The Role of Dexmedetomidine in Airway Management for Tracheostomy in Pediatric Patient with Obstructed Airway Due to Diphtheria: A Case Report.

Introduction: Diphtheria is an infectious disease caused by exotoxin-producing Corynebacterium diphteriae and was a leading cause of death in childhood during the prevaccine era. This toxin is usually localized in the upper respiratory tract and may cause fatal airway obstruction. Many have used orotracheal intubation to secure the airway in diphtheria cases. However, the efficacy of tracheostomy under sedation while maintaining spontaneous ventilation and analgesia using trans-tracheal and superficial cervical block remains to be elucidated. Case Presentation: A 6-year-old presented to the emergency room with respiratory distress and was diagnosed with diphtheria. A thick membrane in the oropharyngeal area and chest X-ray showed infiltrations indicative of pneumonia. The patient successfully underwent emergency tracheostomy under sedation using a combination of sevoflurane and dexmedetomidine to achieve prompt sedation and trans-tracheal injection and bilateral superficial cervical block as analgesia for the intra-tracheal and the incision. The patient's condition deteriorated the next day, and the bronchoscopy showed that the carina and main bronchus were covered by a pseudomembrane, obstructing the airway below the tracheostomy. The patient eventually died two days after admission. Conclusions: Dexmedetomidine has minimal impact on ventilatory function and anti-sialagogue properties, while sevoflurane has minimal effect on respiratory depression. This case presentation showed that a combination of sevoflurane and dexmedetomidine with spontaneous assisted ventilation could be helpful in tracheostomy procedures in pediatric patients with airway obstruction due to diphtheria, along with the use of trans-tracheal and superficial cervical block as the analgesia. This report also indicates that being vigilant in rapidly-progressing and fatal pediatric diphtheria cases is vital.

Evaluation of continuous intravenous lidocaine on brain relaxation, intraoperative opioid consumption, and surgeon's satisfaction in adult patients undergoing craniotomy tumor surgery: A randomized controlled trial.

BACKGROUND: In craniotomy tumor removal, brain relaxation after dura opening is essential. Lidocaine is known to have analgesic and antiinflammatory effects. It is excellent in decreasing cerebral metabolic rate of oxygen, cerebral blood flow, and cerebral blood volume; and can potentially reduce intracranial pressure, resulting in exceptional brain relaxation after dura opening. However, no study has examined continuous intravenous lidocaine infusion on brain relaxation, intraoperative opioid consumption and surgeon's satisfaction in adult patients undergoing craniotomy tumor removal. METHODS: A total of 60 subjects scheduled for craniotomy tumor removal were enrolled in a double-blind, randomized controlled trial with consecutive sampling. Patients received either an intravenous bolus of lidocaine (2%) 1.5 mg/kg before induction followed by 2 mg/kg/h continuous infusion up to skin closure (lidocaine group) or placebo with similar volume (NaCl 0.9%). Neurosurgeons evaluated brain relaxation and surgeon's satisfaction with a 4-point scale, total intraoperative opioid consumption was recorded in µg and µg/kg/min. RESULTS: All sixty subjects were included in the study. Lidocaine group showed better brain relaxation after dura opening (96.7% vs 70%; lidocaine vs placebo, P < .006), less intraoperative fentanyl consumption (369.2 µg vs 773.0 µg; P < .001, .0107 vs .0241 µg/kg/min; lidocaine vs placebo, P < .001). Higher surgeon's satisfaction was found in lidocaine group (96.7% vs 70%, P = .006). No side effects were observed during this study. CONCLUSIONS: Continuous lidocaine intravenous infusion improves brain relaxation after dura opening, and decreases intraoperative opioid consumption, with good surgeon satisfaction in adult patients undergoing craniotomy tumor removal.

Assessing clinical reasoning in airway related cases among anesthesiology fellow residents using Script Concordance Test (SCT).

INTRODUCTION: Clinical reasoning is a core competency for physicians. In the field of anesthesia, many situations require residents to use their clinical reasoning to make quick and appropriate decisions such as during emergency airway cases. The Script Concordance Test (SCT) is a test developed in recent years and validated that objectively assess clinical reasoning ability. However, studies involving SCT to assess clinical reasoning in airway management is scarce. AIM: To evaluate SCT in assessing clinical reasoning for airway management in anesthesiology residents. METHOD: A cross-sectional study involving residents and anesthesiology consultants from the Department of Anesthesiology and Intensive Care, Faculty of Medicine Universitas Indonesia was conducted to complete SCT. A panel of five anesthesiology consultants with more than 15 years of work experience constructed 20 SCT vignettes based on prevalent airway cases in our center from the past 10 years. Each SCT has three nested questions, with a total of 60 questions, to be answered within 120 min. RESULTS: The SCT of 20 case vignettes with three nested questions were tested on 99 residents from the junior, intermediate, and senior residents, compared to answers from the expert group consisting of ten anesthesiology consultants with more than 5 years of experience. There were significant differences in mean SCT scores in the junior, intermediate, senior and expert groups, 59.3 (46.1-72.8), 64.7 (39.9-74.9), 67.5 (50.6-78.3), and 79.6 (78.4-84.8); p < 0,001 consecutively. Cronbach Alpha 0.69 was obtained, indicating good reliability. CONCLUSION: Our SCT was proven to be a valid and reliable test instrument to assess the clinical reasoning in airway management for anesthesiology residents. SCT was able to discriminate between groups of different clinical experiences and should be included to evaluate airway competencies in anesthesiology residents.