Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations.

Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.

Anaplastic thyroid cancer:Improved understanding of what remains a deadly disease.

BACKGROUND: Anaplastic thyroid cancer (ATC) is a rare, undifferentiated form of thyroid cancer accounting for less that 2 % of thyroid cancers. Here we provide an overview of the contemporary understanding of ATC as well as discussing in detail any pertinent updates in the molecular understanding and treatment of this disease with reference to the 2021 American Thyroid Association (ATA) guidelines. METHODS: A review of the literature regarding the understanding, management and prognosis of ATC was undertaken using both Pubmed and Cochrane databases along with local institutional experience. Studies published in the last 5 years were prioritised for inclusion. RESULTS: Between 80 and 90 % of patients will have disease that has spread beyond the thyroid gland at presentation. Despite the use of aggressive, multimodal, conventional treatment strategies encompassing surgery and chemoradiotherapy, the median overall survival has remained between 3 and 6 months. Our understanding has evolved regarding the key oncogenic mutations involved in the development of ATC. These include BRAF, RAS, PI3K, PTEN, TP53 and TERT mutations. There is growing evidence that novel targeted therapies against these mutations may improve outcomes in this disease which has led to FDA approval of dabrafenib/trametinib combined BRAF/Mek inhibition. CONCLUSIONS: The prognosis of ATC remains dismal. Recent development and approval of targeted therapies offers hope of improved oncologic outcomes with further data eagerly awaited surrounding the impact of these targeted therapies.

Pressure sensitive adhesives and paper spray-mass spectrometry for the collection and analysis of fentanyl-related compounds from shipping materials.

The rise of fentanyl and fentanyl analogs in the drug supply pose serious threats to public health. Much of these compounds enter the United States through shipping routes. Here we provide a method for fentanyl screening and analysis that utilizes pressure-sensitive adhesive (PSA) lined paper to recover drug residues from parcel-related surfaces. The paper used is commercially available repositionable notes (also called post-it or sticky notes). From this paper, mass spectra were obtained by paper spray-mass spectrometry (PS-MS), where PSA paper served as both a sampling and analysis substrate. Seven fentanyl-related compounds were analyzed: fentanyl, 4-anilino-N-phenethylpiperidine (4-ANPP), N,1-diphenethyl-N-phenylpiperidin-4-amine (phenethyl-4-ANPP), valerylfentanyl, 4-fluoroisobutyrylfentanyl (4-FIBF), carfentanil, and p-fluorofentanyl. These compounds were recovered by PSA paper and identified by PS-MS from packaging tape and plastic at 50 ng and from cardboard and shipping labels at 100 ng. The impact of cutting agents on PS-MS analysis of fentanyl analogs was explored. No trends of analyte suppression were found at high concentrations of the cutting agents caffeine, diphenhydramine, and lidocaine when recovered from surfaces. A cartridge that required no precise cutting of PSA paper prior to sampling or analysis was evaluated for use in PS-MS for fentanyl screening. Recovery and detection of fentanyl from plastic sheeting was demonstrated with this cut-free cartridge. The cut-free cartridge showed somewhat less consistency and lower analyte signal than the standard cartridge, but performance was suitable for potential screening applications. In combining PSA surface sampling with PS-MS for drug screening, both sampling and detection of fentanyl-related compounds is simple, rapid, and low-cost.

Combining presumptive color tests, pressure-sensitive adhesive-based collection, and paper spray-mass spectrometry for illicit drug detection.

Illicit drug trafficking and abuse is a significant public safety and health concern. Color tests are commonly used for drug screening, but their poor specificity results in false positives. This study demonstrates the combination of drug residue collection using pressure-sensitive adhesive paper, on-paper color testing, and post-reaction analysis by paper spray mass spectrometry (PS-MS) on both portable and benchtop ion trap MS. All steps, including residue collection, color testing, and paper spray analysis, were performed on the same piece of paper. Three common color tests were investigated: the cobalt thiocyanate test for cocaine, the Simon test for methamphetamine, and the Marquis test for phenethylamine stimulants and opiates. The detection threshold for color tests ranged from 1.25 to 10 µg on paper. Drug residues were successfully confirmed by paper spray MS at the color test threshold in all cases, except for heroin after reaction with the Marquis reagent, when using the portable MS. In this case, the MS detection threshold was 4-fold higher than the color test threshold. The stability of the color test products was assessed through a time study. Drug residues could be detected by MS at least 24 hours after reaction. A series of realistic samples, including false positives, were analyzed to demonstrate the technique's utility in real-world scenarios. Overall, combining color tests with PS-MS offers a rapid, low-cost method for the collection and analysis of illicit drugs.

"Cannot intubate, cannot oxygenate": A novel 2-operator technique for cannula tracheotomy in an infant animal model-a feasibility study.

BACKGROUND: Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy. AIMS: To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates. METHODS: Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25 cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique). Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt. RESULTS: 72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect). Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique. CONCLUSION: Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials.

The 'Can't intubate can't oxygenate' scenario in pediatric anesthesia: a comparison of the Melker cricothyroidotomy kit with a scalpel bougie technique.

BACKGROUND: While the majority of pediatric intubations are uncomplicated, the 'Can't intubate, Can't Oxygenate' scenario (CICO) does occur. With limited management guidelines available, CICO is still a challenge even to experienced pediatric anesthetists. OBJECTIVES: To compare the COOK Melker cricothyroidotomy kit (CM) with a scalpel bougie (SB) technique for success rate and complication rate in a tracheotomy on a cadaveric 'infant airway' animal model. METHODS: Two experienced proceduralists repeatedly attempted tracheotomy in eight rabbits, alternately using CM and SB (4 fr) technique. The first attempt was performed at the level of the first tracheal cartilage with subsequent experimental trials of insertion progressively more caudad. Success was defined as intratracheal placement of cannula as seen on bronchoscope. Complications were assessed both by bronchoscopic and macropathological appearance. RESULTS: 32 attempts were made at tracheotomy. CM had an overall success rate of 100% compared to a 75% success rate for SB. Success rate for the first attempt was dependent on the level of the tracheotomy (Level 1 100%, level 2 62.5% and level 3 & 4 25%). While CM was associated with lateral and/or posterior wall damage on bronchoscopy/macropathology in 6% of 19% and 25% of 50% respectively, the damage observed was greater and more frequent with SB (19%/44% and 31%/50%, respectively). CONCLUSIONS: At level 1, the first attempt success rate was 100% for both devices. Overall CM showed a better success rate than SB; however, both techniques were associated with significant complication rates, which were more pronounced following the scalpel bougie technique.

Surgical management of chronic salivary aspiration.

AIM OF THE STUDY: Sialorrhoea and chronic salivary aspiration are a major problem in many neurologically impaired children causing embarrassment, skin issues and recurrent lower respiratory tract infections (LRTI). The aim of this study was to assess the efficacy of salivary gland surgery in the treatment of chronic salivary aspiration in such children. OBJECTIVES: To compare admission rates for LRTI per annum before and after surgical intervention. METHODS: Retrospective review of all patients who underwent salivary management surgery for chronic aspiration under Princess Margaret Hospital's (PMH) Otolaryngology department from 2006 until 2013. RESULTS: Twelve patients were included in this review. Their ages ranged from 3 to 21 years (mean=11.4). Their genders were equally distributed. Two patients had underlying congenital disorders; one had an acquired brain injury, while the majority (n=9, 75%) had cerebral palsy secondary to a sustained perinatal injury. Most patients (n=11, 91.7%) had bilateral submandibular gland excision and parotid duct ligation as a primary procedure. One patient had a laryngotracheal separation. Two patients went on to have a second procedure. The mean follow up time was five years. Using Wilcoxon Signed-Rank test we showed that the median rate of admission per annum for LRTI pre-operatively was 1.0. This was reduced to 0.5 post-operatively, which was statistically significant (p≤0.05). CONCLUSIONS: We hypothesize that the combination of bilateral submandibular gland excision and bilateral parotid duct ligation is effective in reducing admissions with aspiration pneumonia in neurologically impaired children, and therefore improves the quality of life in these patients.