value: 99.1, Negative Predictive Value was 91.7 and Accuracy was 98.3%. Ultrasonography can be used as an adjunct tool to verify the ETTposition by Emergency Physicians which can be performed easily after a brieng or short-course training.Conclusion:This study demonstrates that US imaging has a high diagnostic accuracy to immediately conrm proper ETT placement post-intubation in an emergency setup. Therefore, it seems that ultrasonography using a static technique only is a proper screening tool in determining endotracheal tube placement.

Optical Devices in Tracheal Intubation—State of the Art in 2020

The review article is focused on developments in optical devices, other than laryngoscopes, in airway management and tracheal intubation. It brings information on advantages and limitations in their use, compares different devices, and summarizes benefits in various clinical settings. Supraglottic airway devices may be used as a conduit for fiberscope-guided tracheal intubation mainly as a rescue plan in the scenario of difficult or failed laryngoscopy. Some of these devices offer the possibility of direct endotracheal tube placement. Hybrid devices combine the features of two different intubating tools. Rigid and semi-rigid optical stylets represent another option in airway management. They offer benefits in restricted mouth opening and may be used also for retromolar intubation. Awake flexible fiberoptic intubation has been a gold standard in predicted difficult laryngoscopy for decades. Modern flexible bronchoscopes used in anesthesia and intensive care are disposable devices and contain optical lenses instead of fibers. Endotracheal tubes with an incorporated optics are used mainly in thoracic anesthesia for lung separation. They are available in double-lumen and single-lumen versions. They offer a benefit of direct view to the carina and do not require flexible fiberscope for their correct placement.

The Effect of Fiberoptic Bronchoscopy-guided Technique for Placement of a Left-sided Double-lumen Tube on the Intubation Performance Compared with the Conventional Method Using a Macintosh Laryngoscope

Background: The accurate placement of the double-lumen endotracheal tube is imperative for effective one-lung ventilation in thoracic surgery. Malpositioning and repositioning of a misplaced tube may cause excessive trauma. Objective: We hypothesized that the fiberoptic bronchoscope-guided method for double-lumen endotracheal tube placement would reduce the incidence of malpositioning as compared to the conventional method using the Macintosh laryngoscope. Methods: Fifty patients scheduled to undergo elective thoracic surgery were recruited and randomly assigned to the fiberoptic bronchoscope-guided [n=25; Group F] and conventional [n=25; Group C] method groups, according to the method of double-lumen endotracheal tube placement. The primary outcome was the incidence of double-lumen endotracheal tube malpositioning observed under the fiberoptic bronchoscope after initial placement. Secondary outcomes included the times for placement, confirmation, and total procedure of double-lumen endotracheal tube intubation. Results: The incidence of malpositioning after initial double-lumen endotracheal tube placement was significantly lower in Group F than in Group C (20.0% vs 68.0%). In addition, the time for placement was significantly higher in Group F than in Group C, and that for confirmation was significantly lower in Group F than in Group C. Conclusion: The fiberoptic bronchoscope-guided method for double-lumen endotracheal tube placement can reduce the incidence of malpositioning after initial placement and expedite the intubation process with a double-lumen endotracheal tube in thoracic surgery.