The effect of pharyngeal packing on gastric volume in patients undergoing nasal surgery: a randomised, controlled trial.

OBJECTIVE: To explore the effects of pharyngeal packing on antral cross-sectional area, gastric volume and post-operative complications. METHODS: In this prospective, randomised, controlled study, 180 patients were randomly assigned to a control group or a pharyngeal packing group. Gastric antral dimensions were measured with pre- and post-operative ultrasound scanning. Presence and severity of post-operative nausea and vomiting and sore throat were recorded. RESULTS: Post-operative antral cross-sectional area and gastric volume were significantly larger in the pharyngeal packing group compared to the control group. The incidence and severity of post-operative nausea and vomiting were significantly less in the pharyngeal packing group. More frequent and severe sore throat was observed in the control group within the ward. An increased Apfel simplified risk score and post-operative antral cross-sectional area were associated with post-operative nausea and vomiting during the first 2 hours, whereas septorhinoplasty and functional endoscopic sinus surgery, absent pharyngeal packing, and lower American Society of Anesthesiologists' physical status were associated with post-operative nausea and vomiting within the ward. CONCLUSION: Regardless of operation type, pharyngeal packing use resulted in smaller gastric volume, which was associated with reduced post-operative nausea and vomiting frequency and severity, and lower sore throat incidence.

Airway management during unusual tracheal stenosis: A clinical feasibility trial.

Objectives: Prolonged intubation is a known risk factor of LTS. LTS related to COVID-19 may result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in these patients may carry unique challenges for both anesthesiologists and surgeons.This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow-controlled ventilation (FCV) in the management of patients with COVID-19-related LTS undergoing laryngeal surgery. Methods: 20 patients suffering from COVID-19-related LTS, as diagnosed by CT, requiring endolaryngeal surgery, with or without CO2 laser, were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency, and surgical exposure were evaluated. Results: Median duration of mechanical ventilation during their ICU stay was 17 days, (range, 7-27), and all patients had been pronated. In 18/20 patients, endoscopic diagnosis confirmed the initial CT diagnosis: posterior subglottic stenosis. Surgeons' satisfaction on the view was rated 9 out of 10 (range 7-10), where 0 was the worst view and 10 was the best view. Hemodynamic and respiratory variables were within the normal clinical range during the surgical procedure. One patient that had a SpO2 of 90% before induction of anesthesia, a temporal drop to 89%, caused meeting the predefined requirement of "respiratory complication." Conclusion: This study demonstrates the feasibility of using Tritube with FCV in patients with relatively unusual subglottic posterior location tracheal stenosis, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provides highly adequate ventilation especially in patients with compromised lung mechanics. Level of Evidence: IV, non-comparitive prospective clinical trial with 20 patients.

The changes of endotracheal tube intracuff pressures after ear and head and neck surgery-related positions: a prospective observational study / Alterações na pressão intracuff do tubo endotraqueal após posições cirúrgicas nas cirurgias de orelha e cabeça e pescoço: estudo observacional prospectivo

Abstract Introduction The cuff of an endotracheal tube seals the airway to facilitate positive-pressure ventilation and reduce subglottic secretion aspiration. However, an increase or decrease in endotracheal tube intracuff pressure can lead to many morbidities. Objective The main purpose of this study is to investigate the effect of different head and neck positions on endotracheal tube intracuff pressure during ear and head and neck surgeries. Methods A total of 90 patients undergoing elective right ear (Group 1: n = 30), left ear (Group 2: n = 30) or head and neck (Group 3: n = 30) surgery were involved in the study. A standardized general anesthetic was given and cuffed endotracheal tubes by the assistance of video laryngoscope were placed in all patients. The pilot balloon of each endotracheal tube was connected to the pressure transducer and standard invasive pressure monitoring was set to measure intracuff pressure values continuously. The first intracuff pressure value was adjusted to 18.4 mmHg (25 cm H2O) at supine and neutral neck position. The patients then were given appropriate head and neck positions before related-surgery started. These positions were left rotation, right rotation and extension by under-shoulder pillow with left/right rotation for Groups 1, 2 and 3, respectively. The intracuff pressures were measured and noted after each position, at 15th, 30th, 60th, 90th minutes and before the extubation. If intracuff pressure deviated from the targeted value of 20-30 cm H2O at anytime, it was set to 25 cm H2O again. Results The intracuff pressure values were increased from 25 to 26.73 (25-28.61) cm H2O after left neck rotation (p = 0.009) and from 25 to 27.20 (25.52-28.67) cm H2O after right neck rotation (p = 0.012) in Groups 1 and 2, respectively. In Group 3, intracuff pressure values at the neutral position, after extension by under-shoulder pillow and left or right rotation were 25, 29.41 (27.02-36.94) and 34.55 (28.43-37.31) cm H2O, respectively. There were significant differences between the neutral position and extension by under-shoulder pillow (p < 0.001), and also between neutral position and rotation after extension (p < 0.001). However, there was no statistically significant increase of intracuff pressure between extension by under-shoulder pillow and neck rotation after extension positions (p = 0.033). Conclusion Accessing the continuous intracuff pressure value measurements before and during ear and head and neck surgeries is beneficial to avoid possible adverse effects/complications of surgical position-related pressure changes.

Resumo Introdução O manguito ou cuff de um tubo endotraqueal sela as vias aéreas para facilitar a ventilação com pressão positiva e reduzir a aspiração de secreção subglótica. Entretanto, o aumento ou diminuição da pressão intracuff do tubo endotraqueal pode levar a muitas morbidades. Objetivo Investigar o efeito de diferentes posições da cabeça e pescoço da pressão intracuff do tubo endotraqueal durante cirurgias de orelha e cabeça e pescoço. Método Participaram do estudo 90 pacientes submetidos à cirurgia eletiva na orelha direita (Grupo 1: n = 30), orelha esquerda (Grupo 2: n = 30) ou cabeça e pescoço (Grupo 3: n = 30). Um anestésico geral padronizado foi administrado e o tubo endotraqueal com cuff foi colocado em todos os pacientes através de videolaringoscopia. O balão-piloto de cada tubo endotraqueal foi conectado ao transdutor de pressão e o monitoramento-padrão da pressão invasiva foi estabelecido para medir continuamente os valores da pressão intracuff. O primeiro valor de pressão intracuff foi ajustado para 18,4 mmHg (25 cm H2O) na posição supina e neutra do pescoço. Em seguida, os pacientes foram colocados nas posições cirúrgicas apropriadas de cabeça e pescoço antes do início da cirurgia. Essas posições foram rotação esquerda, rotação direita e extensão por rotação esquerda/direita com almofada sob o ombro, para os grupos 1, 2 e 3, respectivamente. As pressões intracuff s foram medidas e anotadas após cada posição, aos 15, 30, 60, 90 minutos e antes da extubação. Se a pressão intracuff saísse do valor desejado de 20 ~ 30 cm H2O a qualquer momento, ela era definida em 25 cm H2O novamente. Resultados Os valores de pressão intracuff aumentaram de 25 para 26,73 (25-28,61) cm H2O após a rotação do pescoço para a esquerda (p = 0,009) e de 25 a 27,20 (25,52-28,67) cm H2O após rotação do pescoço para a direita (p = 0,012) nos grupos 1 e 2, respectivamente. No Grupo 3, os valores da pressão intracuff na posição neutra, após extensão com almofada sob o ombro e rotação para a esquerda ou direita, foram 25, 29,41 (27,02-36,94) e 34,55 (28,43-37,31) cm H2O, respectivamente. Houve diferenças significativas entre a posição neutra e a extensão com almofada sob o ombro (p < 0,001) e também entre a posição neutra e a rotação após a extensão (p < 0,001). Entretanto, não houve aumento estatisticamente significante da pressão intracuff entre extensão com almofada sob o ombro e rotação do pescoço após as posições de extensão (p = 0,033). Conclusão As medições contínuas do valor da pressão intracuff antes e durante cirurgias de orelha e cabeça e pescoço são benéficas para evitar possíveis efeitos adversos/complicações de alterações de pressão relacionadas à posição cirúrgica.

The changes of endotracheal tube intracuff pressures after ear and head and neck surgery-related positions: a prospective observational study.

INTRODUCTION: The cuff of an endotracheal tube seals the airway to facilitate positive-pressure ventilation and reduce subglottic secretion aspiration. However, an increase or decrease in endotracheal tube intracuff pressure can lead to many morbidities. OBJECTIVE: The main purpose of this study is to investigate the effect of different head and neck positions on endotracheal tube intracuff pressure during ear and head and neck surgeries. METHODS: A total of 90 patients undergoing elective right ear (Group 1: n=30), left ear (Group 2: n=30) or head and neck (Group 3: n=30) surgery were involved in the study. A standardized general anesthetic was given and cuffed endotracheal tubes by the assistance of video laryngoscope were placed in all patients. The pilot balloon of each endotracheal tube was connected to the pressure transducer and standard invasive pressure monitoring was set to measure intracuff pressure values continuously. The first intracuff pressure value was adjusted to 18.4mmHg (25cm H2O) at supine and neutral neck position. The patients then were given appropriate head and neck positions before related-surgery started. These positions were left rotation, right rotation and extension by under-shoulder pillow with left/right rotation for Groups 1, 2 and 3, respectively. The intracuff pressures were measured and noted after each position, at 15th, 30th, 60th, 90th minutes and before the extubation. If intracuff pressure deviated from the targeted value of 20-30cm H2O at anytime, it was set to 25cm H2O again. RESULTS: The intracuff pressure values were increased from 25 to 26.73 (25-28.61) cm H2O after left neck rotation (p=0.009) and from 25 to 27.20 (25.52-28.67) cm H2O after right neck rotation (p=0.012) in Groups 1 and 2, respectively. In Group 3, intracuff pressure values at the neutral position, after extension by under-shoulder pillow and left or right rotation were 25, 29.41 (27.02-36.94) and 34.55 (28.43-37.31) cm H2O, respectively. There were significant differences between the neutral position and extension by under-shoulder pillow (p<0.001), and also between neutral position and rotation after extension (p<0.001). However, there was no statistically significant increase of intracuff pressure between extension by under-shoulder pillow and neck rotation after extension positions (p=0.033). CONCLUSION: Accessing the continuous intracuff pressure value measurements before and during ear and head and neck surgeries is beneficial to avoid possible adverse effects/complications of surgical position-related pressure changes.

The Role of Indirect Laryngoscopy, Clinical and Ultrasonographic Assessment in Prediction of Difficult Airway.

OBJECTIVES: Pre-operative airway evaluation is essential to decrease the proportion of possible mortality and morbidity due to difficult airway (DA). The study aimed to evaluate the accuracy of pre-operative ultrasonographic airway assessment (UAA) and indirect laryngoscopy (IL) in predicting DA. STUDY DESIGN: Prospective obsevational study. METHODS: Preoperative clinical examination (body mass index [BMI], mallampati classification [MP], thyromental distance, sternomental distance, neck circumference), UAA (epiglottis-skin distance [ESD], hyoid bone-skin distance [HSD], the thickness of tongue root [ToTR], anterior commissure-skin distance [ACSD]) and IL with the rigid 70-degree laryngoscope were performed to predict DA (Cormack-Lehane grade 3 and 4). The sensitivity, specificity, positive predictive value (PP), and negative predictive values of the parameters were assessed. RESULTS: Twenty-two of 140 (15.7%) patients were diagnosed with DA. The cut-off points of ESD, HSD, ToTR, ACSD, and BMI were 2.09 cm, 0.835 cm, 4.05 cm, 0.545 cm, and 27.10, respectively. AUC values were 0.874, 0.885, 0.871, 0.658, and 0.751 in the same order. AUC values for IL and MP were 0.773 and 0.925, respectively. MP and HSD had the best sensitivity (91%), IL grading had the best specificity (100%), and PP (100%) value among all measurements. The best-balanced sensitivity (91%), specificity (97%), and PP (88%) values were obtained by combining the IL with MP and ESD or with MP and HSD. CONCLUSIONS: Ultrasonographic measurements and IL were found significantly correlated to predict DA. Combined parameters, the IL with MP and ESD or with MP and HSD, are the best parameters in predicting the DA. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E555-E560, 2021.

[Effects of paravertebral block and intravenous analgesic methods on postoperative pain management and opioid consumption in laparoscopic cholecystectomies]. / Laparoskopik kolesistektomilerde paravertebral blok ve intravenöz analjezik yöntemlerin postoperatif agri yönetimi ile opioid tüketimine etkileri.

OBJECTIVES: The aim of this study was to evaluate the efficiency of a thoracic paravertebral block (TPVB) for postoperative analgesia in cases of a laparoscopic cholecystectomy performed under general anesthesia. METHODS: A total of 78 patients aged 18-70 years, with an American Society of Anesthesiologists classification of I-III who were to undergo an elective laparoscopic cholecystectomy were enrolled. The patients were randomly separated into 2 groups: Group 1 (38 patients) received a TPVB performed unilaterally at T6 before surgery and Group 2 (40 patients) received only general anesthesia. Postoperatively, both groups received patient-controlled analgesia with an infusion pump. Visual analog scale (VAS) scores at rest and with movement were recorded during the first 24 hours after surgery. Tramadol consumption during the first 24 hours, nausea and vomiting rate, time to first passage of bowel gas and defecation, nutrition, mobilization, and discharge were also noted. RESULTS: The patients who received an ultrasonography-guided TPVB had significantly lower postoperative VAS scores at rest and on movement at 4, 6, 12,18, and 24 hours and significantly lower levels of postoperative tramadol consumption. It was observed that 77.5% of the patients in Group 2 needed at least 1 dose of additional fentanyl intraoperatively. Group 2 had a significantly higher vomiting rate and it was observed that the time of first bowel gas and defecation, nutrition, and mobilization was later. There was no significant difference between groups in the discharge time. CONCLUSION: Preoperatively performed TPVB provided efficient analgesia after a laparoscopic cholecystectomy. A TPVB can also reduce perioperative and postoperative opioid requirements.

Learning curve of ultrasound measurement of subglottic diameter for endotracheal tube selection in pediatric patients.

BACKGROUND: Endotracheal tube size can be predicted according to ultrasound measurement of subglottic airway diameter. The learning curve for this method is not yet established. The aim was to evaluate the learning curve of anesthesiology residents in ultrasound measurement of subglottic airway diameter for prediction of endotracheal tube size using cumulative sum analysis. METHODS: Sixteen anesthesiology residents measured transverse subglottic airway diameter in children undergoing general anesthesia with cuffed endotracheal intubation. Each resident performed 30 ultrasound examinations. Primary outcome was the successful prediction of endotracheal tube size according to ultrasound measurement. Cumulative sum analysis was performed with acceptable and unacceptable failure rates set as 20 and 40%, respectively. RESULTS: Ten out of 16 residents (62.5%) were deemed successful as they were able to pass lower decision boundary, whereas six residents' CUSUM scores were between the decisions lines deeming them indeterminate. The overall success rate for determining the correct endotracheal tube size was 77.5%. Median number of attempts to cross lower decision boundary was 29 with minimum of 18 and maximum of 29 attempts among successful residents. CONCLUSION: Learning curves constructed with cumulative sum analysis in this study showed that only 62.5% of residents were able to correctly predict cuffed endotracheal tube size with 80% success rate. Considerable variability in achieving competency necessitates objective follow-up of individual improvement.

Learning Curves for Two Fiberscopes in Simulated Difficult Airway Scenario With Cumulative Sum Method.

INTRODUCTION: The aims of this randomized prospective mannequin study were to determine the amount of attempts required for successful intubation using different fiberscopes (Bonfils and SensaScope) by inexperienced anesthesiologists in a difficult airway scenario and to build the associated learning curves. METHODS: Difficult airway simulation was achieved with tongue edema in mannequin. After approval of volunteers, we asked 15 anesthesiology residents without any experience with fiberscopes to intubate with each device in a random order. Intubation success (endotracheal intubation within 120 seconds), the degree of difficulty of intubation, and reality of simulation using a 10-point scale were recorded. Learning curves were generated with cumulative sum method. RESULTS: With Bonfils, 13 volunteers were able to pass lower decision boundary with a median number of 26 [95% confidence interval (CI) = 21.4-25.9] attempts, whereas in SensaScope, the same outcome was observed in 10 residents with a median number of attempts of 26 (95% CI = 23.5-32.5). Total success rate was found significantly higher with Bonfils compared with SensaScope (550/600 vs 512/600, respectively, P < 0.001). Intubation with Bonfils was considered as less difficult compared with SensaScope [median = 4 (95% CI = 3.32-4.42) and 6 (95% CI = 4.96-6.64), P = 0.01, respectively]. The reality of the simulation was rated as a median of 5 (95% CI = 4.37-5.8). CONCLUSIONS: Although a similar number of attempts were required to reach predetermined competency for both fiberscopes, only 10 of residents were able to obtain the targeted success using SensaScope as compared with 13 with Bonfils. Inexperienced residents found intubation via Bonfils less difficult than SensaScope. High individual variability in obtaining competency observed in this study with cumulative sum analysis underlines the importance of defining success a priori to simulation, the need for follow-up of individual progress, and the need to offer adequate trials to achieve competency. Therefore, learning opportunities should be adapted accordingly.

Haemodynamic Response to Four Different Laryngoscopes.

OBJECTIVE: In this prospective randomized study, we aimed to evaluate the effect of tracheal intubation with four different laryngoscopes [Macintosh direct laryngoscope-classic laryngoscope (CL), McCoy (MC), C-Mac video-laryngoscope (CM) and McGrath video-laryngoscope (MG)] on haemodynamic responses in patients with a normal airway. METHODS: One hundred and sixty patients were included. Succeeding haemodynamic measurements were performed immediately after intubation (T2) and for 5 min with 1-min intervals (T3-T4-T5-T6-T7). The primary outcome was the heart rate (HR) and systolic blood pressure (SBP) change triggered by the four different laryngoscopes. The intubation time, the number of intubation attempts, need for stylet or additional manipulation, glottic view and traumatic complications caused by intubation procedure were recorded as secondary outcomes. RESULTS: HR values significantly increased with the completion of laryngoscopy and intubation at T2 for the CL, MC and CM groups. Lesser fluctuation in HR and SBP was observed in the MG group. Intubation time was significantly shorter in the MG group (p<0.001). There was no statistically significant difference between the groups regarding the number of intubation attempts, need for stylette and glottic view. Fewer patients in the MG and CM groups experienced a moderate and severe sore throat than in the other two groups. Shorter intubation time and lesser sore throat incidence were observed in the MG group. CONCLUSION: MG offers less haemodynamic stimulation than CL, MC, and CM. Our findings showed that tracheal intubation with MG is advantageous in preventing cardiovascular stress responses with short intubation time and less sore throat incidence.

High frequency jet ventilation during endolaryngeal surgery: Risk factors for complications.

Objective: Microlaryngeal surgery requires teamwork between surgeons and anesthesiologists. High-frequency jet ventilation (HFJV) is an artificial breathing technique, preferred during endolaryngeal interventions, which offers a good solution for the requirements. Most studies investigating independent risk factors for intraoperative complications during HFJV in endolaryngeal surgery (ELS) has been retrospective and not standardized and the anesthetic approach has not been standardized. This prospective cohort study aimed to identify risk factors of complications related to HFJV in ELS under a standardized anesthesia regimen. Methods: 243 patients who underwent ELS with infraglottic HFJV were investigated. Infraglottic jet ventilation catheter was placed and anesthesia was standardized. Demographic and operative data were noted. Hemodynamics, SpO2 and end-tidal CO2 were recorded at regular intervals. Complications such as hemodynamic disturbances, respiratory problems, barotrauma, equipment failure and requirement for conventional ventilation were also documented. Results: 222 patients were included. Hypoxia, hypercapnia and the need for intubation were observed in 20(9%), 4(1.8%), 10(4.5%) patients. Bradycardia, hypotension and arrhythmia were observed in six (2.7%), 24(10.8%), and four (1.8%) patients respectively. Respiratory complications were associated with body mass index (BMI) (p < 0.001, OR: 1.57, 95%CI: 1.31­1.88) and previous major airway surgery (p < 0.001, OR: 34.0, 95%CI:3.52­328.24), whereas hemodynamic complications were associated with duration of the operation (p = 0.034, OR:1.04, 95%CI:1.0­1.09) and history of previous major airway surgery (p = 0.005, OR:9.57, 95%CI:1.97­46.49). Conclusion: Infraglottic HFJV can be evaluated as an alternative breathing technique to conventional ventilation during endolaryngeal interventions. However, longer operation and previous laryngeal surgeries can increase the incidence of respiratory complications.

[Effects of cerebral oxygen changes during coronary bypass surgery on postoperative cognitive dysfunction in elderly patients: a pilot study]. / Efeitos das alterações no oxigênio cerebral durante cirurgia de revascularização do miocárdio sobre a disfunção cognitiva no pós­operatório em pacientes idosos: estudo piloto.

BACKGROUND AND OBJECTIVES: Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring. METHODS: Patients undergoing coronary surgery above 60 years, were included and randomized to 2 groups; control and NIRS groups. Peroperative management was NIRS guided in GN; and with conventional approach in control group. Test battery was performed before surgery, at first week and 3 rd month postoperatively. The battery comprised clock drawing, memory, word list generation, digit spam and visuospatial skills subtests. Postoperative cognitive dysfunction was defined as drop of 1 SD (standard deviation) from baseline on two or more tests. Mann-Whitney U test was used for comparison of quantitative measurements; Chi-square exact test to compare quantitative data. RESULTS: Twenty-one patients in control group and 19 in NIRS group completed study. Demographic and operative data were similar. At first week postoperative cognitive dysfunction were present in 9 (45%) and 7 (41%) of patients in control group and NIRS group respectively. At third month 10 patients (50%) were assessed as postoperative cognitive dysfunction; incidence was 4 (24%) in NIRS group (p:0.055). Early and late postoperative cognitive dysfunction group had significantly longer ICU stay (1.74+0.56 vs. 2.94+0.95; p<0.001; 1.91+0.7 vs. 2.79+1.05; p<0.01) and longer hospital stay (9.19+2.8 vs. 11.88+1.7; p<0.01; 9.48+2.6 vs. 11.36+2.4; p<0.05). CONCLUSION: In this pilot study conventional monitoring and near infrared spectroscopy resulted in similar rates of early postoperative cognitive dysfunction. Late cognitive dysfunction tended to ameliorate with near infrared spectroscopy. Early and late cognitive declines were associated with prolonged ICU and hospital stays.

The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients.

BACKGROUND: The aim of this prospective study was to investigate the success of ultrasound in pediatric patients in determining the appropriate sized cuffed endotracheal tube and to compare the results with conventional height-based (Broselow) tape and age-based formula tube size. METHODS: One hundred and fifty-two children of 1-10 years of age, who received general anesthesia for adenotonsillectomy were enrolled to the study. In all participants, the transverse diameter of the subglottis was measured with ultrasound during apnea. An endotracheal tube was chosen with the outer diameter matched to the measured subglottic airway diameter. An age-based (Motoyama-Khine) and height-based (Broselow) endotracheal tube size was calculated. If there was resistance to passage of the tube into the trachea or an airway pressure >25 cmH2 0 was required to detect an audible leak, the endotracheal tube was replaced with internal diameter of 0.5 mm smaller. If there was an audible leak at airway pressure <10 cmH2 O, or peak pressure >25 cmH2 0 or a cuff pressure > 25 cmH2 O was required to seal, the tube was changed to the 0.5 mm larger internal diameter. Best-fit tube internal diameter was the resultant tube internal diameter that met the previously stated conditions. The need for endotracheal tube replacement and peak airway pressure were recorded. RESULTS: The internal diameter of ultrasound determined tube was the same as best-fit tube in 88% of children. Endotracheal tube was replaced in 15 patients with a one size larger, and in three patients with one size smaller tube. Using Bland-Altman analysis, a better agreement was observed with ultrasound measurement rather than height-based estimation and age-based formulas. CONCLUSION: Our findings show that subglottic diameter measured by ultrasound appears to be a reliable predictor for the assessment of the subglottic diameter of the airway in estimating appropriate size pediatric endotracheal tube.

The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery / Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio

Abstract Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the "Tight Control" group (GI), the glycemia was maintained between 80 and 120 mg dL-1 while in the "Liberal" group (GII), it ranged between 80-180 mg dL-1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment.

Resumo Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Foram randomizados em dois grupos 40 pacientes acima de 50 anos e submetidos à cirurgia coronariana eletiva. No grupo "controle rigoroso" (GI), a glicemia foi mantida entre 80-120 mg.dL-1; enquanto no grupo "liberal" (GII), variou entre 80-180 mg.dL-1. A bateria de testes neuropsicológicos foi feita três vezes: fase basal, antes da cirurgia e na primeira e 12ª semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente.

[The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery]. / Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio.

INTRODUCTION: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. METHODS: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the "Tight Control" group (GI), the glycemia was maintained between 80 and 120mg·dL-1 while in the "Liberal" group (GII), it ranged between 80-180mg·dL-1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. RESULTS: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p=0.047). CONCLUSION: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment.

Effects of Head Position on Cerebral Oxygenation and Blood Flow Velocity During Thyroidectomy.

OBJECTIVE: Determining the blood flow through intra and extra-cranial arteries during neck extension may be helpful but is a controversial issue. We aimed to elucidate the changes in cerebral blood flow related to head positioning during thyroid surgery by carotid Doppler examination and regional oxygen saturation variations. METHODS: Thirty patients were recruited to the study. Patients were positioned with a final position of thyroidectomy consisting a 30° semi Fowler with the extension of neck and head. Values of peak systolic velocity, average velocity, arterial diameter and blood flow volume of the common carotid artery were calculated. Bilateral regional cerebral oxygen saturation were monitored continuously. RESULTS: At the end of the operation, peak systolic velocity, average velocity and blood flowvolume of the common carotid artery decreased significantly compared to the baseline measurement (p<0.001). Both left and right cerebral oximetry measurements showed a significant increase after induction and the increased oxymetric values persisted at the end of the operation (p<0.001). Age, body mass index, surgical duration and anaesthesia duration were found not to be correlated with the changes occurred in the values of peak systolic velocity, average velocity, arterial diameter, blood flow volume of the common carotid artery, left and right regional cerebral oxygen saturation after induction and at the end of surgery. CONCLUSION: The head and neck extension given for thyroidectomy negatively affect carotid blood flow and cerebral oxygenation gradually and become pronounced especially at the end of surgery. In conclusion, it is important to maintain the cerebral perfusion pressure and cerebral blood flow.

Bilateral hypoglossal nerve paralysis following elongated styloid process resection: case report.

We report a case of anesthetic management of a 43-year-old patient with Eagle's syndrome (ES) in whom post-extubation acute airway obstruction occurred due to bilateral hypoglossal nerve paralysis. After an accurate examination, elongated bilateral stylohyoid ligament was observed and surgical resection was planned. After completion of the surgery following extubation, significant dysfunction in swallowing, speech function, and tongue motion was observed. The clinical situation was evaluated as bilateral hypoglossal nerve paralysis related to the procedure. The patient was closely observed over 48 h in the intensive care unit. After 2 days, the patient was discharged to a surgical ward. Following clinical assessment, the patient was discharged from hospital for monthly return. At the 6-month follow-up, there were no further episodes of paresthesia and other symptoms. In conclusion, patients with ES represent a real challenge for physicians from diagnosis to treatment, especially regarding perioperative complications, and close collaboration between surgeons and anesthesiologists is of crucial importance.

Comparison of 4 Laryngoscopes in 2 Difficult Airway Scenarios: A Randomized Crossover Simulation-Based Study.

INTRODUCTION: The performance of laryngoscopes that have been developed for difficult airways can vary widely. The aim of the study was to compare Macintosh, McCoy, McGrath MAC, and C-MAC laryngoscopes in cervical immobilization and tongue edema scenarios in a mannequin, primarily to evaluate the time to intubation. METHODS: In this randomized crossover study, 41 anesthesiology residents used 4 laryngoscopes in a mannequin (SimMan 3G) in 2 different scenarios. Intubation time (insertion of the blade between the teeth, to placement of the endotracheal tube into the trachea) longer than 120 seconds or inability to successfully place the endotracheal tube into the trachea after 5 or more attempts was defined as intubation failure. Besides intubation time, laryngoscopic view, number of intubation attempts, presence of esophageal intubation, need for stylet, difficulty of intubation, and success rate were recorded as secondary outcomes. RESULTS: Intubation time was observed from longest to shortest as McGrath > McCoy > C-MAC > Macintosh in both scenarios. Laryngeal view was better with C-MAC laryngoscope. McGrath laryngoscope performed poorly specifically in tongue edema scenarios, which resulted in higher number of intubation attempts, esophageal intubation, need for intubation stylets, and overall intubation failure. CONCLUSIONS: The short intubation time observed with the Macintosh underlines the necessity of familiarity in success. Tongue edema is a more challenging scenario for simulated difficult airway and the McGrath may not be a good choice for such a scenario.

Ultrasonographic Measurement of Subglottic Diameter for Paediatric Cuffed Endotracheal Tube Size Selection: Feasibility Report.

OBJECTIVE: The aim of this feasibility study was to investigate the first attempt success of ultrasonography (USG) in paediatric patients in predicting an appropriate cuffed endotracheal tube (ETT) size. METHODS: Fifty children who were 1-10 years of age and who received general anaesthesia with endotracheal intubation for adenoidectomy or adenotonsillectomy were enrolled in the study. In all participants, the transverse diameter of the subglottic airway was measured with USG at the cricoid level without ventilation. The outer diameter (OD) of the maximum allowable ETT was chosen according to the measured subglottic airway diameter. In the presence of resistance to passage of the tube into the trachea or in the absence of an audible leak at airway pressure of >25 cm H2O, the ETT was replaced with a tube whose internal diameter (ID) was 0.5 mm smaller. If a leak was audible at airway pressures of <10 cm H2O, if a seal could not be achieved with a cuff pressure of >25 cm H2O or if a peak airway pressure of >25 cm H2O was observed during ventilation, the tube was changed to a tube one size larger. The OD of the best-fit ETT was converted to the ID. The best-fit ID, the requirement for ETT replacement, the duration of airway diameter measurement by USG and the peak airway pressure were recorded. RESULTS: The success rate of the first attempt with USG was 86%; the ETT was replaced in five patients with a tube one size larger and in two patients with a tube one size smaller. CONCLUSION: Our findings show the subglottic diameter measured by USG to be a reliable predictor in estimating the appropriate paediatric ETT size.

Airway Surgery in Tracheostomised Patients with Wegener Granulomatosis Leading to Subglottic Stenosis.

Wegener granulomatosis (WG) is a multisystemic disorder characterised by granulomatous inflammation of the respiratory system. The growing of proliferative tissue towards the larynx and trachea may cause airway obstruction on account of subglottic stenosis. In this situation, the surgical goal is to eliminate the airway obstruction by providing natural airway anatomy. While mild lesions do not require surgical intervention, in fixed lesions, surgical intervention is required, such as tracheostomy, laser resection and dilatation. In tracheostomised patients, granuloma formation surrounding the tracheostomy cannula may occur in the trachea. Inflammation and newly formed granulation tissue result in severe stenosis in the airways. During surgical treatment of such patients, airway management is important. In this case report, we will discuss gas exchange and airway management with jet ventilation (JV) during excision of the granulation tissue with endolaryngeal laser surgery, leading to subglottic stenosis in tracheostomised patients in WG.