Effectiveness Comparison of Using Macintosh Blade and Mccoy Blade For Endotracheal Intubation In Anesthesia Residents

Introduction: Laryngoscopy is one of the critical points in the intubation process and a mechanical trauma that provides noxious stimulation, affecting cardiovascular, respiratory, and intracranial changes. Practitioner competence is a significant factor that supports laryngoscope intubation procedures. That can influence the intubation duration and amount of mechanical trauma besides caused by laryngoscope type. Objective: To analyze the effectiveness of using Macintosh blade compared to McCoy blade in intubation laryngoscopy by Anesthesia Residents. Materials and Methods: This research is an experimental study in adult patients who underwent elective surgery at GBPT Dr. Soetomo Hospital. Intubation did by Anesthesia Residents at levels 5-9 using Macintosh or McCoy Laryngoscope and chosen randomly. The data of laryngeal visualization (Cormack Lehane), hemodynamics (blood pressure, pulse), pain scale (qNOX), intubation time length, and pain scale data (VAS) after extubation were taken during intubation laryngoscope. Result and Discussion: The study was conducted on 28 samples that met the criteria. Anesthesia Resident's competence levels based on the semester in both groups laryngoscopes were not different (p 0.868). Based on laryngeal visualization data laryngoscopy, the McCoy's blade had better visualization with CL 1 at 85.7% of the samples and p-value 0.020. This good visualization makes it possible to speed up the laryngoscope-intubation in the McCoy blade group with a significant difference of time compared to the Macintosh blade group. Hemodynamic parameters, there were significant differences for hemodynamics increase. In the Macintosh blade group, the blood pressure and pulse were significantly increased after laryngoscopy intubation. The pain scale during the intubation procedure, which was rated based on the qNOx score, showed a significant increase in the Macintosh blade group with a p-value of 0.003. The postoperative pain scale (VAS) was smaller in the McCoy blade group compared to the Macintosh group (p-value <0.001). Conclusion: The ability to use both laryngoscopes at some levels of Anesthesia residents was equally good, and the use of McCoy Blade is more effective than Macintosh Blade in the intubation laryngoscopy procedure.

Accuracy Comparison of Endotracheal Tube (ETT) Placement Using Chula Formula With Manubrium Sternal Joint (MSJ) Formula

Introduction: Intubation mistakes, such as ETT malposition, will result in serious complications. Endobronchial intubation can cause pneumothorax and contralateral lung collapse (atelectasis). On the contrary, superficial ETT could increase the risk of being released easily, leading to desaturation or even cardiac arrest. A shallow ETT position could cause the compression of the vocal cord and laryngeal nerve by ETT's cuff. An optimal position can be reached if the cuff position is 1.5-2.5 cm under the vocal cord and the tip is 3-5 cm above the carina. Several methods of ETT depth measurement based on airway length data can be an alternative, especially during the COVID-19 era, where the use of a stethoscope to check ETT depth is limited. Objectives: To analyze the accuracy of ETT depth placement using Chula and MSJ formula. Methods and Material: We conducted the prospective comparative analytic research on 50 patients who had elective surgery in GBPT operating room at Dr. Soetomo Hospital Surabaya. The research data during the intubation and FOL (Fyber Optic Laryngoscope) from each patient were height, MSJ length, initial ETT length, the distance of carina-ETT tip, the distance of cuff-vocal cord, and final ETT length. Result and Discussion: In the Chula formula group, the average patients' height was 160.60cm ± 9.738 for men and 157.76 cm ± 8.604 for women. The average MSJ length was 20.28 cm. The application of the Chula formula is more accurate because ETT revision was carried out in only 8.0% of the samples, with an average revision is 0.04. On the other hand, the ETT revision with an average of 0.868 on the MSJ formula group was conducted in 84% of the samples. This research also found a linear correlation between increasing ETT depth and body height. Conclusion: Applying the Chula formula to measure the ETT depth for Indonesian (Javanese) people is more appropriate than the MSJ formula.

Validity of Urine Syndecan-1 as A Predictor of Acute Kidney Injury In Pediatric Sepsis Patients

Introduction: AKI (Acute Kidney Injury) complications in sepsis patients generally occur 24 hours after admission to ICU. Creatine Serum Concentration is a standard parameter to diagnose AKI. Unfortunately, the changes in creatine serum concentration will only be seen several days after the decrease of renal function to 50%. The low detection ability has been linked with time loss before preventive therapy is commenced. Furthermore, this instigates the need for biomarkers to ensure early detection. Objective: This study aimed to identify cut-off points of urine syndecan-1 and to measure the prediction ability of urine syndecan-1 towards the AKI occurrence in pediatric sepsis patients. Materials and methods: This study was a prospective cohort study performed at a single center in Dr. Soetomo General Hospital, Surabaya. The inclusion criterion was all children admitted to the resuscitation room from October until December 2019. Furthermore, urine sampling is carried out at 0, 6, 12, and 24 hours for a syndecan-1 urine examination, and every procedure performed on the patient will be recorded. This action was continued up to the third day and aimed to evaluate some factors related to AKI at 48-72 hours of admission. Result and Discussion: Out of 41 pediatric sepsis patients, 30 patients fulfilled the inclusion criteria and 57% had AKI. The value of urine syndecan-1 at hour-0 and hour-6 was significantly featured a cut-off point. Conclusion: The value of urine syndecan-1 at hour-0 and hour-6 are valid parameters to predict the occurrence of AKI grades 1, 2, and 3 in pediatric septic patients at 48-72 hours after their hospital admission. The best cut-off value of urine syndecan-1 at the 0th hour was 0.67 ng/ml.

In Pursuit of Phrenic Nerve-Sparing Regional Anesthesia For Awake Shoulder Manipulation In Patients With Adhesive Capsulitis

Introduction. While interscalene brachial plexus block remains the gold standard of any shoulder procedure, including shoulder manipulation in patients with adhesive capsulitis, anesthesiologists are reluctant to face the risk of phrenic nerve paresis, especially in patients with preexisting pulmonary conditions. Hence, many studies have targeted specific regional anesthesia of the shoulder low enough by the blockade level, leaving phrenic nerve function intact but still providing satisfying anesthesia for shoulder procedures. Until recently, no comparison between these regional anesthesia techniques focusing on shoulder manipulation for adhesive capsulitis has been published. Case Report. We compared the profiles between suprascapular nerve block, shoulder interfascial plane block, and superior trunk block as the sole anesthesia technique in patients with adhesive capsulitis undergoing awake shoulder manipulation. Conclusion. This report descriptively signifies superior trunk block excellence among other regional anesthesia techniques in achieving complete anesthesia for awake shoulder manipulation in patients with adhesive capsulitis while sparing the phrenic-nerve function

Profile of Patients With Respiratory Failure at Pediatric Intensive Care Unit (PICU) Dr. Soetomo General Hospital

Introduction: Respiratory failure is the respiratory system’s inability to maintain its gas exchange functions, oxygenation, and carbon dioxide elimination. Infant and children are more susceptible to develop respiratory failure. Respiratory failure can also be caused by several diseases/conditions, which is a common reason for pediatrics to be admitted to the intensive care unit. Objective: This study aims to describe patients’ demographic and clinical profile with respiratory failure at the PICU of Dr. Soetomo General Hospital, Surabaya. Materials and Methods: This is a prospective study with the descriptive method using the medical records of patients with respiratory failure who were admitted to the PICU from September 2019 to February 2020 and had arterial BGA data (PaCO2, PaO2), which were examined in the PICU or resuscitation room before the patients were admitted to the PICU. Results: This study showed that out of 35 patients, 24 (68.6%) were female, 19 (54.3%) were <1 year old, and 20 (57.1%) had normal nutritional status. Type I (hypoxemic) and type II (hypercapnic) respiratory failures were found in 13 patients (37.1%), respectively. The most common clinical signs were fever in 26 patients (74.3%), shortness of breath in 24 patients (68.6%), and chest retraction in 24 patients (68.6%). The primary diagnosis that commonly occurred was respiratory system disorders in 15 patients (42.9%). The other diagnosis that mainly occurred was nutrition and metabolic disorders of 19 patients (54.3%). The patients' outcome was that 24 patients were survived (68.6%), and ten patients died (28.6%). Conclusions: Various clinical signs and diagnoses can be found in patients with respiratory failure at PICU. The most common respiratory failure types are type I (hypoxemic) and type II (hypercapnic) respiratory failure.

The Use of Modified High Flow Nasal Cannula (HFNC) In Preterm Infants With Neonatal Respiratory Distress Syndrome (NRSD) In Primary ICU Services

Introduction: NRSD (Neonatal Respiratory Distress Syndrome) is one of the most frequent causes of newborns in intensive care (NICU). Several NICU centers are now using the High Flow Nasal Cannula (HFNC) in recent years. With the use of HFNC as a breath aid in preterm infants, HFNC had the same efficacy ratio as nasal Continuous Positive Airway Pressure (CPAP) (continuous or intermittent). Case Report: A three-day-old baby boy was admitted to anesthesia with respiratory failure due to grade II HMD with suspicion of congenital heart failure. The initial condition showed that a respiratory rate of 70-80x / minute, breathing of the nostrils and retractions in the intercostals and abdomen with 85% post ductal SpO2 with the help of a CPAP mask (Pinsp 10, Fio2 70%). There was a Ronchi sound in the right and left basal lungs, and hemodynamics obtained a pulse of 180-195x / minute, non-invasive blood pressure 95/34 mmHg (54), heart murmurs were not found. During day 1 - day three, the patient uses a CPAP mask until the patient vomits and being consulted to an Anesthesiologist. On day 3 - day seven, the patient uses HFNC; after day seven until day 10, the patient uses neonatal nasal canularis oxygen. Until day 10, the patient is still being treated at the NICU by administering oxygen 0.5 liters/minute with SpO2 ranging from 93-96% with stable conditions but still needing oxygen. Conclusion: The use of Modified High Flow Nasal Cannula (HFNC) in preterm infants with Neonatal Respiratory Distress Syndrome (NRSD) is more effective and efficient than CPAP. The use of HFNC was associated with a lower incidence of nasal trauma and pneumothorax than nasal CPAP.

Modified Infant Feeding Tube as an Indigenous Endotracheal Tube in Unanticipated Congenital Subglottic Stenosis

Introduction: In neonates with an unanticipated difficult airway, there is an increased probability of failed intubation even with highly trained hands while performing direct laryngoscopy. Aims: We describe our experience of using a modified infant feeding tube (IFT) as an indigenous endotracheal tube (ETT) in a series of paediatric surgical patients with congenital subglottic stenosis (SGS). Material and Methods: A retrospective study was performed in our institute from January 2018 to December 2019. ETT with modified 6 and 8 French (Fr) sized IFT’s were used. A stylet obtained from the VP shunt system was used to aid in intubation. Results: Out of 12,500 admissions in our department, there were 5 pediatric cases with SGS which were managed using modified IFT. Four were neonates and 1 infant (M:F = 2:3). Modified IFT(s) were used after failed intubation with ETT of size 2.5 mm in 4 patients (non-availability of ETT of size 2 mm), while in one neonate, even 2 mm ETT could not be negotiated due to SGS. In all the 5 children, successful intubation was finally performed with modified 8 French (Fr) IFT in 3, and with modified 6 Fr IFT in two cases. The surgical procedure was completed in 4 neonates out of 5 cases, while in one infant it was deferred due to the clinical condition of the patient and significant SGS. Conclusion: All 5 patients with SGS were managed without performing a tracheostomy. Modified IFT(s) is an effective alternative if smaller sized ETT(s) cannot be negotiated or unavailable in difficult neonatal and paediatric airway. This modified IFT as ETT has to be an important part of the emergency airway tray. It should not be considered as a replacement for routine use of standard ETT.

Systematic Review Comparison of Endotracheal Intubation Success Rate Using McGrath® Mac Videolaryngoscope with Direct Laryngoscope (Macintosh): A Manikin Studies

Introduction: McGrath® MAC videolaryngoscope is a single-handed device designed to facilitate intubation in patients both in patients with normal airway conditions (without any complications) or airway conditions with complications such as cervical spine and/or anatomic abnormalities. Objective: This study aims to compare McGrath® MAC videolaryngoscope and direct laryngoscope using Macintosh blades as learning material or study simulators for medical personnel (including anesthesiologist and paramedics) and novice operator (medical students). Method: this study is a systematic review using the PRISMA method which was carried out systematically. Data was collected through Pubmed, direct science, EBSCOHost, and Proquest using the keywords ‘airway management ', ‘laryngoscopy', and 'manikin'. Journal included based on published publication time between 2008 and 2020, a study using SimMan Laerdal Airway manikin, a journal discussing intubation using McGrath® MAC videolaryngoscope and direct laryngoscope with Macintosh blades here, where it is normal airway (without complications) and difficult airway. Results: 1556 journals were collected through 4 journal search sites and then carried out a screening process for the publication year approved in 2008 to 2020. Four studies use adult manikin SimMan Laerdal Airway including 247 participants were included in this systematic review. Conclusion: Based on journals that have been reviewed, McGrath® MAC videolaryngoscope provides better and superior results compared to Macintosh in terms of the success rate and visualization of glottis. Also, the intubation time using McGrath® MAC videolaryngoscope is shorten compared to Macintosh both on the normal airway (without complication) and difficult airway. The participants (medical personnel and novice operators) in all studies that reviewed prefer to use McGrath® Mac videolaryngoscope instead of using direct laryngoscope with Macintosh blade for Endotracheal Intubation mainly used for learning or study simulators.

The Role of “Robotic Assisted Intensivist” As Solution Of Resources Management In Covid-19 Pandemic Era

Providing expertise in the care of critically ill patients is one of the main needs of critical care medicine, especially in the COVID-19 pandemic era. This goal is particularly challenging, given the acknowledged shortage of intensive care specialists. We need the bedside nurse to have real-time access to get continuous reporting monitoring. The intensivist also has access to bed site examination at some time when they are not possible for coming to the intensive care unit (ICU). The big problems during COVID-19 are the limited personal protective equipment, the limited number of intensivist doctors, and the nature of the disease was very contagious and deadly. It is necessary to find a solution so as not to cause new problems, namely the death of medical staff and nurses due to frequent contact with Covid-19 patients. In this article, the author wants to open a view to getting solutions to problems in the field by presenting human replacement technology.

Laparotomy Exploration In Pediatric With Severe Thrombocytopenia: A Report

Introduction: Perioperative bleeding in patients was a serious problem in the exploration of laparotomy, especially in severe thrombocytopenia patients. In addition, spontaneous bleeding often occurs in patients who have a platelet count of less than 10 to 20.109 cells. L-1 blood. When surgery must be performed on a patient with platelet counts < 50.109 cells L-1, platelet concentrate was urgently needed to be transfused during induction of anesthesia. Benefits and risks of transfusion before surgery had to be done on a per-patient basis. The available data was very limited in informing perioperative management of patients with thrombocytopenia. However, there have been previous reports of surgery cases in 66-year-old patients with a history of immune thrombocytopenia (ITP) and diagnosed with acute appendicitis related to disseminated intravascular coagulation (DIC), showing excellent postoperative hemostasis. Another one, a seven-year-old boy who has a severe refractory case of ITP with very low platelet counts was referred to urgent splenectomy performed without increase platelet counts before, and then the patient underwent plasma exchange (PE) after surgery. Those reports aimed to present 2 cases of laparotomy exploration in pediatric patients with severe thrombocytopenia. Case Report: The first laparotomy exploration was conducted on an 11-year-old boy who suffered acute perforated appendicitis. The patient obtained general anesthesia with intubation. The second laparotomy exploration was conducted on a 1-month-old baby boy with a weight of 3400 grams who suffered bowel low-level obstruction suspect Hirschsprung disease. The patient also obtained general anesthesia with intubation. Discussion The general anesthesia with oral intubation was successfully afforded to both patients for the laparotomy exploration with the preoperative condition under severe thrombocytopenia with receiving platelet transfusion therapy before surgery. Complications of spontaneous bleeding at the time of intubation were not found, no bleeding-difficult-intubation during surgery, and no symptoms of spontaneous bleeding were found. Postoperatively, platelet levels gradually improved. Conclusion: Exploration of laparotomy in patients with severe thrombocytopenia can be carried out with the support of platelet transfusion and providing general anesthesia with oral intubation to patients.