Airway Management for Penetrating Neck Trauma: A Case Report.

Penetrating neck injuries comprise 5-10% of traumatic injuries in adults and can cause immediate life-threatening compromise. Performing awake fibreoptic intubation in cooperative patients when airway management is not time critical has been suggested as a method of securing these potentially complicated airways. We report a case of a male in his 20s who presented to the emergency service with neck trauma following a bicycle road accident. With the exception of a wound in the neck region, there were no alarming distress signs or symptoms of airway endangerment. Imagiological evaluation revealed a rupture of the right lateral tracheal wall. He was referred for urgent surgery. We performed intubation with video laryngoscopy assisted by a neck surgery team, keeping the patient breathing spontaneously and under deep sedation. After advancing the tube through the vocal cords, the surgeon explored the cervical wound, guiding the tube through the trachea. Keeping spontaneous ventilation and advancing the tracheal tube beyond the lesion under visualization is essential when managing a traumatized airway. Tracheal intubation using video laryngoscopy, assisted by a neck surgeon guiding the tube, and avoiding creation of a false passage can be a safe alternative to fibreoptic intubation in selected cases of tracheal laceration.

How Anaesthesiology Helped to Fight the First Wave of the COVID-19 Pandemic in Portugal.

INTRODUCTION: The dissemination of the COVID-19 pandemic in Europe, namely in Portugal, demanded an organizational and clinical reaction from the Portuguese National Health Service. With the unpredictable impact of COVID-19 infected patients redefining hospital logistics, reducing non-priority elective care and extending the hospital capacity for critical care patients made mobilizing a significant part of human resources a priority. We conducted a national survey to monitor the contribution and the role of anaesthesiologists belonging to the 53 Portuguese National Health Service hospitals in the first wave fight against the pandemic. MATERIAL AND METHODS: This prospective cross-sectional observational study used a weekly survey sent to the Directors of the Anaesthesiology Departments of all Portuguese National Health Service hospitals, between the period of 13th April and 21st June 2020. Directors were asked about human resources, hospital logistics, anaesthetic activity and residency programs in their departments as well as contingency plans facing the impact of the pandemic growth in the PNHS. RESULTS: Contingency strategy for all Portuguese National Health Service hospitals planned for a total of 1524 level III critical care beds during the initial phases of the pandemic, an increase of 151% from the existing 607 level III critical care beds in Portugal in January 2020. This re-configuration effort of the Portuguese National Health Service was only possible due to the partial or total suspension of non-urgent elective activity that reached over 90% of these institutions in the first pandemic months (March and April) and the deployment of anaesthesiologists from their normal activities to the treatment of critical care patients. During the peak of the first pandemic wave, 209 anaesthesiology specialists and 170 trainees (22.9% of the total anaesthesiologist's staff in the Portuguese National Health Service) were deployed in critical care. There was an almost complete interruption of the residency program rotation in 70.4% of hospitals with anaesthesiology residents, between March and April 2020. CONCLUSION: During the first pandemic wave there was an effective and fast reorganisation of the Portuguese National Health Service in order to increase level III critical care beds, which might have contributed to the low mortality rates in Portugal. We believe that this could have also been a result of the contribution given by all public anaesthesiology departments.

Introdução: A disseminação da pandemia por COVID-19 na Europa, designadamente em Portugal, exigiu uma resposta clínica e organizativa por parte do Serviço Nacional de Saúde português. Com o imprevisível impacto da COVID-19 nos doentes infectados, foi prioritário redefinir a logística hospitalar, reduzir a prestação de cuidados electivos não prioritários, e estender a capacidade hospitalar ao tratamento do doente crítico, mobilizando uma parte significativa dos recursos humanos. Utilizou-se um inquérito nacional que permitisse monitorizar a contribuição que os anestesiologistas pertencentes aos 53 hospitais do Serviço Nacional de Saúde tiveram no combate à COVID-19 durante a primeira vaga da pandemia. Material e Métodos: Estudo observacional transversal de tipo prospectivo, baseado num inquérito semanal enviado aos directores dos Serviços de Anestesiologia de todos os hospitais do Serviço Nacional de Saúde, entre 13 de abril e 21 de junho de 2020. Foi solicitada informação relativa aos recursos humanos, logística hospitalar, atividade assistencial, programa de formação pós-graduado, assim como plano de contingência face ao crescimento da pandemia. Resultados: O plano de contingência hospitalar nos hospitais do Serviço Nacional de Saúde previu um total de 1524 camas de cuidados intensivos de nível III, o que corresponde a um crescimento de 151% das 607 camas existentes em janeiro de 2020. Esta reconfiguração dos hospitais do Serviço Nacional de Saúde só foi possível devido à suspensão parcial ou total da atividade eletiva não prioritária que afectou mais de 90% das instituições hospitalares nos primeiros meses da pandemia (março e abril), e à mobilização dos anestesiologistas das suas atividades eletivas para o tratamento do doente crítico. Nos piores momentos, esta mobilização envolveu 209 especialistas e 170 internos de especialidade (22,9% do total destes profissionais nos hospitais do Serviço Nacional de Saúde). Por outro lado, registou-se uma interrupção quase total do programa de formação pós-graduada em mais de 70,4% dos hospitais com esta idoneidade formativa, de março a abril de 2020. Conclusão: Durante a primeira vaga da pandemia houve uma rápida reorganização do Serviço Nacional de Saúde que poderá ter contribuído para a baixa taxa de mortalidade em Portugal. Os autores acreditam que para esse resultado poderá ainda ter contribuído a ajuda dada pelos serviços de Anestesiologia do Serviço Nacional de Saúde.

Horner's syndrome and paresthesia in the trigeminal nerve territory secondary to epidural analgesia for labor / Síndrome de Horner e parestesia do território do nervo trigêmeo secundário a analgesia peridural para trabalho de parto

Abstract Currently, epidural analgesia is a common procedure for labor analgesia. Although it is considered a safe technique, it is not without complications. Horner's syndrome and paresthesia within the trigeminal nerve distribution are rare complications of epidural analgesia. We report a case of a pregnant woman who developed Horner's syndrome and paresthesia within the distribution of the trigeminal nerve following epidural analgesia for the relief of labor pain.

Resumo A analgesia peridural é hoje em dia um procedimento comum para analgesia do trabalho de parto. Embora seja considerada uma técnica segura, não está isenta de complicações. A síndrome de Horner e a parestesia do território do nervo trigêmeo são complicações raras da analgesia peridural. Relatamos um caso de uma grávida que desenvolveu a síndrome de Horner e parestesia do território do nervo trigêmeo após analgesia peridural para o alívio da dor do trabalho de parto.

[2017 Census: are there enough anaesthesiologists in Portugal?] / Censos 2017: Existe Número Suficiente de Anestesiologistas em Portugal?

INTRODUCTION: The objective of this study is to identify the number of anaesthesiologists working in Portugal and to monitor the national activity of this medical specialty by comparing it with a similar Census performed in 2014. MATERIAL AND METHODS: Observational cross-sectional study. Data related to the month of May 2017 was collected from Anaesthesiology departments of 53 Portuguese public institutions from a total of 86 hospitals. RESULTS: The Census registered 615 127 surgical procedures (3.4% more than in 2013), 84.1% of which on a non-emergent basis, and 49.6% day case surgery (6.1% more than in 2013). Moreover, 89 608 procedures were performed outside the operating rooms (19.0% less than in 2013), 282 944 were anaesthetic clinics (1.3% more than in 2013) and 112 183 were chronic pain evaluations (13.1% more than in 2013). In addition, 51 380 labour analgesia were performed for delivery (14.3% more than in 2013) corresponding to 70.5% of all deliveries occurring in the Obstetric department of Portuguese public hospitals in 2016 (5% more than in 2013). A total of 1280 Anaesthesiologists were identified (2.1% more than in May 2014), corresponding to a ratio of 12.4 per 100 000 inhabitants (it was 12.0 in May 2014). Together with the 262 anaesthesiologists that work exclusively in the private system, we found a total sum of 1542 anaesthesiologists indicating a ratio of 15.1 per 100 000 inhabitants (it was 13.9 in 2014). DISCUSSION: We predict that the identified deficit of 541 anaesthesiologists in the Portuguese National Health Service should be reduced by two thirds until 2023. The reduction of the shortage of anaesthesiologists will allow an increase in human resource capacity in Anaesthesiology. CONCLUSION: Even though there was a slight increase in the ratio of Anaesthesiologists per inhabitant in 2017 compared to 2014, Portugal maintains a shortage of Anaesthesiologists.

Introdução: O objectivo deste estudo é identificar o número de anestesiologistas e monitorizar a actividade da Anestesiologia em Portugal, comparando-a com idêntico Censos realizado em 2014. Material e Métodos: Estudo observacional transversal. Foram contactados, em maio de 2017, os diretores dos serviços de Anestesiologia das instituições hospitalares com actividade cirúrgica que compõem o Serviço Nacional de Saúde, num total de 53 instituições hospitalares, correspondendo a 86 hospitais. Resultados: O Censos registou um total de 615 127 intervenções cirúrgicas (mais 3,4% que em 2013), das quais 84,1% foram cirurgias programadas e destas 49,6% em regime de ambulatório (mais 6,1% que em 2013). Constatou-se ainda a realização de 89 608 procedimentos com apoio de anestesia fora do bloco operatório (menos 19,0% que em 2013), 282 944 consultas de anestesia (mais 1,3% que em 2013) e 112 183 consultas de dor crónica (mais 13,1% que em 2013). Identificaram-se 51 380 analgesias de parto (mais 14,3% que em 2013), que corresponderam a 70,5% dos partos ocorridos nos serviços de Obstetrícia dos hospitais do Serviço Nacional de Saúde (mais 5% de partos que em 2013). Foram identificados 1280 Anestesiologistas (mais 2,1% do que em maio de 2014), o que corresponde a um rácio de 12,4 por 100 000 habitantes (este valor era de 12,0 em maio de 2014). Com os 262 Anestesiologistas a trabalhar exclusivamente no sector privado, obtém-se um total nacional de 1542 Anestesiologistas, ou seja, um rácio de 15,1 por 100 000 habitantes (este valor era 13,9 em maio de 2014). Discussão: Prevê-se que o déficit de 541 Anestesiologistas identificados, possa ser reduzido em cerca de dois terços até 2023. A redução do déficit de Anestesiologistas permitirá aumentar a capacidade de resposta às crescentes solicitações dos serviços de anestesiologia Portugueses. Conclusão: Apesar de um ligeiro aumento do rácio de anestesiologistas por habitante em 2017 comparativamente a 2014, Portugal continua com um déficit de Anestesiologistas.

[Horner's syndrome and paresthesia in the trigeminal nerve territory secondary to epidural analgesia for labor]. / Síndrome de Horner e parestesia do território do nervo trigêmeo secundário a analgesia peridural para trabalho de parto.

Currently, epidural analgesia is a common procedure for labor analgesia. Although it is considered a safe technique, it is not without complications. Horner's syndrome and paresthesia within the trigeminal nerve distribution are rare complications of epidural analgesia. We report a case of a pregnant woman who developed Horner's syndrome and paresthesia within the distribution of the trigeminal nerve following epidural analgesia for the relief of labor pain.

Osler-Weber-Rendu syndrome: an anaesthetic challenge?

Osler-Weber-Rendu syndrome, or hereditary haemorrhagic telangiectasia (HHT), is an autosomal dominant vascular dysplasia characterised by mucocutaneous telangiectases and arteriovenous malformations (AVMs). Diagnosis is clinical and treatment is supportive. The authors demonstrate a safe anaesthetic approach for a patient with HHT. A 53-year-old woman with a left trochanteric fracture was scheduled for urgent orthopaedic surgery. She was diagnosed as having HHT and presented with recurrent epistaxis, telangiectases and gastrointestinal AVMs. She had undergone a nasal dermoseptoplasty 4 weeks earlier, with total nasal occlusion. Surgery was undertaken with a lumbar and sacral plexus block performed with neurostimulation. She was sedated and spontaneous ventilation was maintained. The procedure was completed without complications. Anaesthetic management of patients with HHT is a challenge. The patients should be carefully studied before surgery, to reduce perioperative morbidity and mortality. Regional anaesthesia may be a good alternative to general anaesthesia, but the use of neuroaxial techniques is still controversial.