Microendoscopic Ultrasound-Guided Percutaneous Tracheostomy (MUGPT): A Case Series Describing a Novel Technique for Performing Percutaneous Tracheostomy.

A percutaneous tracheostomy is a common surgical procedure done in intensive care. Several different techniques have been described. Recently, the addition of bronchoscopy or ultrasound has been advocated to decrease the risks and complications associated with the procedure; however, both aids used alone, bronchoscopy or ultrasound, have some drawbacks and pitfalls. In this manuscript, we describe a new technique implementing a new technology, Microendoscopy coupled with ultrasound to perform percutaneous dilation tracheostomy MUGPT. MUGPT relies on dual real-time feedback microendoscopy and ultrasound to perform percutaneous dilation tracheostomy. This technique helps reduce the risk of bleeding, airway loss, tracheal wall injury, tracheal ring fracture, damage to adjacent structures, pneumothorax, pneumomediastinum, subcutaneous emphysema, false placement, hypoxia, carbon dioxide retention bronchospasm, cardiac dysrhythmias, and cost reduction. Methods. This is a case series of 6 patients who underwent single-step percutaneous dilation tracheostomy using the MUGPT technique. All the patients were in ICU and were candidates for tracheostomy. Intraoperative data collection, vital signs, oxygen saturation, and end-tidal CO2 were measured. No postoperative or intraoperative complications were documented. Conclusion. Microendoscopic ultrasound-guided percutaneous tracheostomy (MUGPT) is a promising technique with minimal complications. It is a procedure that can be performed and taught easily to Junior physicians and is a lifesaver in difficult cases.

Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial.

BACKGROUND: Spinal anesthesia using the midline approach might be technically difficult in geriatric population. We hypothesized that pre-procedural ultrasound (US)-guided paramedian technique and pre-procedural US-guided midline technique would result in a different spinal anesthesia success rate at first attempt when compared with the conventional landmark-guided midline technique in elderly patients. METHODS: In this prospective, randomized, controlled study, one hundred-eighty consenting patients scheduled for elective surgery were randomized into the conventional surface landmark-guided midline technique (group LM), the pre-procedural US-guided paramedian technique (group UP), or the pre-procedural US-guided midline technique (group UM) with 60 patients in each group. All spinal anesthesia were performed by a novice resident. RESULTS: The successful dural puncture rate on first attempt (primary outcome) was higher in groups LM and UM (77 and 73% respectively) than in group UP (42%; P < 0.001). The median number of attempts was lower in groups LM and UM (1 [1] and 1 [1-1.75] respectively) than in group UP (2 [1, 2]; P < 0.001). The median number of passes was lower in groups LM and UM (2 [0.25-3] and 2 [0-4]; respectively) than in group UP (4 [2-7.75]; P < 0.001). The time taken to perform the spinal anesthesia was not different between groups LM and UM (87.24 ± 79.51 s and 116.32 ± 98.12 s, respectively) but shorter than in group UP (154.58 ± 91.51 s; P < 0.001). CONCLUSIONS: A pre-procedural US scan did not improve the ease of midline and paramedian spinal anesthesia as compared to the conventional landmark midline technique when performed by junior residents in elderly population. TRIAL REGISTRATION: Retrospectively registered at Clinicaltrials.gov, registration number NCT02658058, date of registration: January 18, 2016.

Perioperative Management of Pancreaticoduodenectomy: Avoiding Admission to the Intensive Care Unit.

INTRODUCTION: With the advancement in surgical expertise at high-volume centers and advances in perioperative management, pancreaticoduodenectomy is becoming safer and remains the gold standard for treating periampullary pathologies. We describe our experience in optimizing perioperative management in order to avoid admission to the intensive care unit and improve outcomes. METHOD: Retrospective data were collected on 370 surgical patients who underwent a pancreaticoduodenectomy between the years 1994 and 2016. RESULTS: Of the 370 patients, 200 operated between 2009 and 2016 did not require intensive care admission, blood transfusion, or central line insertion. The results were compared between different time intervals: before the year 1998, between the years 1998 and 2008, and between the years 2009 and 2016. The median blood loss dropped from 800 to 400 to 300 mL, respectively. The median operative time also dropped from 360 to 335 to 215 min, respectively. In addition, the median length of hospital stay decreased from 25 to 16 to 7 days, respectively. CONCLUSION: With the centralization of pancreaticoduodenectomy in high-volume centers and with specialized surgeons performing the surgery, there is a significant decrease in the onset of postoperative complications with a lesser need for blood transfusions and, subsequently, better recovery of patients without the need for intensive care unit admission.

Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation / Relaxantes musculares não despolarizantes melhoram a visibilidade em laringoscopia direta sem efeito sobre a ventilação via máscara facial

Abstract Background: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. Methods: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. Results: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p = 0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. Conclusion: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

Resumo Justificativa: A ventilação difícil ou impossível via máscara facial complicada pela intubação traqueal difícil durante a indução da anestesia ocorre em 0,4% dos casos de anestesia em adultos, possivelmente leva a complicações fatais. Devido a tais catástrofes, recomendou-se que a administração de relaxantes musculares seja feita após a confirmação de ventilação adequada via máscara facial, sem uma validação científica sólida dessa conduta. Métodos: Neste estudo observacional, a facilidade de ventilação e os escores de visibilidade em laringoscopia direta antes e após a administração de cisatracúrio foram avaliados em 90 adultos jovens e saudáveis, sem riscos anestésicos e sem intubação difícil prevista, agendados para cirurgias eletivas gerais. Resultados: Antes do relaxamento muscular, 43 pacientes (48%) eram Cormack Grau I, enquanto os 47 (52%) restantes eram ou Cormack Grau II (28, 31%) ou Cormack Grade III (19, 21%). Após o relaxamento muscular com cisatracúrio, o número de pacientes com Cormack Grau I aumentou significativamente de 43 (48%) para 65 (72%) (p = 0,0013). Apenas um paciente (5%) dos 19 melhorou sua classificação de Cormack do Grau III para o Grau I, enquanto 16 dos 19 (84%) melhoraram suas classificações de Cormack do Grau III para o grau II após o uso de cisatracúrio. A qualidade da ventilação via máscara facial não diferiu com ou sem relaxantes musculares em todos os pacientes. Conclusão: O uso de cisatracúrio em adultos jovens saudáveis submetidos a cirurgias eletivas gerais sem intubação traqueal difícil prevista não teve efeito sobre a qualidade da ventilação via máscara facial, mesmo resultando em melhora quantificável da visibilidade da laringe.

[Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation]. / Relaxantes musculares não despolarizantes melhoram a visibilidade em laringoscopia direta sem efeito sobre a ventilação via máscara facial.

BACKGROUND: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. METHODS: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. RESULTS: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p=0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. CONCLUSION: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

Advancing the tracheal tube over a flexible fiberoptic bronchoscope by a sleeve mounted on the insertion cord.

UNLABELLED: The advancement of an endotracheal tube (ETT) over a flexible fiberoptic bronchoscope (FOB) is often impeded at the glottis. This is attributed to the creation of a cleft by the difference in the outer diameter of the fiberscope and the internal diameter of the tube. We designed a conical-shaped polyvinyl chloride sleeve to fit the insertion cord. This report compares the ease of advancement of the tube over a sleeved versus a nonsleeved bronchoscope. General anesthesia was induced, and one anesthesiologist introduced the FOB (a 3.8-mm Olympus LF2). Patients were randomly assigned to undergo tracheal intubation with the regular bronchoscope (25 patients) or the sleeved bronchoscope (25 patients). The FOB was advanced to approximately 1 cm above the carina. A blinded operator advanced the tube over the bronchoscope. The ETT was successfully advanced over the nonsleeved bronchoscope into the trachea on the first attempt in 64% of the patients, whereas tracheal intubation succeeded from the first attempt in 96% of patients when the sleeved FOB was used (P < 0.05). Advancement of the ETT over the fiberscope can be facilitated by using a conically shaped sleeve mounted on the insertion cord. IMPLICATIONS: This report shows that a conical sleeve mounted on the insertion cord of a fiberoptic bronchoscope will facilitate advancing the endotracheal tube into the trachea.