Perioperative Management During the COVID-19 Pandemic: Strategies at Three General Hospitals in Japan and a Narrative Review.

Coronavirus disease 2019 (COVID-19) has rapidly spread globally ever since the virus was first identified in December 2019 in Wuhan, China. Despite efforts to accelerate the supply of COVID-19 vaccines worldwide, the global pandemic has continued. Polymerase chain reaction (PCR) test is currently considered the gold standard for the diagnosis of COVID-19. However, the rate of false-negative PCR for COVID-19 has been reported to be over 10%. Furthermore, an asymptomatic period can last up to 14 days following the infection. Under these circumstances, standard anesthetic practice, surgery scheduling, and approaches to appropriate management of the operating room to protect both patients and medical personnel against COVID-19 transmission need to be reviewed and appropriately modified. In this review, based on our institutional experiences along with the guidelines reported elsewhere, we propose safer and more effective perioperative management amidst the COVID-19 pandemic.

Airway scope laryngoscopy under manual inline stabilization and cervical collar immobilization: a crossover in vivo cinefluoroscopic study.

BACKGROUND: Direct laryngoscopy along with manual inline stabilization (MIS) is currently the standard care for patients with suspected neck injuries. However, cervical collar immobilization is more commonly performed in the prehospital environment, and its early removal is necessary before intubation. We hypothesized that if usability of Airway Scope (AWS) in a difficult airway could also bring merits to intubation under cervical collar immobilization, unnecessary risk caused by the removal of a neck collar may be prevented. METHODS: In this crossover study, 30 consenting patients presenting for surgery were assigned to undergo intubation using AWS. Neck was stabilized manually and by a neck collar in a random order before laryngoscopy was performed by the same anesthesiologist. Measurements include interincisor distance (IID), success rate, intubation time, and fluoroscopic examination of the upper and middle cervical spine. RESULTS: IID was notably narrower after application of a neck collar (mean ± SE: MIS, 19 mm ± 1 mm; collar, 10 mm ± 1 mm; p < 0.01). One and 9 failures were encountered in MIS and collar groups, respectively (p = 0.012). Intubation time proved no statistical significance. Extension of craniocervical junction was observed in both groups, but occipitoatlantal joint was significantly more extended in collar group (median [range]: AWS, 10-degree angle [-1 to 20-degree angle]; collar, 14-degree angle [5 to 26-degree angle]; p < 0.01). DISCUSSION: AWS laryngoscopy under cervical collar immobilization fails to meet our expectation. Intubation failed in 30% of the cases in collar group whereas only 3.3% of the cases in MIS group. Significant difference of mouth opening limitation is probably the major reason, as 7 of 9 failed cases in collar group had IID <10 mm. This was insufficient to insert the 18-mm blade of AWS. In addition, occipitoatlantal joint suffered a greater extension when wearing a neck collar. Differences in the method to stabilize the neck may be the reason. CONCLUSION: When compared with cervical collar immobilization, AWS laryngoscopy along with MIS seems to be a safer and more definite method to secure airway of neck-injured trauma patients because it limits less mouth opening and upper cervical spine movement.

Airway scope versus macintosh laryngoscope in patients with simulated limitation of neck movements.

BACKGROUND: Tracheal intubation in patients with suspected neck injuries should achieve two contradicting goals-sufficient laryngeal exposure and the least cervical spine movement. Because the former involves displacements of the cervical vertebrae, intubation under immobilization is widely performed today to prevent exacerbation of spinal code injuries. The unique curving blade of the Airway Scope (AWS) is designed to fit the oropharyngeal anatomy. A camera at the tip of the blade displays the view of the larynx, but unlike the direct laryngoscope, it needs no line-of-sight of the oral, pharyngeal, and tracheal axis. Our purpose is to determine whether AWS could be a suitable airway device for the intubation of patients with potential neck injury. METHODS: Thirty-six patients scheduled for surgery were randomly assigned to undergo intubation using either AWS or Macintosh laryngoscope (MLS). After general anesthetic induction, the patient's head was set in a neutral position, and an appropriately sized semi-rigid neck collar was placed. Measurements include intubation time, number of attempts, success rate, Cormack-Lehane classification, airway optimization maneuver, Intubation Difficulty Scale scores, and complications. RESULTS: Intubation time proved no statistical significance (mean ± SD, AWS, 62.9 seconds ± 26.0 seconds, MLS, 55.6 seconds ± 26.0 seconds; p = 0.42). AWS scored less in Cormack-Lehane classification (median [range], AWS I [I-I], MLS IIIa [I-IIIb]; p < 0.0001), required fewer additional airway optimization maneuvers (p = 0.0003), and scored less in Intubation Difficulty Scale scores (AWS 0 [0-1], MLS 2 [0-5]; p < 0.0001). CONCLUSIONS: In neck-immobilized patients using semi-rigid cervical collars, AWS improves laryngeal exposure and facilitates tracheal intubation. AWS may be a suitable intubation device for trauma patients.

Pre-anesthetic evaluation can play a crucial role in the determination of airway management in a child with oropharyngeal tumor.

We experienced a case of a huge hemangioma occupying the oropharyngeal space in an 11-year-old child. Although urgent surgical tracheostomy under local anesthesia was suggested initially, medical interview and findings of computerized tomography and fiberoptic laryngoscopy revealed that the airway of the patient was relatively stable when she was in the semi-left decubitus position. General anesthetic induction would have had potential risks of airway obstruction. Thus, after placing the patient in the semi-left decubutus position, we chose semi-awake induction to secure the airway. With a small dose of fentanyl, we accomplished orotracheal intubation. In this report, we discuss the importance of referring to an airway management algorithm when encountering a difficult airway.