Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.

Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao2 <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao2 <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange During Electroconvulsive Therapy: A Feasibility Study.

BACKGROUND: In electroconvulsive therapy (ECT), a generalized seizure is provoked under general anesthesia. Standard airway management is done by face mask ventilation, but this is difficult during generalized seizure. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a method to increase apnea tolerance and permit apnea oxygenation. We hypothesize that THRIVE can oxygenate the patient during ECT and that it is comfortable for patients. METHODS: In this single-center feasibility study, 13 patients with a pharmacotherapy-resistant depressive disorder underwent 20 ECT sessions with the use of THRIVE. They received general anesthesia under standard monitoring and transcutaneous carbon dioxide monitoring. Afterward, they completed a survey comparing their prior experience with face mask oxygenation. RESULTS: There were no desaturations during the procedure, and patient comfort showed no difference in comparison to face mask. Compared with data from earlier ECT with face mask ventilation in the same patient, THRIVE did not seem to shorten seizure duration. CONCLUSIONS: THRIVE is a novel, safe oxygenation method during ECT.

Visual recognition of anatomical structures in a circulated and in a non-circulated airway.

INTRODUCTION: Pre-hospital airway management is complex and complications occur frequently. Guidelines advice using waveform capnography to confirm correct tube position, but in the emergency setting this is not universally available. Continuous visualization of the airway with a video tube (VivaSight SL™) could serve as an alternative confirmation method, provided that airway structures are properly recognized. With this study we wanted to investigate whether airway management practitioners were able to recognize anatomical structures both in a circulated and in a non-circulated airway. METHODS: Ten staff anesthetists, ten trainee anesthetists and ten paramedics were asked to examine four pictures of a circulated airway, obtained in a healthy patient and four pictures of a non-circulated airway, obtained in a human cadaver. Correct recognition of the tube position in the airway was scored. RESULTS: Anatomic structures in the circulated airway were more often recognized than in the non-circulated airway, 90% vs. 43% respectively (P<.001). Overall, anesthetists performed better than paramedics (P=.009), but also when only pictures of the non-circulated model were taken into account (P=.007). The majority of participants and all staff anesthetists correctly recognized the vocal cords in both the circulated and non-circulated airway. CONCLUSIONS: Pictures of a circulated airway were more often recognized than of a non-circulated airway and personnel with a daily routine in airway management performed better than personnel with less frequent exposure. Future research should determine whether continuous visualization of the airway with a video tube could reduce the number of misplaced tracheal tubes in pre-hospital airway management.

Current cancer therapies - a guide for perioperative physicians.

Cancer is expected to be the leading cause of death around the world. New cancer therapies have improved survival but they can also lead to complications and toxicity. In this article, the effects of modern anti-cancer therapies are reviewed. The perioperative effects of chemotherapy, radiotherapy and experimental therapies in relation to anaesthesia are discussed. Common and rare complications are summarised as is advice for optimal treatment of the cancer patient in the perioperative period.

[Awake fibrecapnic intubation]. / Fibercapnische intubatie bij wakkere patiënten.

Awake flexible intubation is the gold standard for difficult airway management but failures have been reported in up to 13% of cases. A novel technique called 'awake fibrecapnic intubation', developed in the Netherlands, is described here for the intubation of patients with head and neck cancer who have a difficult airway. After topical anaesthesia is administered, a flexible fibrescope is introduced into the pharynx. A special suction catheter is then advanced through the suction channel of this scope and then into the airway for the recording of carbon dioxide measurements. The catheter may also be used for oxygenation during the procedure. Spontaneous respiration is maintained in all patients. When four capnograms have been obtained, the flexible scope is railroaded over the catheter and after identification of tracheal rings or carina, the tracheal tube is placed. This new intubation technique is easier to learn than awake flexible intubation.

Laryngeal radiation fibrosis: a case of failed awake flexible fibreoptic intubation.

Awake fibreoptic intubation is accepted as the gold standard for intubation of patients with an anticipated difficult airway. Radiation fibrosis may cause difficulties during the intubation procedure. We present an unusual severe case of radiation induced changes to the larynx, with limited clinical symptoms, that caused failure of the fibreoptic intubation technique. A review of the known literature on radiation fibrosis and airway management is presented.

Volatile anesthetics modulate gene expression in breast and brain tumor cells.

Gene expression is increasingly used for diagnostic, prognostic, and therapeutic purposes in clinical practice. We tested the hypothesis that volatile anesthetics (VA) affect gene expression of tumor cells. Cells from the neuronal cell line SH-SY5Y and from the breast cell line MCF-7 were exposed ex vivo to enflurane, isoflurane, desflurane, halothane, sevoflurane, or nitrous oxide. Microarray gene expression profiles were studied. We observed significant differences in gene expression levels of cell cultures and response in time when exposed to different VA. Some genes used for predictive genetic fingerprints for breast cancer were affected by VA. Our findings suggest that VA modulate gene expression in breast and brain tumor cell cultures in a unique and time-dependent manner.

A comparison of postoperative throat and neck complaints after the use of the i-gel and the La Premiere disposable laryngeal mask: a double-blinded, randomized, controlled trial.

BACKGROUND: Many supralaryngeal airway devices are available. Because of the absence of an inflatable cuff, we hypothesized that use of the i-gel should produce fewer postoperative throat and neck complaints compared with a standard disposable laryngeal mask (LM). METHODS: Two hundred eighteen patients were randomized to have either an i-gel or La Premiere LM airway placed for airway management. Patients were interviewed postoperatively for throat and neck complaints at 1, 24, and 48 h. Interviewers and patients were blinded to the device used. RESULTS: One hundred nine patients had an i-gel and 103 had a La Premiere supraglottic device inserted. The incidence of sore throat was significantly lower with the i-gel than with LM at 1 (6 vs 32), 24 (7 vs 48), and 48 h (5 vs 25). Similar results were seen for dysphagia. The incidence of neck pain was also lower for the i-gel at 24 (1 vs 7) and 48 h (1 vs 7). CONCLUSION: In this randomized study, the i-gel supraglottic device resulted in a lower incidence of throat and neck complaints than the La Premiere LM airway.

Cardiovascular and respiratory complications after major head and neck surgery.

BACKGROUND: Our aim was to gain insight into the incidence rates for, distribution of, and risk factors of postoperative cardiovascular and respiratory complications in major head and neck surgery. METHODS: We performed a retrospective review of 469 patients who had undergone primary major head and neck surgery. Outcome measures were incidence rates, risk factors, and distribution over time for postoperative cardiovascular and respiratory complications. A multivariate analysis was performed. RESULTS: The incidence rates for cardiovascular and respiratory complications were 57 of 469 (12%) and 50 of 469 (11%), respectively. The incidence rate for heart failure exceeded that for pneumonia. The peak incidence for cardiovascular complications was on the first postoperative day; for respiratory complications, on the second postoperative day. Risk factors for cardiovascular complications were age, pulmonary disease, alcohol abuse, and tumor location; risk factors for respiratory complications were pulmonary disease, previous myocardial infarction, and American Society of Anesthesiologists (ASA) grade. CONCLUSION: In this study, the incidence rates for cardiovascular and respiratory complications were very similar. The first postoperative day was crucial with regard to cardiovascular complications. Age and chronic pulmonary diseases were the common risk factors for cardiovascular and respiratory complications.