ABSTRACT:The submental route for endotracheal intubation is an alternative to nasal intubation or tracheostomy in the surgical management of patients with complex cranio-maxillofacial injuries. The critical indication for submental intubation is the requirement for intraoperative maxillamandibular fixation (MMF) in the presence of injuries that preclude nasal intubation and in a situation where a tracheostomy is not otherwise required. MMF to re-establish dental occlusion is essential for a normal functional result in dentate patients with fractures involving alveolar segments of the jaws. However, MMF precludes orotracheal intubation. Nasotracheal intubation is often used but is contraindicated in the presence of skull base fractures and will interfere with the access to certain fracture types. A tracheostomy has a high potential complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. Submental intubation is a simple and useful technique with low morbidity in selected cases of cranio-maxillofacial trauma.

INTRODUCTIONDirect laryngoscopy is the mainstay of airway management, and despite the proliferation of difficult airway devices, alternative methods of intubation are used extremely infrequently in all settings. Proper positioning of the head and the neck is prerequisite for optimizing the laryngeal view during direct laryngoscopy. Its importance has been recognized since Kirstein 1 first described the procedure in 1895.Inadequate positioning may result in prolonged or failed tracheal intubation attempts because of the inability to visualize the larynx.There is a large discrepancy between the incidence of difficult laryngoscopy ranging from 5% of multiple attempts and 18% of poor laryngeal view to the rate of failed laryngoscopy ranging from less than 0.4% in the emergency department to 0.05% in the operating room. In most instances, difficult laryngoscopy correlates with ABSTRACT Background: Airway management is critical to the care of patients and direct laryngoscopy is the mainstay of airway management. Despite the proliferation of difficult airway devices, sniffing position for laryngoscopy remains the gold standard and ideal position. This prospective, randomized and single-blind study was done to evaluate and compare the laryngoscopic view, complexity of intubation and sympathetic response during laryngoscopy in sniffing position and simple head extension. Methods: One hundred and twenty patients, aged 20-50 years with American Society of Anesthesiologists (ASA) status 1 and 2 undergoing general anesthesia requiring orotracheal intubation were randomized into two groups. Group A used sniffing position and group B was put in simple head extension. Glottis visualization was assessed using Cormack and Lehane grade and ease of intubation was assessed on intubation difficulty scale. Laryngoscopic sympathetic response in two positions was also assessed. Results: Both the groups were comparable in demographic profiles. Glottic visualization and intubation difficulty score were better and statistically significant in sniffing position as compared to simple head extension. Although, sympathetic response was lower in sniffing position as compared to simple head extension, it was statistically insignificant. Conclusion: Sniffing position provided better glottis visualization and intubation difficulty score and increased the success rate of intubation as compared to simple head extension.

PURPOSE:The objectives of this study were to compare the effects of caudal dexmedetomidine combined with Ropivacaine to provide postoperative analgesia in children and also to establish its safety in the pediatric patients. METHODS: In a randomized, prospective, parallel group, double-blinded study, 80 children of 1 year to 6years posted for lower abdominal surgeries were recruited and allocated into two groups: Group RD (n=40) received 0.25% Ropivacaine 1 ml/kg with dexmedetomidine2 μg/kg, making the volume to 0.5 ml and Group R (n=40) received 0.25% Ropivacaine1 ml/kg + 0.5 ml normal saline. Induction of anesthesia was achieved with Inj. Ketamine 2mg/kg + Inj. Succinylcholine 2mg/kg. Intubated with appropriate-sized Endotracheal tube and caudal block was performed in all patients. Maintained with 66% nitrous oxide in Oxygen and isoflurane 0.2-0.4%.Post-operative pain assessed with FLACC score. RESULTS: The duration of postoperative analgesia recorded a mean of 339 minutes (5.6hrs ± 2.4 hrs.) in Group R compared with 884 minutes (14.7 hrs. ±5hrs) in Group RD, with a p value of <0.001. Group RD patients achieved a statistically significant higher FLACC score compared with Group RD patients. The peri-operative hemodynamics were stable among both the groups. CONCLUSION: Caudal dexmedetomidine (2 μg/kg) with 0.25%Ropivacaine (1 ml/kg) for pediatric lower abdominal surgeries provides significant postoperative pain relief and better quality of sleep and a prolonged duration of arousable sedation.