Croatian national audit on videolaryngoscopes and alternative intubation devices in the era of COVID-19 pandemic.

INTRODUCTION: Videolaryngoscopy (VL) is the recommended strategy for airway management in COVID-19 patients and guidelines recommends that all anesthesiologists should be trained to use and have immediate access to the device. However, the availability of VL in hospitals and its use may vary, as well as the choice of the device and necessary training. Our primary aim was to investigate data on availability of VL in Croatia, its use, the choice of the device and its implementation, with special consideration of COVID-19 management. MATERIALS AND METHODS: An electronic survey was sent to all Croatian hospitals that have anesthesiology service available. The survey was designed to examine data on availability and use of VL with special consideration of COVID-19 wards. The survey was conducted between 1.03.2021 and 30.08.2021. RESULTS: Response rate was 83%. VL was available in 86% of hospitals and the best supplied areas were intensive care units, general surgery and gynecology/obstetrics. The most common VL devices were Bonfils, C-MAC and C-MAC D-blade. The choice of VL was mainly based on centralized hospital procurement and informal introduction was found to be the most frequent training method. The VL was mainly used in Croatian hospitals in cases of difficult airway or as a backup method after failed intubation. Only 16% of hospitals reported regular use in everyday practice. Even though, VL was available in 64% of COVID-19 wards, only 21% of hospitals reported routine use. CONCLUSION: Although VL is available in the majority of Croatian hospitals, its use is still mainly restricted to difficult airway scenarios. Use of VL in COVID-19 management is also low and education on the method is still mainly informal. Based upon our results better implementation in practice should be targeted, as well as formal skill trainings especially regarding COVID-19 care.

LARYNGEAL MASK AIRWAY VERSUS ENDOTRACHEAL INTUBATION FOR ADENOIDECTOMY IN OUTPATIENT SURGERY - SINGLE CENTER EXPERIENCE.

Adenoidectomy with or without tonsillectomy remains one of the most routinely performed surgical procedures in children. The duration of the procedure is usually less than half an hour and is done in a day surgery setting. Airway management for adenoidectomy can be especially challenging as the airway is shared between the surgeon and the anesthesiologist. The gold standard for airway management is an endotracheal tube (ETT), even though there has been an increase in the use of laryngeal mask airway (LMA) over the past decade. This retrospective study investigated patient data collected over a 4-year period (2016 to 2020). Data included 210 cases in a day surgery setting. We analyzed the choice of airway device and use of neuromuscular blockers and analgesics for pain management. The use of LMA was noted in 67.62% while endotracheal intubation was performed in 32.38% of cases. LMA resulted in fewer respiratory complications compared to ETT (p=0.006). The need for neuromuscular blockers was also lower in the LMA group (p=0.01). There was no statistically significant difference in the intraoperative dose of opioid analgesia (p=0.09). Flexible LMA is a satisfactory alternative to endotracheal intubation for outpatient pediatric adenoidectomy.

AWAKE FIBEROPTIC TRACHEAL INTUBATION AND AT-RISK EXTUBATION IN A PATIENT WITH ANTICIPATED DIFFICULT AIRWAY DUE TO POST-TRAUMATIC ANKYLOSIS OF TEMPOROMANDIBULAR JOINTS.

In this case report we present successful airway management in a patient with predicted difficult airway using the Difficult Airway Society guidelines. Our patient presented with recurrence of severely reduced mouth opening due to post-traumatic bilateral temporomandibular ankylosis, and was scheduled for surgical resection of the mandibular articular processes. Awake fiberoptic intubation was planned. After light sedation and thorough topicalization of the nasal cavity the flexible optic bronchoscope was successfully navigated into the trachea with 'spray-as-you-go' technique and the endotracheal tube was railroaded over it. After a two-point check of the endotracheal tube placement the patient was put under anesthesia. The surgery was uneventful. Finally, a plan with surgeons for safe extubation was made and the patient was extubated uneventfully on the next day using the airway exchange catheter in the intensive care unit.

COMBINED USE OF VIDEOLARYNGOSCOPE AND BONFILS INTUBATION ENDOSCOPE AS RESCUE OPTION FOR DIFFICULT AIRWAY MANAGEMENT: A CASE REPORT.

Difficult airway management poses a great challenge for clinicians, especially if it is unanticipated. Numerous guidelines and a wide array of devices constitute the anesthesiologist's armamentarium for managing the airway. When the use of individual devices fails, the use of combination techniques is advised. We present a case of difficult intubation in a 50-year-old male patient scheduled for aortic valve replacement. He had no prior history of difficult airway management, and no abnormalities were detected on preoperative airway assessment. Body mass index was 29 kg/m2. After the separate use of direct laryngoscopy, videolaryngoscopy and a BONFILS intubation endoscope (BIE) had failed, we resorted to a combination technique, combining videolaryngoscopy and BIE. While the videolaryngoscope provided the space needed for BIE and visual guidance through copious secretions, the BIE served as a stylet for endotracheal tube guidance, leading to successful intubation. Since the technique requires costly equipment, experience in handling it and at least two operators, it is more appropriate as a rescue measure than an elective procedure. Given the potentially disastrous outcomes of failed intubation, mastering advanced airway management techniques remains of vital importance, and the combination technique is one of them.

VOICE CONDITION FOLLOWING SHORT-TERM ENDOTRACHEAL INTUBATION IN HEAD AND NECK SURGERY: STUDY PROTOCOL FOR CLINICAL TRIAL.

Endotracheal intubation is an airway management procedure commonly performed under general anesthesia. It is linked with postoperative voice changes. The incidence and reasons of hoarseness and vocal cord injury are not very well investigated, especially after short-term anesthesia and intubation in head and neck surgery. The aim of the study is to identify the causes of voice changes after short endotracheal anesthesia in head and neck surgery. The study will include patients scheduled for head and neck surgery under general anesthesia with endotracheal intubation up to 3 hours. There will be 3 groups of patients, as follows: thyroid surgery, non-thyroid surgery, and control group undergoing surgery outside head and neck. Videostroboscopy will be recorded before and after surgery. Further diagnostic workup will include voice status; subjective voice self-analysis; perceptive and objective acoustic voice analysis at 4 time points (preoperatively, postoperative day 2, 2 weeks and 1 month after surgery). Endotracheal intubation is a safe method of airway management although it can temporarily alter a patient's voice quality. It is not known how much of this is the result of anesthesia, general condition of the patient, or surgery. This trial is expected to shed some light on this issue.

THE MULTIDISCIPLINARY TEAM (MDT) IN THE TREATMENT OF HEAD AND NECK CANCER - A SINGLE-INSTITUTION EXPERIENCE.

Head and neck cancers are associated with significant morbidity and mortality despite advancements in treatment in recent decades. A multidisciplinary approach to the treatment of these diseases is thus of essential importance and is becoming the gold standard. Head and neck tumors also endanger relevant structures of the upper aerodigestive tracts, including bodily functions such as voice, speech, swallowing, and breathing. Damage to these functions can significantly influence quality of life. Thus, our study examined not only the roles of head and neck surgeons, oncologists and radiotherapists, but also the importance of the participation of different scientific professions such as anesthesiologists, psychologists, nutritionists, stomatologists, and speech therapists in the work of a multidisciplinary team (MDT). Their participation results in a significant improvement of patient quality of life. We also present our experiences in the organization and work of the MDT as part of the Center for Head and Neck Tumors of the Zagreb Clinical Hospital Center.

Prophylactic Central Neck Dissection in Well-differentiated Thyroid Cancer.

Well-differentiated cancers, both papillary and follicular, account for 90% of all diagnosed thyroid cancers. They have an indolent disease course with a 20-year disease-specific survival over 90%. According to current guidelines, the therapy of choice for well-differentiated thyroid carcinoma is total thyroidectomy or lobectomy. The indication for prophylactic central neck dissection is still a controversial issue and the subject of unfinished and ongoing debate. There is no indication for prophylactic central neck dissection in follicular thyroid carcinomas, which primarily metastasize hematogenously. In small solitary papillary thyroid carcinomas (T1 and T2), prophylactic central neck dissection is not indicated as it does not bring benefits in terms of improved patient survival and at the same time significantly increases the risk of temporary and permanent postoperative complications. Prophylactic central neck dissection is indicated in advanced papillary thyroid cancers (T3 and T4) and all other high-risk well-differentiated thyroid cancer, as well as in the presence of metastatic lymph nodes in the lateral neck.