Endobronchial Intubation With the King Vision® and McGrath® Laryngoscopes in Simulated Easy and Difficult Airways by Novices (eKingMath).

Objective. The competency of using video laryngoscopes (VL) for double-lumen tube (DLT) endobronchial intubations can be improved with constant training as assessed by measuring the learning curves. We hypothesized that the time to DLT intubation would be reduced over the intubation attempts. Design. A crossover manikin study. Settings. University-affiliated hospital. Participants. Forty-two novice medical students unfamiliar with DLT intubation. Interventions. Participants were randomly allocated to two sequences, including DLT intubation, using King Vision and McGrath VLs. Each participant completed 100 DLT intubation attempts on both simulated easy and difficult airways on two different mannikins using the study devices (25 attempts for each). Measurements and Main Results. The primary outcome was the time to DLT intubation. The secondary outcomes included the best glottic view, optimizing maneuvers, and intubation first-pass success. The use of King Vision VL was associated with a significantly shorter time to DLT intubation (P < 0.044 and P < 0.05, respectively) and a higher percentage of glottic opening (POGO) compared to the McGrath VL (P < 0.011 and P < 0.002, respectively) in the simulated "easy" and "difficult" over most of the intubation attempts. In the simulated "easy" airway, the first-pass success ratio was higher when using the King Vision VL (median [Minimum-Maximum] 100% [100%-100%] and 100% [88%-100%], P = 0.012). Conclusion. Novice medical students developed skills over intubation attempts, meaning achievement of a faster DLT intubation, better laryngeal exposure, and higher success rate on simulated "easy" and "difficult" airways. A median of 9 DLT intubations was required to achieve a 92% or greater DLT intubation success rate.

Airway management for one lung ventilation during COVID-19 pandemic: a survey within Italian anesthesiologists.

BACKGROUND: Airway management for thoracic surgery represents a high risk setting for SARS-CoV-2 infection diffusion due to complex and invasive airway instrumentation and techniques. RESULTS: An 18-item questionnaire was submitted to the 56 members of the Thoracic subcommittee of the SIAARTI Cardio-Thoraco-Vascular Research Group to provide a snapshot of current situation and national variability of devices and procedures for airway management during the COVID-19 pandemic. The response rate was 64%. Eighty-three percent of anesthetists declared that they modified their airway management strategies. The Hospital Management considered necessary to provide a complete level 3 personal protective equipment for thoracic anesthetists only in 47% of cases. Double-lumen tube and bronchial blocker were preferred by 53% and 22% of responders to achieve one-lung ventilation respectively. Over 90% of responders considered the videolaryngoscope with separate screen and rapid sequence induction/intubation useful to minimize the infection risk. Thirty-nine percent of participants considered mandatory the bronchoscopic check of airway devices. Vivasight-DL was considered comfortable by more than 50% of responders while protective box and plastic drape were judged as uncomfortable by most of anesthetists. CONCLUSIONS: The survey reveals many changes in the clinical practice due to SARS-CoV-2 outbreak. A certain diffusion of new devices such as the VivaSight-DL and barrier enclosure systems emerged too. Finally, we found that most of Italian hospitals did not recognize thoracic anesthesia as a high-risk specialty for risk of virus diffusion.

Blind intubation through Laryngeal Mask Airway in a cannot intubate-difficult to ventilate patient with massive hematemesis.

Massive hematemesis could be challenging situation requiring emergency airway control and urgent surgical treatment. We report a case of difficult airway management with blind intubation through Laryngeal Mask Airway in a 56-year-old patient with massive hematemesis. After failed endoscopic attempts to stop bleeding, worsening of hemodynamics called for emergency intubation and surgery. After failed intubation attempts and face-mask ventilation worsening, a classic LMA was used for rescue ventilation and decision was made to intubate through LMA. The airway exchange was aided by a nasogastric tube (NGT) through LMA, confirmed with capnography and surgery was started successfully and uneventfully. Unexpected difficult airway can be extremely challenging situation, especially in emergency settings with no possibility to delay surgery. In those cases, literature suggests different intubating techniques through LMA. Blind intubation through LMA aided by NGT showed to be a suitable option in resources-limited settings, where advanced supraglottic devices and/or optical devices are not available.

Evaluation of two neck ultrasound measurements as predictors of difficult direct laryngoscopy: A prospective observational study.

BACKGROUND: Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially if difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common clinical screening tests have shown low sensitivity and specificity with a limited predictive value. Ultrasound-based airway assessment has been proposed recently as a useful, simple, noninvasive bedside tool as an adjunct to clinical methods, but to date, few studies are available about the potential role of ultrasound in difficult airway evaluation, and these are mostly limited to specific groups of patients. OBJECTIVES: The aim of this study was to determine the correlation between the sonographic measurements of anterior cervical soft tissues thickness and Cormack-Lehane grade view at direct laryngoscopy in patients with normal clinical screening tests. DESIGN: Prospective, single blinded, observational study. SETTING: Operating theatre of a teaching hospital from May 2017 to September 2017. PATIENTS: A total of 301 patients at least 18 years of age undergoing elective surgery under general anaesthesia with tracheal intubation were included in the study. OUTCOME MEASURES: Pre-operative evaluation was performed before surgery, demographic variables were collected and clinical screening tests to predict a difficult airway were performed. Patients with predicted difficult intubation were excluded. A 10 to 13-MHz linear ultrasound transducer was placed in the transverse plane and the thickness of the anterior cervical soft tissues was measured at two levels [thyrohyoid membrane (pre-epiglottic space) and vocal cords (laryngeal inlet)] with the patient's head in a neutral position. At each level, the distance from the skin in the median axis and the surrounding area was measured. The laryngoscopic view was graded by a different anaesthetist with more than 5 years of experience with direct laryngoscopy, blinded to the ultrasound assessments. RESULTS: The 'pre-epiglottic space thickness' at the level of thyrohyoid membrane was measured as the median distance from skin to epiglottis (mDSE) and the pre-epiglottic area was calculated; the mDSE cut-off value of 2.54 cm (sensitivity 82%, specificity 91%) and the pre-epiglottic area cut-off value of 5.04 cm (sensitivity 85%, specificity 88%) were the best predictors of a Cormack-Lehane grade at least 2b at direct laryngoscopy and of difficult intubation. The cut-off value of mDSE showed greater sensitivity in female patients (94 vs. 86%) and greater specificity in male patients (92 vs. 83%). No correlation was found between difficult laryngoscopy and ultrasound assessments at the level of the vocal cords. CONCLUSION: Airways ultrasounds might be considered as a predictor of restricted/difficult laryngoscopy and unpredicted difficult intubation. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03547193.

Clinical indices and biomarkers for perioperative cardiac risk stratification: an update.

European Society of Cardiology (ESC)/ European Society of Anesthesiology (ESA) highlighted that anesthesiologist has a leading role in perioperative cardiovascular assessment and management in the year of 2014. During cardiovascular assessment one can rely on cooperation of multidisciplinary specialists like: other anesthesiologists, cardiologists and surgeons. For the purpose of precise systematization and decision making the Lee Score or NSQUIP database can be used besides the traditionally used ASA Score. Additional help is provided with specific palette of cardiac biomarkers like: cardiac troponins T, cardiac troponins I, C-reactive protein, N-terminal pro-brain natriuretic peptide, brain natriuretic peptide, etc. Biomarkers are considered to represent a foundation of evidence based medicine and they help anesthesiologists in the decision-making process. They increase the chance to achieve the best clinical outcome for each patient. An ideal biomarker does not exist and therefore new research are currently being conducted with the aim to find and declare more specific biomarkers like heart-type fatty acid-binding protein, micro RNA, PAMP and high sensitivity troponins T.

AIRWAY VISUALIZATION: EYES SEE WHAT MIND KNOWS.

Airway management is basic for anesthesia practice, and sometimes it can represent a really dramatic scenario for both the patient and the physicians. Laryngoscopy has been the gold standard of airway visualization for more than 60 years, showing its limitations and failure rates with time. New technology has made available an opportunity to move the physician's eye inside patient airways thanks to video laryngoscopy and video assisted airway management technique. Undoubtedly, we have entered a new era of high resolution airway visualization and different approach in airway instrumentation. Nevertheless, each new technology needs time to be tested and considered reliable, and pitfalls and limitations may come out with careful and long lasting analysis, so it is probably not the right time yet to promote video assisted approach as a new gold standard for airway visualization, despite the fact that it certainly offers some new prospects. In any case, whatever the visualization approach, no patient dies because of missed airway visualization or failed intubation, but due to failed ventilation, which remains without doubt the gold standard of any patient safety goal and airway management technique.

Long-term outcome of strabismus and ptosis surgery in a mother and daughter with congenital fibrosis of extraocular muscles.

BACKGROUND: Congenital fibrosis of extraocular muscles (CFEOM) is a very rare congenital condition, characterized by variable amounts of restriction of the extraocular muscles, with or without ptosis. The aim of this report was to describe a severe, atypical, exposure-induced corneal stromal lysis in two patients. CASE REPORT: A mother and a daughter with a severe CFEOM were presented. The surgery of both extraocular muscles and ptosis led to a fair outcome in mother even 30 years after, and a very good outcome in daughter 4 years after the treatment. CONCLUSION: Though frequently challenging and dissapointing the outcome of surgery of both extraocular muscles and ptosis in CFEOM can be favorable even in rather severe cases. To the best of our knowledge, the atypical keratolysis we described has not been highlighted in the literature on CFEOM so far.