The effect of pharyngeal packing on gastric volume in patients undergoing nasal surgery: a randomised, controlled trial.

OBJECTIVE: To explore the effects of pharyngeal packing on antral cross-sectional area, gastric volume and post-operative complications. METHODS: In this prospective, randomised, controlled study, 180 patients were randomly assigned to a control group or a pharyngeal packing group. Gastric antral dimensions were measured with pre- and post-operative ultrasound scanning. Presence and severity of post-operative nausea and vomiting and sore throat were recorded. RESULTS: Post-operative antral cross-sectional area and gastric volume were significantly larger in the pharyngeal packing group compared to the control group. The incidence and severity of post-operative nausea and vomiting were significantly less in the pharyngeal packing group. More frequent and severe sore throat was observed in the control group within the ward. An increased Apfel simplified risk score and post-operative antral cross-sectional area were associated with post-operative nausea and vomiting during the first 2 hours, whereas septorhinoplasty and functional endoscopic sinus surgery, absent pharyngeal packing, and lower American Society of Anesthesiologists' physical status were associated with post-operative nausea and vomiting within the ward. CONCLUSION: Regardless of operation type, pharyngeal packing use resulted in smaller gastric volume, which was associated with reduced post-operative nausea and vomiting frequency and severity, and lower sore throat incidence.

Integration of functional capacity to medically necessary, time-sensitive scoring system: A prospective observational study.

OBJECTIVES: To evaluate 2 new modifications to medically necessary, time-sensitive (MeNTS) scoring systems integrating functional capacity assessment in estimating intensive care unit (ICU) requirements. METHODS: This prospective observational study included patients undergoing elective surgeries between July 2021 and January 2022. The MeNTS scores and our 2 modified scores: MeNTS-METs (integrated Duke activity status index [DASI] as metabolic equivalents [METs]) and MeNTS-DASI-5Q (integrated modified DASI [M-DASI] as 5 questions) were calculated. The patients' ICU requirements (group ICU+ and group ICU-), DASIs, patient-surgery-anesthesia characteristics, hospital stay lengths, rehospitalizations, postoperative complications, and mortality were recorded. RESULTS: This study analyzed 718 patients. The MeNTS, MeNTS-METs, and MeNTS-DASI-5Q scores were higher in group ICU+ than in group ICU- (p<0.001). Group ICU+ had longer operation durations and hospital stay lengths (p<0.001), lower DASI scores (p<0.001), and greater hospital readmissions, postoperative complications, and mortality (p<0.001). The MeNTS-METs and MeNTS-DASI-5Q scores better predicted ICU requirement with areas under the receiver operating characteristic curve (AUC) of 0.806 and 0.804, than the original MeNTS (AUC=0.782). CONCLUSION: The 5-questionnaire M-DASI is easy to calculate and, when added to a triage score, is as reliable as the original DASI for predicting postoperative ICU requirements.

Evaluation of Postoperative Complication with Medically Necessary, Time-Sensitive Scoring System During Acute COVID-19 Pandemic: A Prospective Observational Study.

BACKGROUND: High scores in the Medically Necessary, Time-Sensitive (MeNTS) scoring system, used for elective surgical prioritization during the coronavirus disease 2019 pandemic, are assumed to be associated with worse outcomes. We aimed to evaluate the MeNTS scoring system in patients undergoing elective surgery during restricted capacity of our institution, with or without moderate or severe postoperative complications. STUDY DESIGN: In this prospective observational study, MeNTS scores of patients undergoing elective operations during May and June 2020 were calculated. Postoperative complication severity (classified as Group Clavien-Dindo < II or Group Clavien-Dindo ≥ II), as well as Duke Activity Index, American Society of Anesthesiologists (ASA) physical status, presence of smoking, leukocytosis, lymphopenia, elevated C-reactive protein (CRP), operation and anesthesia characteristics, intensive care requirement and duration, length of hospital stay, rehospitalization, and mortality were noted. RESULTS: There were 223 patients analyzed. MeNTS score was higher in the Clavien-Dindo ≥ II Group compared with the Clavien-Dindo < II Group (50.98 ± 8.98 vs 44.27 ± 8.90 respectively, p < 0.001). Duke activity status index (DASI) scores were lower, and American Society of Anesthesiologists physical status class, presence of smoking, leukocytosis, lymphopenia, elevated CRP, and intensive care requirement were higher in the Clavien-Dindo ≥ II Group (p < 0.01). Length of hospital stay was longer in the Clavien-Dindo ≥ II Group (15 [range 2-90] vs 4 [1-30] days; p < 0.001). Mortality was observed in 8 patients. Area under the receiver operating characteristic curve of MeNTS and DASI were 0.69 and 0.71, respectively, for predicting moderate/severe complications. CONCLUSIONS: Although significant, MeNTS score had low discriminating power in distinguishing patients with moderate/severe complications. Incorporation of a cardiovascular functional capacity measure could improve the scoring system.

Learning Curves for Two Fiberscopes in Simulated Difficult Airway Scenario With Cumulative Sum Method.

INTRODUCTION: The aims of this randomized prospective mannequin study were to determine the amount of attempts required for successful intubation using different fiberscopes (Bonfils and SensaScope) by inexperienced anesthesiologists in a difficult airway scenario and to build the associated learning curves. METHODS: Difficult airway simulation was achieved with tongue edema in mannequin. After approval of volunteers, we asked 15 anesthesiology residents without any experience with fiberscopes to intubate with each device in a random order. Intubation success (endotracheal intubation within 120 seconds), the degree of difficulty of intubation, and reality of simulation using a 10-point scale were recorded. Learning curves were generated with cumulative sum method. RESULTS: With Bonfils, 13 volunteers were able to pass lower decision boundary with a median number of 26 [95% confidence interval (CI) = 21.4-25.9] attempts, whereas in SensaScope, the same outcome was observed in 10 residents with a median number of attempts of 26 (95% CI = 23.5-32.5). Total success rate was found significantly higher with Bonfils compared with SensaScope (550/600 vs 512/600, respectively, P < 0.001). Intubation with Bonfils was considered as less difficult compared with SensaScope [median = 4 (95% CI = 3.32-4.42) and 6 (95% CI = 4.96-6.64), P = 0.01, respectively]. The reality of the simulation was rated as a median of 5 (95% CI = 4.37-5.8). CONCLUSIONS: Although a similar number of attempts were required to reach predetermined competency for both fiberscopes, only 10 of residents were able to obtain the targeted success using SensaScope as compared with 13 with Bonfils. Inexperienced residents found intubation via Bonfils less difficult than SensaScope. High individual variability in obtaining competency observed in this study with cumulative sum analysis underlines the importance of defining success a priori to simulation, the need for follow-up of individual progress, and the need to offer adequate trials to achieve competency. Therefore, learning opportunities should be adapted accordingly.

High frequency jet ventilation during endolaryngeal surgery: Risk factors for complications.

Objective: Microlaryngeal surgery requires teamwork between surgeons and anesthesiologists. High-frequency jet ventilation (HFJV) is an artificial breathing technique, preferred during endolaryngeal interventions, which offers a good solution for the requirements. Most studies investigating independent risk factors for intraoperative complications during HFJV in endolaryngeal surgery (ELS) has been retrospective and not standardized and the anesthetic approach has not been standardized. This prospective cohort study aimed to identify risk factors of complications related to HFJV in ELS under a standardized anesthesia regimen. Methods: 243 patients who underwent ELS with infraglottic HFJV were investigated. Infraglottic jet ventilation catheter was placed and anesthesia was standardized. Demographic and operative data were noted. Hemodynamics, SpO2 and end-tidal CO2 were recorded at regular intervals. Complications such as hemodynamic disturbances, respiratory problems, barotrauma, equipment failure and requirement for conventional ventilation were also documented. Results: 222 patients were included. Hypoxia, hypercapnia and the need for intubation were observed in 20(9%), 4(1.8%), 10(4.5%) patients. Bradycardia, hypotension and arrhythmia were observed in six (2.7%), 24(10.8%), and four (1.8%) patients respectively. Respiratory complications were associated with body mass index (BMI) (p < 0.001, OR: 1.57, 95%CI: 1.31­1.88) and previous major airway surgery (p < 0.001, OR: 34.0, 95%CI:3.52­328.24), whereas hemodynamic complications were associated with duration of the operation (p = 0.034, OR:1.04, 95%CI:1.0­1.09) and history of previous major airway surgery (p = 0.005, OR:9.57, 95%CI:1.97­46.49). Conclusion: Infraglottic HFJV can be evaluated as an alternative breathing technique to conventional ventilation during endolaryngeal interventions. However, longer operation and previous laryngeal surgeries can increase the incidence of respiratory complications.

The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients.

BACKGROUND: The aim of this prospective study was to investigate the success of ultrasound in pediatric patients in determining the appropriate sized cuffed endotracheal tube and to compare the results with conventional height-based (Broselow) tape and age-based formula tube size. METHODS: One hundred and fifty-two children of 1-10 years of age, who received general anesthesia for adenotonsillectomy were enrolled to the study. In all participants, the transverse diameter of the subglottis was measured with ultrasound during apnea. An endotracheal tube was chosen with the outer diameter matched to the measured subglottic airway diameter. An age-based (Motoyama-Khine) and height-based (Broselow) endotracheal tube size was calculated. If there was resistance to passage of the tube into the trachea or an airway pressure >25 cmH2 0 was required to detect an audible leak, the endotracheal tube was replaced with internal diameter of 0.5 mm smaller. If there was an audible leak at airway pressure <10 cmH2 O, or peak pressure >25 cmH2 0 or a cuff pressure > 25 cmH2 O was required to seal, the tube was changed to the 0.5 mm larger internal diameter. Best-fit tube internal diameter was the resultant tube internal diameter that met the previously stated conditions. The need for endotracheal tube replacement and peak airway pressure were recorded. RESULTS: The internal diameter of ultrasound determined tube was the same as best-fit tube in 88% of children. Endotracheal tube was replaced in 15 patients with a one size larger, and in three patients with one size smaller tube. Using Bland-Altman analysis, a better agreement was observed with ultrasound measurement rather than height-based estimation and age-based formulas. CONCLUSION: Our findings show that subglottic diameter measured by ultrasound appears to be a reliable predictor for the assessment of the subglottic diameter of the airway in estimating appropriate size pediatric endotracheal tube.

Can surgical approach affect postoperative analgesic requirements following laparoscopic nephrectomy: Transperitoneal versus retroperitoneal? A prospective clinical study.

OBJECTIVES: We performed this prospective clinical study to compare the postoperative recovery profile of our patients after transperitoneal (Group T) and retroperitoneal (Group R) laparoscopic nephrectomy approaches. Our primary hypothesis was that epidural analgesic consumption in Group R would be higher at the end of the first postoperative day. METHODS: Forty-four patients scheduled for elective transperitoneal or retroperitoneal laparoscopic nephrectomies were enrolled. All patients in both groups received epidural catheter and general anesthesia induction. At the end of the operation, patients were given 10 ml 0.25% bupivacaine through epidural catheters and extubated. Postoperatively, patients started to receive a continuous infusion of 0.1% bupivacaine and 1µg/ml fentanyl 5ml/h with patient-controlled boluses of an additional 4ml through a patient controlled epidural analgesia (PCEA) device. They were prescribed IV tramadol 1mg/kg as a rescue analgesic VAS≥4). Total analgesic consumption from PCEA devices and VAS scores during the first 24 postoperative hours were recorded as well as number of patients who required analgesic rescue. RESULTS: Forty patients completed the study, 20 in each group. Total epidural analgesic consumption during the first 12 hours were significantly higher in Group R (p<0.05). Basal, postoperative 30 min, 2, 6 hours VASrest, VASmobilization and 12 h VASmobilization scores, and number of patients who required rescue analgesic at 0, 30 min in Group R were significantly higher than Group T (p<0.05). CONCLUSION: Retroperitoneal laparoscopic nephrectomy was found to be more painful and patients in this group required more epidural and analgesic rescue during the first 12 postoperative hours. ClinicalStudys.gov: (NCT02622893).

Comparison of 4 Laryngoscopes in 2 Difficult Airway Scenarios: A Randomized Crossover Simulation-Based Study.

INTRODUCTION: The performance of laryngoscopes that have been developed for difficult airways can vary widely. The aim of the study was to compare Macintosh, McCoy, McGrath MAC, and C-MAC laryngoscopes in cervical immobilization and tongue edema scenarios in a mannequin, primarily to evaluate the time to intubation. METHODS: In this randomized crossover study, 41 anesthesiology residents used 4 laryngoscopes in a mannequin (SimMan 3G) in 2 different scenarios. Intubation time (insertion of the blade between the teeth, to placement of the endotracheal tube into the trachea) longer than 120 seconds or inability to successfully place the endotracheal tube into the trachea after 5 or more attempts was defined as intubation failure. Besides intubation time, laryngoscopic view, number of intubation attempts, presence of esophageal intubation, need for stylet, difficulty of intubation, and success rate were recorded as secondary outcomes. RESULTS: Intubation time was observed from longest to shortest as McGrath > McCoy > C-MAC > Macintosh in both scenarios. Laryngeal view was better with C-MAC laryngoscope. McGrath laryngoscope performed poorly specifically in tongue edema scenarios, which resulted in higher number of intubation attempts, esophageal intubation, need for intubation stylets, and overall intubation failure. CONCLUSIONS: The short intubation time observed with the Macintosh underlines the necessity of familiarity in success. Tongue edema is a more challenging scenario for simulated difficult airway and the McGrath may not be a good choice for such a scenario.

[A comparison of vertical infraclavicular and coracoid approaches in forearm surgery]. / Ön kol cerrahisinde infraklaviküler ve korakoid yaklasimlarin karsilastirilmasi

OBJECTIVES: Despite several risks, infraclavicular approaches to the brachial plexus gained popularity. The present study compared success rates, block onset times, block performance times, and frequency of adverse effects of vertical infraclavicular (VIB) and coracoid blocks (CB) in patients undergoing forearm surgery. METHODS: After ethical committee approval and informed consent 40 patients undergoing forearm surgery were included. The brachial plexus was located using a nerve stimulator and an insulated pencil point needle. Thirty ml bupivacaine 0.5% was used for the block. The blocks were assessed every minute for the first 5 min, then every 5 min for 15 min and then every 15 min and at the end of the operation. RESULTS: Block onset times of both groups were similar. Higher rates of sensory block were found in group CB at the 5th, 10th, and 15th minutes of assessment. Also higher rates of motor block were found in group CB at the 5th, 10th, 15th and 30th minutes of assessment. Time to perform block was shorter in group VIB. One patient in CB group required general anaesthesia. Except two vascular punctures in group CB no other side-effects were observed. CONCLUSION: Coracapid block provided higher rates of sensorial and motor blocks in a similar onset time without serious complications. CB can be accepted as a safe and reliable alternative to VIB for forearm surgery.