Cardiac arrest due to an unexpected inability to ventilate in a tracheostomy patient suggesting the need for a routine anesthesia checklist and an anesthesia relevant emergency pathway for tracheostomy management: a case report.

Background: Up to 30% of patients worldwide have a significant complication related to their tracheostomy. We report a case of a 'cannot ventilate' event resulting in cardiac arrest due to an unexpected airway occlusion in a patient with a pre-existing brain injury The following case report is unique as the patient had developed a mucus plug that turned into a crystal following a coronavirus disease 19 (COVID-19) infection. Case Description: The patient was a young adult who suffered a traumatic brain injury from a motor vehicle collision. He presented for elective cystoscopy to treat recurrent urinary tract infections. During induction of anesthesia, the patient became agitated, desaturated, and ventilation became impossible. With chest compressions underway the tracheostomy was removed, and the patient was quickly and successfully orally intubated using a video-laryngoscope. Subsequent inspection of the tracheostomy tube revealed a mucus plug in the distal portion which had hardened into a rock-like appearance. The inner cannula was also missing. Follow-up revealed that the patient recently had a COVID-19 infection and because of this received less frequent suctioning of his tracheostomy tube. Conclusions: Reviewing the literature, we recognized that there has been no case report documenting a mucus plug that turned into a stone. Reviewing guidelines for handling tracheostomy emergencies, we recognize that there are no anesthesia specific guidelines in the USA. We also recognize that there are no established checklists for patients with tracheostomy undergoing surgery. We therefore recommend establishing a routine checklist and anesthesia specific guideline for emergencies that follows every patient with a tracheostomy undergoing surgery.

Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Airway Management for Endoscopic Laryngotracheal Stenosis Surgery During COVID-19.

The novel coronavirus disease 2019 (COVID-19) pandemic presents unique challenges for surgical management of laryngotracheal stenosis. High viral concentrations in the upper aerodigestive tract, the ability of the virus to be transmitted by asymptomatic carriers and through aerosols, and the need for open airway access during laryngotracheal surgery create a high-risk situation for airway surgeons, anesthesiologists, and operating room personnel. While some surgical cases of laryngotracheal stenosis may be deferred, patients with significant airway obstruction or progressing symptoms often require urgent surgical intervention. We present best practices from our institutional experience for surgical management of laryngotracheal stenosis during this pandemic, including preoperative triage, intraoperative airway management, and personal protective measures.

The OxyTain Algorithm: An Approach to Airway Management in the Cannot Intubate and Cannot Oxygenate Scenario.

Although rare, cannot intubate and cannot oxygenate situations are challenging acute events. The development of management algorithms, standardized equipment provisions, and appropriate clinical training in the application of front-of-neck access techniques are necessary to optimize procedural success to ensure adequate oxygenation. The OxyTain algorithm is an institutionally developed protocol to manage cannot intubate and cannot oxygenate events. With proper implementation, this unique process aligning the cannula cricothyroidotomy and scalpel bougie as primary and secondary techniques, respectively, can potentially optimize procedural success. This algorithmic approach is trained routinely among our anesthesia providers, while the equipment is standardized throughout our anesthetizing locations.

Developing BrightHearts: A Pediatric Biofeedback-Mediated Relaxation App to Manage Procedural Pain and Anxiety.

OBJECTIVE: The objective of this study was to develop a child-friendly biofeedback-mediated relaxation device called BrightHearts. METHODS: Qualitative data were collected at a tertiary pediatric hospital to inform an iterative design process. Clinicians participated in expert group interviews to identify practical considerations that would facilitate the use of BrightHearts during procedures and provide feedback on prototype designs. Children 7 to 18 years of age participated in interactive exhibitions of the prototypes and were interviewed about their experiences using BrightHearts. RESULTS: Twenty-four clinicians participated in 6 group interviews. Thirty-nine children participated in interactive exhibitions, and 21 were interviewed. Clinicians placed high value on the following factors in the management of procedural pain: providing children with an element of control, the use of relaxation techniques, and the use of portable electronic devices such as iPads. They highlighted the need for BrightHearts to be cost effective, portable, and capable of engaging children's interest. They confirmed the utility of developing a biofeedback-assisted relaxation device for children. Based on the factors identified by clinicians, BrightHearts was developed as an iPad application (app) paired with a wireless heart rate monitor. The BrightHearts heart rate biofeedback app displays digital geometric artwork that responds to changes in heart rate. Children 7 to 17 years of age understood the concept of biofeedback and operated the app by slowing their heart rates. CONCLUSION: The BrightHearts app can be used to teach children biofeedback-assisted relaxation. Ongoing studies are evaluating its efficacy for the management of procedural pain in children.