Volume 17 No. 1&2 2004 Make
JOURNAL OF THE BANGLADESH SOCIETYOF ANAESTHESIOLOGISTSVOLUME - 17NUMBER - 1 & 22004CONTENTSEditoriallInformation Technology (IT): Means of Improving Patient Care in OT & ICUOriginal ArticlelAssessment of Tracheal Intubation GradingMir Mahmud Hossain, Moniul Hossain, AKM Akhtaruzzaman,Kazi Mesbahuddin Iqbal13lEffect of Hydroxyethyl starch for preloading in pre-eclamptic patientsundergoing caesarean section under sub-arachnoid block : A comparisonwith Hartman’s solutionsMd. Shahidul Islam, Abdul Kader, AKM Akhtaruzzaman, KM IqballPost-Operative Pulmonary Function : A Comparison between UpperAbdominal Open Cholecystectomy and Laparoscopic CholecystectomyShahnaz Afroza, M.M. Masum-Ul- Haque, Nibedita Nargis,Nezamuddin Ahmed, Lutful Aziz, KM Iqbal12lPre-emptive analgesia : effect of low dose Ketamine as pre-emptive analgesiain postoperative pain management after lower abdominal surgerySajjad Ahmed, Md. Mozaffer Hossain, U H Shahera Khatun17lMidazolam and Thiopentone as Co-InductionMd. Habibur Rahman, Mahbub Hassan, Md. Monirul Islam23lFoeto-Maternal Outcome in Pre-Eclamptic Parturient UndergoingCaesarean Section -Influence of Pre-Operative Control of Blood PressureM Mozaffer Hossain, AKM Akhtaruzzaman, Hasina Begum,Niaz Ahmed, M Khalilur Rahman28lTracheal Intubation without Muscle Relaxant ComparisonBetween Three TechniquesM. Ali, KM Iqbal, AYF Elahi Chowdhury32lRadio-frequency thermal ablation of lung cancer under epidural anaesthesia:comparison of the effectiveness of blocks between higher and mid-thoracic levelMR Khandoker, H Razwanul, H Rashadul, AM Sarwar, UH Shahera Khatun36Review ArticlelPre-Anaesthetic Assessment: It’s Role in Preventing MortalityBrig. General Razia Khanam (Rtd.)Case ReportlHigh Thoracic Epidural anaesthesia for Off-pump CABG in aspontaneously breathing (conscious) patient (ACAB)Naimul Haque, Shahadat Hossain, Shahnaz Ferdous,NA Kamrul Ahsan, Nazmul HossainlObituary7394851
Journal of BSA, Vol. 17, No. 1 & 2, 2004EditorialINFORMATION TECHNOLOGY (IT): MEANS OFIMPROVING PATIENT CARE IN OT & ICUThe information technology immensely influencesthe medical practice, education and research whichinclude computer system and communication tools.Impact of information technology on medicalprofession is increasing in the same race as withdevelopment of component technologies likeprocessors, memory, network and software.Recently the physicians are becoming morefamiliar with information technology in applyingthese tools to their patient management.ComputerA computer is an electronic device that accepts,processes, stores and then output the data accordingto programmed instructions. The computer and theinformation it provide, are being used in the ICUand operation theatre, where the patient’s life is atthe stake. Like the other specialty,anaesthesiologists also find it very convenient touse computerized devices to serve their purpose.The internet is probably the most reliable sourcefrom where much information can be obtained. Inmost developed countries, the whole medicalcommunity has been linked together throughbroadband and net telephony. The dominantcomponent of the internet is World Wide Web(WWW). The web transmits both text and graphicsto a user’s computer screen through browsers.Beside web, other forms of communication on theinternet continued to be vital in facilitatingcommunication. Electronic mail (e-mail) is textbased form of communication employed by mostinternet users in a store-and-forward fashion. Theprotocols and procedures of the operating room andcritical care of some leading medical institutionsare available on net. The electronic form of Journaland current references are available globally. Theonline consultation practice is available in developedand some of the developing countries. Now-a-days,the internet has been associated with anaesthesiain various ways. Many web sites have beendeveloped where informations are available aboutanaesthesia, OT & ICU. But it should be used withcaution. Long and inaccurate sitting posture infront of computer may causes deep vein thrombosisand backache.Cell PhoneCellular phone improve communication and provedto be effective in updating the medical specialties.The Anaesthesiologists are highly mobile during theworking hour. Mobile phone is the best to keep intouch with these busy hospital staffs. It is alsobeneficial for multi-disciplinary care of the patientin ICU; where a prompt and accurate communicationimproves outcome of the patients. The patients inthe hospital feel lonely and felling of isolation isminimized by talking to the relatives and otherfamily members. Relatives sometimes have reliedimportant information to the other family members.The cell phone in medical scenario includes textmessaging to keep in touch with patients aboutappointments, treatment investigations, regularintake of medicine and preoperative findings for OPDanaesthesia. Cell phone is not without problem. Cellphone-operate with radio frequencies (RF) of 3 kHz– 300 GHz, which is one of the important form ofelectro-magnetic energy. The radio frequency energyis absorbed in human body at-specific absorption rate.When this absorption level is increased, the patientmay suffer from harmful biological effects. Excessiveuse may cause headache, nausia, dizziness, sleepdiscomfort and difficulty to concentrate. Mobilephones should not be used in areas, where medicalelectronic devices are used in patient care like CCU& ICU, HDU, OT, Cath Lab etc. Effect of long termuse is not-yet-known. Till to-day, use of the device isconsidered safe.ConclusionInternet and mobile phones have been proved tobe patient friendly. The anaesthesiologists andcritical care specialists are the best subscribersfor these information technologies. Theinformation technology can not solve all theproblems but it seems to have a genuine role inthe day-to-day medical practice which is nowconsidered to be an integral part of their patientmanagement.UH Shahera KhatunProfessor & Head, Department of AnaesthesiologyDhaka Medical College Hospital, Dhaka
Journal of BSA, Vol. 17, No. 1 & 2, 2004Original ArticleASSESSMENT OF TRACHEAL INTUBATION GRADINGMir Mahmud Hossain1, Moniul Hossain2, AKM Akhtaruzzaman2, Kazi Mesbahuddin Iqbal3SUMMARYIn this prospective study, one hundred adultpatients, fifty in each group were assessed beforeoperation, using the modified mallampati test inGroup-A and mallampati & measurement ofThyromental Distance (TMD) in Group-B. Thegroups were matched for age (P 0.539), Sex(P 0.688), weight (P 0.077), and ASA physicalstatus (P 0.436). Total number of patients facingdifficulties during intubation are significantlyhigher in the Group-A (18 in Group-A and 10 inGroup-B) (p 0.001). The measured sensitivity andspecificity in Group-A are 65% and 25% respectively.On the other hand, the sensitivity, specificity inGroup-B are 75% & 60%. So, the combination ofThyromental Distance and Mallampati test maybe done as screening test during preoperative visitwhich may present fatal consequences of difficultand or failed intubation.INTRODUCTIONTracheal intubation is an important maneuver inanaesthesia and in many emergency situations.Every year a good number of patients die as aresult of failed tracheal intubation. Poormanagement of difficult and failed intubation is asignificant cause of these anaesthetic morbidityand mortality. The reported incidence of difficultintubation is one in every 65 patients. Theincidence of failed intubation is approximately 1in 2000 in general surgical patient but 1 in 300 inobstetric patients1. The Confidential Enquiries intoMaternal Deaths indicates that on an average,three healthy pregnant women die each year solelyas a result of difficult and /or failed intubation.The Confidential Enquiry into Peri-OperativeDeaths (CEPOD) published in 1986 revealed thatout of 4034 deaths reported, six were related withdifficult or failed intubation. Worldwide, up to 600people are thought to die each year from difficultand / or failed intubation1. But, if prediction canbe made at preoperative visit, it will allow the1.2.anaesthesiologists to get prepared for this situationwhich may save many lives. Knowledge of detailedanatomy and development of techniques ofintubation are necessary for anticipation of difficultintubation. The best way to predict difficultintubation is direct laryngoscopic examination andgrading2. But it is not possible to practice in preanaesthetic check up room or during bedsideexamination. The available pre-operative testswhich may be used to predict difficult intubationare-Mallampati, Wilson risk score, horizontallength of mandible, mandibulo-hyoid distance,sterno-mental distance3,4,5. All are useful to someextent, which have been shown in various studiesto have high false-positive value, which detractsfrom their usefulness. Thyromental Distance(TMD) and other’s are useful but the sensitivity,specificity and positive predictive values of thesetests are still being studied. Research is still goingon to find out bedside simple test to anticipatedifficult tracheal intubation. A widely advocatedtest devised by Mallampati and his colleagues failto predict all the difficult cases4,5. ThyromentalDistance, - a method to predict difficult intubation,measures the distance between upper edge ofthyroid cartilage to chin with fully extended head.The Thyromental Distance of less than 6.5cmresults in less space for the tongue, which isdifficult to compressed by the laryngoscope bladefor pharyngeal view. Thyromental Distance isrelatively unreliable test unless combined withother test4,5. So the present study was proposedto assess and compare the specificity and sensitivityof Mallampati test with combined Mallampati testand Thyromental distance to assess the degree ofdifficulty during tracheal intubation.PATIENTS & METHODS:One hundred patients of both sexes requiringassessment for endotracheal intubation beforeelective surgery of different specialties wereDepartment of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical UniversityAssistant Professor, Department of Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib MedicalUniversity, Dhaka3. Chairman, Department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib MedicalUniversity, Dhaka
included in a double blind, randomized study. Theprotocol was approved by Protocol Review Boardof the Department of Anaesthesia, Analgesia andIntensive Care Medicine of BSMMU, Dhaka. Thepurpose of the study was clearly explained andwritten informed consent was taken from eachpatient. Ages of the patients were between 18 to30 years. The patients unable to understandnormal command were excluded, as were patientswith known airway abnormality; pathology in theneck, face, pharynx and larynx; injury to head &neck; cardio-respiratory disorders, pregnancy,collagen diseases and full stomach. No difficulty - Tracheal intubation could be donewithout any aids. Moderate difficulty - Needed some aids likepressure on cricoid cartilage. Difficulty - Other than pressure on cricoidcartilage, laryngoscopic blade to be changed orstylet to be used, but intubation are to be donein 1 minute. Failed intubation - Not possible to intubate withdifferent maneuver.All intubation was done by Anaesthetic Consultantin the operation theatre who was blinded aboutthe grouping. In case of failed intubation, thepatient was allowed to resume spontaneousventilation and the alternative airway managementprotocol were followed.All patients were allocated randomly into twogroups. Randomisation was done by card samplings.A total of hundred cards, fifty for each group wasprepared by another person. Every patient includedin the study was allowed to choose a card.According to card number, the patients weregrouped.Data were collected in a specially design ‘Datacollection sheet’. Data were analysed by Chi-square(c2) and Z test as appropriate using Sigma Plot11.1. The evaluation of sensitivity, specificity andpositive predictive value (the proportion ofpredicted intubation actually proved difficult) wasdone with 95% confidence interval. p 0.05 wasconsidered statistically significant (Table-I).In Group-A, the modified Malampati test (modifiedby Samsoon and Young) was performed in the preanaesthetic check up room. The patient seating ina chair or stool with a head in neutral positionfully opened his or her mouth and protruded thetongue as far as possible. The observer looked fromthe patient eye level and inspected the pharyngealstructures by pen torch.RESULTSThe two groups were statistically matched for age(P 0.539), Sex (P 0.688), weight (P 0.077), andASA physical status (P 0.436).In Group-B, a combination of Malampati test wasperformed and Thyromental distance wasmeasured in each patient. In the pre-anaestheticcheck up room the modified Malampati test wasperformed as it was done in Group-A. ThenThyromental Distance was measured in the samepatients from upper edge of thyroid cartilage tochin with head fully extended by a slide calipers.The mallampati class and Thyromental Distancewere recorded in a prescribed data collectionsheet.Table-IPatient characteristicsParametersGroup - AGroup - Bp ValueAge in years24.06 4.0324.56 4.060.539Weight in kg51.76 7.5749.06 7.650.07721(42%)29 (58%)0.6880.436SexMale24(48%)Female26 (52%)ASA physical statusOn the day of operation, the patients wereanesthetized with intravenous thiopental sodium3-5 mg/kg and tracheal intubation was performedusing intravenous suxamethonium 1.5 mg/kg bodyweight. The head of the patient was extended andneck flexed on a head pillow or ring andlaryngoscopy was done with proper size Macintoshblade and intubation performed. During intubation,intubation condition was observed :I43 (86%)39 (78%)II7(14%)11(22%)Mean SD. In parenthesis are the percentages overcolumn total. Group analyses were done by Chi square(χ2) test. Values are expressed as significant if P 0.05(CI-95%.)4
Table-IVRelation of preoperative anticipation ofsuspected difficult intubation with the difficultydurign intubation in Group-BDuring intubation, patients were graded accordingto Cormack & Lehane grading. In Group-A, 22(44%) in Grade-1, 21(42%) in Grade-2, 4 (8%) inGrade-3 and 3 (6%) Grade-4. In Group-B, 18 (36%)in Grade-1, 16 (32%) in Grade-2, 13 (26%) in Grade3 and 3 (6%) in Grade- 4 (Table-II).Numberof patient50Table-IIDistribution of of patients during intubationaccording to cormack & lehane gradingGroupsGrade-1 Grade-2 Grade-3 Grade-4Values are expressed in frequency. Within paranthesisof are the percentage over colum total. Analysis betweengroups were done for sensitivity & specificity using Ztest.PvalueGroup - A 22 (44%) 21(42%) 04 (8%) 03 (6%)Numbers of patient facing difficulty in two groupsare displayed in Table-V. Eighteen (36%) patientsin Gr-A faced difficulties during intubation, whichis significantly higher than the Gr-B (p 0.001).0.120Group - B 18 (36%) 16(32%) 13(26%) 03 (6%)Values expressed as frequency. In parenthesis arepercentages over column total. Data were analysed byχ2 test. Values are regarded as significant, if p value 0.05 (CI-95%).Table-VDistribution of difficult intubation in two groupsIn Group-A, 18 (36%) patients were difficult tointubate, though during mallampati test, 07 (14%)were suspected to be difficult. The false negativewas 11 (22%). The measured sensitivity andspecificity in Group-A are 65% and 25% respectively(Table-III).Groups /Variablesof patient50Suspected toDifficultSuspected tobe difficultintubationDifficulty inintubationPvalueGroup-A7 (14%)18 (36%)0.001Group-B16 (32%)10 (20%)Values are expressed in frequency. Within paranthesisof are the percentage over colum total. Analysis betweengroups were done for sensitivity & specificity using (χ2)test. Values are expressed as significant if P 0.05 (CI95%).Table-IIIRelation of preoperative anticipation of difficultintubation with the difficulty durign intubationin Group-ANumberSuspected toDifficultFalsebe difficultintubation positivepreoperatively16 (32%)10 (20%) 6 (12%)DISCUSSION:Patient who needs to be intubated must be assessedby screening tests to prevent fatal consequencesof the unexpected difficult and / or failed intubation.A screening tests for prediction of difficultintubation are to be very easy, rapid and shouldgive reproducible result. No screening test isabsolutely sensitive and 100% specific. Thereforeprocess must be develop to minimize suddenunexpected difficulty during intubation.Falsebe difficultintubation negativepreoperatively7 (14%)18 (36%) 11 (22%)Values are expressed in frequency. Within paranthesisof are the percentage over colum total. Analysis betweengroups were done for sensitivity & specificity using Ztest.In Group-B, 10 (20%) patients were difficult tointubate, though 16 (32%) patient were suspectedto be difficult preoperatively using combination ofMalampati test and measring of ThyromentalDistence. The false positive were 6 (12%). Thesensitivity is 75% & specificity is 60% (Table-IV).Oates JDL and his colleagues found 1.8% incidenceof difficult intubation using Mallampati test andWilson risk score in the preoperative check uproom6. In our study, Mallampati test on one groupcompared with combination of Mallampati andThyromental Distance on another group were used5
to assess the degree of difficulty during trachealintubation and compare the specificity andsensitivity of the two groups. The sensitivity inGroup-A (Mallampati alone) is 65% and for GroupB is (Mallampati and TMD measurement) 75%.The measured specificity is also higher in GroupB (25% vs 60%).and the Thyromental Distance less than 6.5 cm.can be expected to have difficultly during trachealintubation. So, it can be concluded that properpreoperative assessment is mandatory to preventfatal consequences of the unexpected difficult and/ or failed intubation.REFERENCES1. Frerk CM. Predicting difficult intubation.Anaesthesia 1991; 46: 1005-1008.Mallampati test is a simple and quick based uponthe visible pharyngeal structures when thepatient’s mouth is wide open. Mallampati and hiscolleagues described first three classes7, Samsonand Young added later on the fourth one8. Thistest predicts only about 50% of difficulties with ahigh incidence of false negative results. Mallampatitest is significantly affected by inadvertentphonation of patient and there is considerableobservers variability9. It cannot discriminate thepatients of difficult laryngoscopy resulting fromlimited movement of head and neck. Tham andcolleagues showed that the grading observed withthe patient in the vertical position did not changewhen the patient was horizontal; thus the test isuseful in an emergency with patient supine or whois unable to sit up10. One of the greatest criticismsof mallampati test, however, has been the problemof inter-observer variation 9. If the posteriorpharyngeal wall can be seen below the soft palate,patient is in Grade-I or II, should be predicted ‘easy’intubation. If pharyngeal wall can not be seen asin Grade-III & IV and if the TMD of these patientis 6.5 the intubation may be difficult.In Group-A, where the patient were assessed usingmallampati test, 11 (22%) of patients exhibited falsenegative results that means these patients weredifficult to intubate but the preoperativeassessment failed to predict any difficulty. A simplebedside test of Patil’s Thyromental Distancereflects the degree of head extension on neck alongwith the position of larynx and length and depth ofthe mandible. By adding TMD with mallampati test,these false negativity of mallampati test wasreduced. In addition, both sensitivity and specificityis higher in Group-B than A. So these two simplebedside tests (Mallampati with TMD) can beperformed during routine preoperative visit. Thepatients having grade III or IV view of the pharynx2.Cormack RS, Lehane J. Difficult trachealintubation in obstetrics. Anaesthesia 1984; 39:1105-1111.3.Atkinson RS, Rushman GB, Davies NJH.Trache
CONTENTS Editorial Information Technology (IT): Means of Improving Patient Care in OT & ICU 1 Original Article Assessment of Tracheal Intubation Grading 3 Mir Mahmud Hossain, Moniul Hossain, AKM Akhtaruzzaman, Kazi Mesbahuddin Iqbal Effect of Hydroxyethyl starch for preloading in pre-eclamptic patients 7 undergoing caesarean section
Find the volume of each cone. Round the answer to nearest tenth. ( use 3.14 ) M 10) A conical ask has a diameter of 20 feet and a height of 18 feet. Find the volume of air it can occupy. Volume 1) Volume 2) Volume 3) Volume 4) Volume 5) Volume 6) Volume 7) Volume 8) Volume 9) Volume 44 in 51 in 24 ft 43 ft 40 ft 37 ft 27 .
Printable Math Worksheets @ www.mathworksheets4kids.com Find the volume of each triangular prism. 1) Volume 36 cm 25 cm 49 cm 2) Volume 3) Volume 4) Volume 5) Volume 6) Volume 7) Volume 8) Volume 9) Volume 27 ft 35 ft t 34 in 21 in 27 in 34 ft 17 ft 30 ft 20 cm m 53 cm 21
Accreditation Programme for Nursing and Midwifery . Date of submission of report to Bangladesh Nursing and Midwifery Council_ 2) The Review Team During the site visit, the review team members validate the self-assessment for each of the criteria. . as per DGNM guideline. Yes ⃝No
uate the quality of grain damaged by rodents with respect to nutritional value, infection by moulds and aflatoxin contamination. 2 Materials and methods 2.1 Study area The study was conducted in Mwarakaya ward (03 49.17́'S; 039 41.498′E) located in Kilifi-south sub-county, in the low landtropical(LLT)zoneofKenya.Thisstudy site wasselect-
Printable Math Worksheets @ www.mathworksheets4kids.com 1) Volume 2) Volume 3) Volume 4) Volume 5) Volume 6) Volume 7) Volume 8) 9) Volume Find the exact volume of each prism. 10 mm 10 mm 13 mm 7 in 14 in 2 in 5 ft 5
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Volume of Gas Produced per Mass of Liquid 0.54 m3/kg 8.6 ft3/lb Volume of Gas Produced per Unit Volume of Liquid 274 274 Volume occupied per mass of Liquid 1968.5 litres/tonne 437 gal/ton Volume of Air to burn Unit Volume of Gas 23 23 Volume of Oxygen to burn Unit Volume of Gas 4.8 4.8 Ignition Temperature 460-580 C 860-1076 F
