The Society of Thoracic Surgeons Adult Cardiac Surgery Database: Intraoperative Echocardiography Reporting.

OBJECTIVES: To identify trends in the reporting of intraoperative transesophageal echocardiographic (TEE) data in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) and the Adult Cardiac Anesthesiology (ACA) module by period, practice type, and geographic distribution, and to elucidate ongoing areas for practice improvement. DESIGN: A retrospective study. SETTING: STS ACSD. PARTICIPANTS: Procedures reported in the STS ACSD between July 2017 and December 2021 in participating programs in the United States. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Intraoperative TEE is reported for 73% of all procedures in ACSD. Although the intraoperative TEE data reporting rate increased from 2017 to 2021 for isolated coronary artery bypass graft surgery, it remained low at 62.2%. The reporting of relevant echocardiographic variables across a wide range of procedures has steadily increased over the study period but also remained low. The reporting in the ACA module is high for most variables and across all anesthesia care models; however, the overall contribution of the ACA module to the ACSD remains low. CONCLUSIONS: This progress report suggests a continued need to raise awareness regarding current practices of reporting intraoperative TEE in the ACSD and the ACA, and highlights opportunities for improving reporting and data abstraction.

Association Between Postoperative Delirium and Long-Term Subjective Cognitive Decline in Older Patients Undergoing Cardiac Surgery: A Secondary Analysis of the Minimizing Intensive Care Unit Neurological Dysfunction with Dexmedetomidine-Induced Sleep Trial.

OBJECTIVES: This study aimed to evaluate whether a measure of subjective cognitive decline (SCD), the Patient-Reported Outcomes Measurement Information System (PROMIS) Applied Cognition-Abilities questionnaire, was associated with postoperative delirium. It was hypothesized that delirium during the surgical hospitalization would be associated with a decrease in subjective cognition up to 6 months after cardiac surgery. DESIGN: This was a secondary analysis of data from the Minimizing Intensive Care Unit Neurological Dysfunction with Dexmedetomidine-induced Sleep randomized, placebo-controlled, parallel-arm superiority trial. SETTING: Data from patients recruited between March 2017 and February 2022 at a tertiary medical center in Boston, Massachusetts were analyzed in February 2023. PARTICIPANTS: Data from 337 patients aged 60 years or older who underwent cardiac surgery with cardiopulmonary bypass were included. INTERVENTIONS: Patients were assessed preoperatively and postoperatively at 30, 90, and 180 days using the subjective PROMIS Applied Cognition-Abilities and telephonic Montreal Cognitive Assessment. MEASUREMENT AND MAIN RESULTS: Postoperative delirium occurred within 3 days in 39 participants (11.6%). After adjusting for baseline function, participants who developed postoperative delirium self-reported worse cognitive function (mean difference [MD] -2.64 [95% CI -5.25, -0.04]; p = 0.047) up to 180 days after surgery, as compared with nondelirious patients. This finding was consistent with those obtained from objective t-MoCA assessments (MD -0.77 [95% CI -1.49, -0.04]; p = 0.04). CONCLUSIONS: In this cohort of older patients undergoing cardiac surgery, in-hospital delirium was associated with SCD up to 180 days after surgery. This finding suggested that measures of SCD may enable population-level insights into the burden of cognitive decline associated with postoperative delirium.

Preliminary Study of Serum Biomarkers Associated With Delirium After Major Cardiac Surgery.

OBJECTIVES: The objective of this study was to identify novel serum biomarkers specific to postoperative delirium after major cardiac surgery to provide insight into the pathologic processes involved in delirium and its sequelae. DESIGN: Nested, case-control study. SETTING: Cardiac surgical intensive care unit in a single-site hospital setting. PARTICIPANTS: The study comprised 24 older adults (aged >60 years) undergoing major cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a positive screen for delirium from postoperative days one through three based on criteria included in the long form of the Confusion Assessment Method. A multiplexed proteomic approach was applied using proximity extension assays to identify and quantify proteins found in serum collected on the day of surgery and postoperative day one in delirious and nondelirious patient cohorts. An increase in serum fibroblast growth factor (FGF)-21 levels was identified in the delirious cohort from a presurgery baseline of (mean ± standard deviation) 5.0 ± 1.1 log2 abundance (95% confidence interval [CI], 4.3-5.7) to 6.7 ± 1.6 log2 abundance (95% CI, 5.7-7.7; p = 0.01) postsurgery. A similar increase was identified in FGF-23 from a presurgery baseline of 1.7 ± 1.3 log2 abundance (95% CI, 0.8-2.5) to 3.4 ± 2.2 log2 abundance (95% CI, 2.0-4.8; p = 0.06) postsurgery. An increase in interleukin-6 serum levels also was identified in the delirious cohort from a presurgery baseline of 3.8 ± 1.1 log2 abundance (95% CI, 3.1-4.5) to 8.7 ± 1.9 log2 abundance (95% CI, 7.5-9.9; p < 0.0001) postsurgery. However, the increase in interleukin-6 serum levels of the nondelirious cohort also met the study's threshold for statistical significance (p < 0.0001). Finally, an increase in monocyte chemotactic protein-3 serum levels was identified in the delirious cohort from a presurgery baseline of 4.1 ± 0.9 log2 abundance (95% CI, 3.6-4.7) to 6.1 ± 2.0 log2 abundance (95% CI, 4.8-7; p = 0.009) postsurgery. CONCLUSIONS: FGF-21, FGF-23, interleukin-6, and monocyte chemotactic protein-3 serum levels were increased postoperatively in patients who developed delirium after major cardiac surgery. This study identified two members of the FGF family as potential putative systemic biomarkers for postoperative delirium after cardiac surgery, suggesting a possible role for metabolic recovery in the pathophysiologic mechanisms underlying neurocognitive dysfunction.

Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.

A polysomnography study examining the association between sleep and postoperative delirium in older hospitalized cardiac surgical patients.

Hospitalized older patients who undergo elective cardiac surgery with cardiopulmonary bypass are prone to postoperative delirium. Self-reported shorter sleep and longer sleep have been associated with impaired cognition. Few data exist to guide us on whether shorter or longer sleep is associated with postoperative delirium in this hospitalized cohort. This was a prospective, single-site, observational study of hospitalized patients (>60 years) scheduled to undergo elective major cardiac surgery with cardiopulmonary bypass (n = 16). We collected and analysed overnight polysomnography data using the Somté PSG device and assessed for delirium twice a day until postoperative day 3 using the long version of the confusion assessment method and a structured chart review. We also assessed subjective sleep quality using the Pittsburg Sleep Quality Index. The delirium median preoperative hospital stay of 9 [Q1, Q3: 7, 11] days was similar to the non-delirium preoperative hospital stay of 7 [4, 9] days (p = .154). The incidence of delirium was 45.5% (10/22) in the entire study cohort and 50% (8/16) in the final cohort with clean polysomnography data. The preoperative delirium median total sleep time of 323.8 [Q1, Q3: 280.3, 382.1] min was longer than the non-delirium median total sleep time of 254.3 [210.9, 278.1] min (p = .046). This was accounted for by a longer delirium median non-rapid eye movement (REM) stage 2 sleep duration of 282.3 [229.8, 328.8] min compared to the non-delirium median non-REM stage 2 sleep duration of 202.5 [174.4, 208.9] min (p = .012). Markov chain modelling confirmed these findings. There were no differences in measures of sleep quality assessed by the Pittsburg Sleep Quality Index. Polysomnography measures of sleep obtained the night preceding surgery in hospitalized older patients scheduled for elective major cardiac surgery with cardiopulmonary bypass are suggestive of an association between longer sleep duration and postoperative delirium.

Brain Protection in Aortic Arch Surgery: An Evolving Field.

Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.

Dissociative and Analgesic Properties of Ketamine Are Independent.

BACKGROUND: Ketamine is a dissociative anesthetic with analgesic properties. Ketamine's analgesic properties have been suggested to result from its dissociative properties. To the authors' knowledge, this postulate is unsubstantiated. The authors hypothesize that the dissociative and analgesic properties of ketamine are independent. METHODS: The authors conducted a single-site, open-label study of ketamine anesthesia (2 mg/kg) in 15 healthy subjects. Midazolam was administered at a prespecified time point to attenuate dissociation. The authors longitudinally assessed precalibrated cuff pain intensity and quality using Patient-Reported Outcomes Measurement Information System questionnaires, and dissociation, using the Clinician Administered Dissociative States Scale. Mixed effects models were used to assess whether dissociation accounted for the effect of ketamine on pain intensity and quality. RESULTS: The dissociation model demonstrated an inverted U-shaped quadratic relationship between time and dissociation scores. Additive to this effect, midazolam reduced the dissociation adjusted means by 10.3 points (95% CI, 3.4 to 17.1; P = 0.005). The pain intensity model also demonstrated a U-shaped quadratic relationship between time and pain intensity. When the pain intensity model was reanalyzed with dissociation scores as an additional covariate, the dissociation term was not retained in the model, and the other effects were preserved in direction and strength. This result was conserved for nociceptive and neuropathic pain quality. CONCLUSIONS: Ketamine's analgesic properties are not exclusively caused by dissociation. Thus, ketamine may be used as a probe to advance our knowledge of dissociation independent neural circuits that encode pain.

Electroencephalogram Burst-suppression during Cardiopulmonary Bypass in Elderly Patients Mediates Postoperative Delirium.

BACKGROUND: Intraoperative burst-suppression is associated with postoperative delirium. Whether this association is causal remains unclear. Therefore, the authors investigated whether burst-suppression during cardiopulmonary bypass (CPB) mediates the effects of known delirium risk factors on postoperative delirium. METHODS: This was a retrospective cohort observational substudy of the Minimizing ICU [intensive care unit] Neurological Dysfunction with Dexmedetomidine-induced Sleep (MINDDS) trial. The authors analyzed data from patients more than 60 yr old undergoing cardiac surgery (n = 159). Univariate and multivariable regression analyses were performed to assess for associations and enable causal inference. Delirium risk factors were evaluated using the abbreviated Montreal Cognitive Assessment and Patient-Reported Outcomes Measurement Information System questionnaires for applied cognition, physical function, global health, sleep, and pain. The authors also analyzed electroencephalogram data (n = 141). RESULTS: The incidence of delirium in patients with CPB burst-suppression was 25% (15 of 60) compared with 6% (5 of 81) in patients without CPB burst-suppression. In univariate analyses, age (odds ratio, 1.08 [95% CI, 1.03 to 1.14]; P = 0.002), lowest CPB temperature (odds ratio, 0.79 [0.66 to 0.94]; P = 0.010), alpha power (odds ratio, 0.65 [0.54 to 0.80]; P < 0.001), and physical function (odds ratio, 0.95 [0.91 to 0.98]; P = 0.007) were associated with CPB burst-suppression. In separate univariate analyses, age (odds ratio, 1.09 [1.02 to 1.16]; P = 0.009), abbreviated Montreal Cognitive Assessment (odds ratio, 0.80 [0.66 to 0.97]; P = 0.024), alpha power (odds ratio, 0.75 [0.59 to 0.96]; P = 0.025), and CPB burst-suppression (odds ratio, 3.79 [1.5 to 9.6]; P = 0.005) were associated with delirium. However, only physical function (odds ratio, 0.96 [0.91 to 0.99]; P = 0.044), lowest CPB temperature (odds ratio, 0.73 [0.58 to 0.88]; P = 0.003), and electroencephalogram alpha power (odds ratio, 0.61 [0.47 to 0.76]; P < 0.001) were retained as predictors in the burst-suppression multivariable model. Burst-suppression (odds ratio, 4.1 [1.5 to 13.7]; P = 0.012) and age (odds ratio, 1.07 [0.99 to 1.15]; P = 0.090) were retained as predictors in the delirium multivariable model. Delirium was associated with decreased electroencephalogram power from 6.8 to 24.4 Hertz. CONCLUSIONS: The inference from the present study is that CPB burst-suppression mediates the effects of physical function, lowest CPB temperature, and electroencephalogram alpha power on delirium.

Type A aortic dissection in the East and West: A comparative study between two hospitals from China and the US.

BACKGROUND: In this study, we compare the clinical characteristics, intraoperative management, and postoperative outcomes of patients with acute type A aortic dissection (ATAAD) between two academic medical hospitals in the United States and China. METHODS: From January 2011 to December 2017, 641 and 150 patients from Nanjing Drum Tower Hospital (NDTH) and Massachusetts General Hospital (MGH) were enrolled. Patient demographics, clinical features, surgical techniques, and postoperative outcomes were compared. RESULTS: The annual number of patients presenting with ATAAD at MGH remained relatively stable, while the number at NDTH increased significantly over the study period. The average age was 51 years at NDTH and 61 years at MGH (P < .001). The percentage of patients with known hypertension at the two centers was similar. The time interval from onset of symptoms to diagnosis was significantly longer at NDTH than MGH (11 vs 3.5 hours; P < .001). Associated complications at presentation were more common at NDTH than MGH. More than 90% of patients (91% NDTH and 92% MGH) underwent surgery. The postoperative stroke rate was higher at MGH (12% vs 4%; P < .001); however, the 30-day mortality rate was lower (7% vs 16%; P = .006). CONCLUSIONS: There was a significant increase in the number of ATAAD at NDTH during the study period while the number at MGH remained stable. Hypertension was a common major risk factor; however, the onset of ATAAD at NDTH was nearly one decade earlier than MGH. Chinese patients tended to have more complicated preoperative pathophysiology at presentation and underwent more extensive surgical repair.

Cognitive function mediates the relationship between age and anaesthesia-induced oscillatory-specific alpha power.

Cognitive decline is common among older individuals, and although the underlying brain mechanisms are not entirely understood, researchers have suggested using EEG frontal alpha activity during general anaesthesia as a potential biomarker for cognitive decline. This is because frontal alpha activity associated with GABAergic general anaesthetics has been linked to cognitive function. However, oscillatory-specific alpha power has also been linked with chronological age. We hypothesize that cognitive function mediates the association between chronological age and (oscillatory-specific) alpha power. We analysed data from 380 participants (aged over 60) with baseline screening assessments and intraoperative EEG. We utilized the telephonic Montreal Cognitive Assessment to assess cognitive function. We computed total band power, oscillatory-specific alpha power, and aperiodics to measure anaesthesia-induced alpha activity. To test our mediation hypotheses, we employed structural equation modelling. Pairwise correlations between age, cognitive function and alpha activity were significant. Cognitive function mediated the association between age and classical alpha power [age → cognitive function → classical alpha; ß = -0.0168 (95% confidence interval: -0.0313 to -0.00521); P = 0.0016] as well as the association between age and oscillatory-specific alpha power [age → cognitive function → oscillatory-specific alpha power; ß = -0.00711 (95% confidence interval: -0.0154 to -0.000842); P = 0.028]. However, cognitive function did not mediate the association between age and aperiodic activity (1/f slope, P = 0.43; offset, P = 0.0996). This study is expected to provide valuable insights for anaesthesiologists, enabling them to make informed inferences about a patient's age and cognitive function from an analysis of anaesthetic-induced EEG signals in the operating room. To ensure generalizability, further studies across different populations are needed.

Styletubation in Bariatric Surgery: A Case Report.

Direct laryngoscopes and videolaryngoscopes are the dominant endotracheal intubation tools. The styletubation technique (using a video-assisted intubating stylet) has shown its advantages in terms of short intubation time, high success rate, less required stimulation, and operator satisfaction. The learning curve can be steep but is easily overcome if technical pitfalls are avoided. Conditions that make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, obesity, etc. In this clinical report, we present the effectiveness and efficiency of the routine use of the styletubation for tracheal intubation in a super-super-obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.

An Approach to Improve the Effectiveness of the Video-Assisted Intubating Stylet Technique for Tracheal Intubation: A Case Series Report.

Direct laryngoscopy and videolaryngoscopy are currently the dominant tools for endotracheal intubation. However, the video-assisted intubating stylet, a type of videolaryngoscopy, has been shown to offer some advantages over these tools, such as rapid intubation time, high first-attempt success rates, less airway stimulation, and high subjective satisfaction. On the other hand, this optical intubating technique also has some technical limitations that need to be addressed, including camera lens fogging, airway path disorientation, and obscured visibility due to secretions. In this clinical report, we describe an approach that improves the visibility of the glottis by introducing a suctioning catheter into the nasopharyngeal airway to enhance the efficiency and accuracy of using the intubating stylet technique for tracheal intubation.

Nighttime dexmedetomidine for delirium prevention in non-mechanically ventilated patients after cardiac surgery (MINDDS): A single-centre, parallel-arm, randomised, placebo-controlled superiority trial.

Background: The delirium-sparing effect of nighttime dexmedetomidine has not been studied after surgery. We hypothesised that a nighttime dose of dexmedetomidine would reduce the incidence of postoperative delirium as compared to placebo. Methods: This single-centre, parallel-arm, randomised, placebo-controlled superiority trial evaluated whether a short nighttime dose of intravenous dexmedetomidine (1 µg/kg over 40 min) would reduce the incidence of postoperative delirium in patients 60 years of age or older undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomised to receive dexmedetomidine or placebo in a 1:1 ratio. The primary outcome was delirium on postoperative day one. Secondary outcomes included delirium within three days of surgery, 30-, 90-, and 180-day abbreviated Montreal Cognitive Assessment scores, Patient Reported Outcome Measures Information System quality of life scores, and all-cause mortality. The study was registered as NCT02856594 on ClinicalTrials.gov on August 5, 2016, before the enrolment of any participants. Findings: Of 469 patients that underwent randomisation to placebo (n = 235) or dexmedetomidine (n = 234), 75 met a prespecified drop criterion before the study intervention. Thus, 394 participants (188 dexmedetomidine; 206 placebo) were analysed in the modified intention-to-treat cohort (median age 69 [IQR 64, 74] years; 73.1% male [n = 288]; 26·9% female [n = 106]). Postoperative delirium status on day one was missing for 30 (7.6%) patients. Among those in whom it could be assessed, the primary outcome occurred in 5 of 175 patients (2.9%) in the dexmedetomidine group and 16 of 189 patients (8.5%) in the placebo group (OR 0.32, 95% CI: 0.10-0.83; P = 0.029). A non-significant but higher proportion of participants experienced delirium within three days postoperatively in the placebo group (25/177; 14.1%) compared to the dexmedetomidine group (14/160; 8.8%; OR 0.58; 95% CI, 0.28-1.15). No significant differences between groups were observed in secondary outcomes or safety. Interpretation: Our findings suggested that in elderly cardiac surgery patients with a low baseline risk of postoperative delirium and extubated within 12 h of ICU admission, a short nighttime dose of dexmedetomidine decreased the incidence of delirium on postoperative day one. Although non-statistically significant, our findings also suggested a clinical meaningful difference in the three-day incidence of postoperative delirium. Funding: National Institute on Aging (R01AG053582).

Development of deflector mode for spin-resolved time-of-flight photoemission spectroscopy.

Spin- and angle-resolved photoemission spectroscopy ("spin-ARPES") is a powerful technique for probing the spin degree-of-freedom in materials with nontrivial topology, magnetism, and strong correlations. Spin-ARPES faces severe experimental challenges compared to conventional ARPES attributed to the dramatically lower efficiency of its detection mechanism, making it crucial for instrumentation developments that improve the overall performance of the technique. In this paper, we demonstrate the functionality of our spin-ARPES setup based on time-of-flight spectroscopy and introduce our recent development of an electrostatic deflector mode to map out spin-resolved band structures without sample rotation. We demonstrate the functionality by presenting the spin-resolved spectra of the topological insulator Bi2Te3 and describe in detail the spectrum calibrations based on numerical simulations. By implementing the deflector mode, we minimize the need for sample rotation during measurements, hence improving the overall efficiency of experiments on small or inhomogeneous samples.

The Use of a Video-Assisted Intubating Stylet Technique in a Critically Ill and Contagious COVID-19 Patient.

Tracheal intubation and ventilatory support are among the important treatments in patients infected with COVID-19 with acute respiratory distress syndrome (ARDS) and severe hypoxia. The intubating team often uses video-assisted intubation equipment to ensure a safe and successful tracheal intubation. In this case report, we demonstrate for the first time, the use of the Shikani video-assisted intubating stylet and the Shikani intubating technique as a safe, speedy, and effective way to intubate a critically ill and highly contagious COVID-19 patient. In addition to the conventional consensus guidelines that are currently available for good practice (such as the proper use of personal protection equipment, etc.), we demonstrated that using the Shikani video-assisted intubating stylet is a reliable and proficient technique that is easy to learn while minimizing the risk of COVID-19 exposure of the airway personnel.

Video-Twin Technique for Airway Management, Combining Video-Intubating Stylet with Videolaryngoscope: A Case Series Report and Review of the Literature.

Direct laryngoscopy (DL) and videolaryngoscopy (VL) have been the most commonly used airway management modalities in the last several decades. Meanwhile, various optional airway tools (e.g., supraglottic devices, fiberoptic bronchoscopes) have been used for alternative rescue modalities when anticipated or unexpected difficulties in airway management has occurred. In recent decades, optical stylets and video-assisted intubating stylets have become another option for difficult airway scenarios. In contrast to other approaches, we have adopted the Shikani video-assisted intubating stylet technique (VS) for both routine and difficult airway management scenarios. In this case series report, we present the video-twin technique, combining a videolaryngoscope with a video-assisted intubating stylet in various clinical case scenarios. We propose that such a combination is easy to learn and employ and is particularly beneficial in situations where an expected difficult airway (EDA) is encountered.

Video-Assisted Intubating Stylet Technique for Difficult Intubation: A Case Series Report.

Induction of anesthesia can be challenging for patients with difficult airways and head or neck tumors. Factors that could complicate airway management include poor dentition, limited mouth opening, restricted neck motility, narrowing of oral airway space, restricted laryngeal and pharyngeal space, and obstruction of glottic regions from the tumor. Current difficult airway management guidelines include awake tracheal intubation, anesthetized tracheal intubation, or combined awake and anesthetized intubation. Video laryngoscopy is often chosen over direct laryngoscopy in patients with difficult airways because of an improved laryngeal view, higher frequency of successful intubations, higher frequency of first-attempt intubation, and fewer intubation attempts. In this case series report, we describe the video-assisted intubating stylet technique in five patients with difficult airways. We believe that the intubating stylet is a feasible and safe airway technique for anesthetized tracheal intubation in patients with an anticipated difficult airway.