Safety of prone emergence from general endotracheal anesthesia in patients undergoing ERCP: a randomized controlled trial.

BACKGROUND: Conventional supine emergence and prone extubation from general endotracheal anesthesia (GEA) are associated with extubation-related adverse events (ERAEs). Given the minimally invasive nature of endoscopic retrograde cholangiopancreatography (ERCP) as well as the improved ventilation/perfusion matching and easier airway opening in the prone position, we aimed to assess the safety of prone emergence and extubation in patients undergoing ERCP under GEA. METHODS: Totally, 242 eligible patients were recruited and randomized into the supine extubation group (n = 121; supine group) and the prone extubation group (n = 121; prone group). The primary endpoint was the incidence of ERAEs during emergence, including hemodynamic fluctuations, coughing, stridor, and hypoxemia requiring airway maneuvers. The secondary endpoints included the incidence of monitoring disconnections, extubation time, recovery time, room exit time, and post-procedure sore throat. RESULTS: The incidence of ERAEs was significantly lower in the prone group compared with the supine group (8.3% vs 34.7%, OR = 0.17, 95% CI 0.18-0.56; P < 0.001). Moreover, the prone group demonstrated no monitoring disconnections, shorter extubation time and room exit time, faster recovery, and, lower frequency and milder sore throat after the procedure. CONCLUSIONS: For patients undergoing ERCP under GEA, compared with supine, prone emergence, and extubation had remarkably lower rates of EAREs and better recovery, and can maintain continuous monitoring and improve efficiency.

Effect of 5% EMLA Cream on Postoperative Sore Throat in Adults Following General Endotracheal Anesthesia: A Randomized Placebo-Controlled Study.

BACKGROUND: Postoperative sore throat (POST) is a distressing complaint in adults after endotracheal intubation. This study aimed to evaluate the effect of topical application of a eutectic mixture of local anesthetics (EMLA) cream over the endotracheal tube (ETT) cuff on the incidence and severity of POST, cough, and hoarseness of voice in adults after surgery. METHODS: In this randomized, placebo-controlled study, adult patients 18 to 65 years old, in American Society of Anesthesiologists (ASA) physical status I and II, and of either sex were scheduled to receive 5% EMLA cream (intervention arm) or lubricant gel (placebo-controlled arm) applied over the ETT cuff. POST was graded as none (0), mild (1), moderate (2), or severe (3). A score of ≥2 was considered as significant POST. The incidence of POST at the sixth postoperative hour was the primary outcome. Secondary outcomes included the incidence of POST at 0, second, and 24 hours, and the incidence of significant POST (score ≥2). The incidence and severity of postoperative cough and hoarseness of voice were recorded simultaneously. RESULTS: Two hundred and four patients completed the study. The incidence of POST was significantly lower in the EMLA group versus placebo at the sixth postoperative hour (4.9% vs 40.1%; relative risk [RR], 0.12; 95% confidence interval [CI], 0.05-0.29; P < .001); and at 0 hour (74.5% vs 93.1%; RR, 0.8; 95% CI, 0.7-0.9; P < .001) and second hour (51.9% vs 84.3%; RR, 0.61; 95% CI, 0.5-0.75; P < .001) but comparable at 24 hours (1.9% vs 3.9%; RR, 0.5; 95% CI, 0.09-2.67; P = .4). The number needed to treat to prevent POST with EMLA cream application was 5 at 0 hour and 3 at the second and sixth hour. The proportion of patients with significant POST over 24 hours were less in the EMLA group (9.8% vs 43.1%; P < .001). The incidence of postoperative cough and hoarseness of voice was significantly less at the 0, second, and sixth hours in the EMLA group, but comparable at 24 hours. The incidence of severe cough (8.8% vs 31.4%; P < .001) and hoarseness of voice (2% vs 7.4%; P < .001) over 24 hours was less in the EMLA group. CONCLUSIONS: The application of EMLA cream over ETT cuff reduces the incidence and severity of POST, cough, and hoarseness of voice in adults after general anesthesia in the early postoperative period compared to lubricant gel.

Preoperative STOP-BANG questionnaire to predict difficult airway in undiagnosed obstructive sleep apnea patients undergoing elective gynecological surgeries under general endotracheal anesthesia: A prospective observational study.

Background: STOP-BANG questionnaire is an established tool for obstructive sleep apnea (OSA) screening. Its utility in predicting difficult airway has not been evaluated. We intend to assess difficulty in airway management and associated perioperative complications in patients with undiagnosed OSA using the STOP-BANG questionnaire. Materials and Methods: We performed a prospective observational study on 250 patients with the American Society of Anesthesiologists Physical Status Class I-II, aged 18-65 years STOP-BANG score were recorded. Occurrences of difficult mask ventilation (DMV), laryngoscopy, and intubation were assessed using mask ventilation grade, intubation difficulty score intubation difficult score (IDS), and modified Cormack-Lehane grading during induction of anesthesia. Hypoxic events, hemodynamic disturbances, laryngospasm, and bronchospasm were also recorded. Results: Overall, 250 patients completed the study (Group H: n = 102, with STOP-BANG questionnaire ≥3 and Group L: n = 148, with STOP-BANG criteria < 3). A total of 67 (26.8%) cases of DMV and 63 (25.2%) cases of difficult tracheal intubation (DIT) were encountered overall. The proportion of patients with DMV during induction was 59.8% in Group H versus 4.05% in Group L (P < 0.001). A higher incidence of difficult intubation was observed in Group H (56.9% vs. 11.5%, P < 0.001). More patients in Group H had airway complications such as bleeding and injury to the posterior pharyngeal wall or teeth (P < 0.001). Complications such as hypoxia, hypertension, and tachycardia were observed to be higher in Group H (P < 0.001). Conclusion: STOP-BANG questionnaire is an effective bedside preoperative tool that helps in identifying unanticipated difficult airway.

Résumé Contexte: Le questionnaire STOP-BANG est un outil établi pour le dépistage de l'apnée obstructive du sommeil (AOS). Son utilité pour prédire les voies respiratoires n'a pas été évaluée. Nous avons l'intention d'évaluer les difficultés de gestion des voies respiratoires et les complications périopératoires associées chez les patients souffrant d'AOS non diagnostiquée à l'aide du questionnaire STOP-BANG. Matériels et méthodes: Nous avons réalisé une étude observationnelle prospective sur 250 patients avec le score STOP-BANG de classe I-II de l'American Society of Anesthesiologists, âgés de 18 à 65 ans ont été enregistrés. Les occurrences de ventilation au masque difficile (DMV), de laryngoscopie et d'intubation ont été évaluées en utilisant le grade de ventilation au masque, la difficulté d'intubation score (IDS) et le classement de Cormack-Lehane modifié lors de l'induction de l'anesthésie. Événements hypoxiques, troubles hémodynamiques, laryngospasme, et le bronchospasme ont également été enregistrés. Résultats: Au total, 250 patients ont terminé l'étude (Groupe H : n = 102, avec questionnaire STOP-BANG ≥3 et Groupe L : n = 148, avec critère STOP-BANG < 3). Un total de 67 (26,8%) cas de DMV et 63 (25,2%) cas de DIT ont été rencontrés global. La proportion de patients avec DMV lors de l'induction était de 59,8 % dans le groupe H contre 4,05 % dans le groupe L (P < 0,001). Une incidence plus élevée d'intubation difficile a été observée dans le groupe H (56,9 % contre 11,5 %, P < 0,001). Plus de patients du groupe H ont eu des complications des voies respiratoires telles que saignement et lésion de la paroi postérieure du pharynx ou des dents (P < 0,001). Des complications telles que l'hypoxie, l'hypertension et la tachycardie ont été observé comme étant plus élevé dans le groupe H (P < 0,001). Conclusion: Le questionnaire STOP-BANG est un outil préopératoire efficace au chevet du patient qui aide dans l'identification des voies respiratoires difficiles imprévues. Mots-clés: Intubation difficile, ventilation difficile du masque, score de difficulté d'intubation, apnée obstructive du sommeil, questionnaire STOP-BANG.

Comparison of general endotracheal anesthesia versus sedation without endotracheal intubation during initial percutaneous endoscopic gastrostomy insertion for infants: A retrospective cohort study.

BACKGROUND: Critical airway incidents are a major cause of morbidity and mortality during anesthesia. Delayed management of airway obstruction quickly leads to severe complications due to the reduced apnea tolerance in infants and neonates. The decision of whether to intubate the trachea during anesthesia is therefore of great importance, particularly as an increasing number of procedures are performed outside of the operating room. AIM: In this retrospective cohort study, we evaluated airway management for infants below 6 months of age undergoing percutaneous endoscopic gastrostomy insertion. We compared demographic, procedural, and health outcome-related data for infants undergoing percutaneous endoscopic gastrostomy insertion under general endotracheal anesthesia (n = 105) to those receiving monitored anesthesia care (n = 44) without endotracheal intubation. METHODS: A retrospective chart review was completed for all infants <6 months of age who underwent percutaneous endoscopic gastrostomy insertion in our institution's endoscopy suite between January 2002 and January 2017. Descriptive statistics summarized numeric variables using medians and corresponding ranges (minimum-maximum), and categorical variables using frequencies and percentages. Differences in study outcomes between patients undergoing general anesthesia or monitored anesthesia care were evaluated with univariate quantile or Firth logistic regression for numerical and categorical outcomes, respectively. Results are presented as ß [95% confidence interval] or odds ratio [95% confidence interval] along with corresponding p-values. RESULTS: Both groups were similar in distribution of age, race, and gender. However, patients selected for general anesthesia had lower median body weights (3.9 kg [range: 2.0-6.7] vs. 4.4 kg [range: 2.6-6.9]), higher percentages of cardiac (95.2% vs. 84.1%), and/or neurologic comorbidities (74.3% vs. 56.8%) and were more frequently given American Society of Anesthesiologists level IV classifications (41.9% vs. 29.6%) indicating that these infants may have had more severe disease than patients selected for monitored anesthesia care. Three monitored-anesthesia-care patients required intraoperative conversion to general anesthesia. General anesthesia patients experienced greater odds of intraoperative hypoxemia (45.2% vs. 29.0%; odds ratio: 2.0 [0.9-4.3], p-value: .09) and required postoperative airway intervention more frequently than monitored-anesthesia-care patients (13.03% vs. 2.3%; odds ratio: 4.6 [0.8-25.6], p-value: .08). Procedure times were identical in both groups (6 min), but general anesthesia resulted in longer median anesthesia times (44 min [range: 22-292] vs. 12 min [range:19-136]; ß:13 [95% 6.9-19.1], p-value: < .001). CONCLUSION: Study results suggest that providers selected general anesthesia over monitored anesthesia care for infants and neonates with low body weights, cardiac comorbidities, and neurologic comorbidities. Increased rates of airway intervention, and increased length of stay may be at least partially related to more severe patient comorbidity, as indicated by higher American Society of Anesthesiologists classifications. However, due to the exploratory nature of these analyses, further confirmatory studies are needed to evaluate the impact of airway selection during PEG on postoperative patient outcomes.

Pro-Con Debate: Monitored Anesthesia Care Versus General Endotracheal Anesthesia for Endoscopic Retrograde Cholangiopancreatography.

Over the past several decades, anesthesia has experienced a significant growth in nonoperating room anesthesia. Gastrointestinal suites represent the largest volume location for off-site anesthesia procedures, which include complex endoscopy procedures like endoscopic retrograde cholangiopancreatography (ERCP). These challenging patients and procedures necessitate a shared airway and are typically performed in the prone or semiprone position on a dedicated procedural table. In this Pro-Con commentary article, the Pro side supports the use of monitored anesthesia care (MAC), citing fewer hemodynamic perturbations, decreased side effects from inhalational agents, faster cognitive recovery, and quicker procedural times leading to improved center efficiency (ie, quicker time to discharge). Meanwhile, the Con side favors general endotracheal anesthesia (GEA) to reduce the infrequent, but well-recognized, critical events due to impaired oxygenation and/or ventilation known to occur during MAC in this setting. They also argue that procedural interruptions are more frequent during MAC as anesthesia professionals need to rescue patients from apnea with various airway maneuvers. Thus, the risk of hypoxemic episodes is minimized using GEA for ERCP. Unfortunately, neither position is supported by large randomized controlled trials. The consensus opinion of the authors is that anesthesia for ERCP should be provided by a qualified anesthesia professional who weighs the risks and benefits of each technique for a given patient and clinical circumstance. This Pro-Con article highlights the many challenges anesthesia professionals face during ERCPs and encourages thoughtful, individualized anesthetic plans over knee-jerk decisions. Both sides agree that an anesthetic technique administered by a qualified anesthesia professional is favored over an endoscopist-directed sedation approach.

Duration of Exposure to General Endotracheal Anesthesia during Cesarean Deliveries at Term and Perinatal Complications.

OBJECTIVE: To examine whether the duration of time from initiation of general endotracheal anesthesia (GETA) to delivery for cesarean deliveries (CDs) performed is related to perinatal outcomes. STUDY DESIGN: This is a retrospective study of patients with singleton nonanomalous gestations undergoing CD ≥37 weeks of gestation under GETA with reassuring fetal status at a single tertiary care center from 2000 to 2016. Duration from GETA initiation until delivery was calculated as the time interval from GETA induction to delivery (I-D), categorized into tertiles. Outcomes for those in the tertile with the shortest I-D were compared with those in the other two tertiles. The primary perinatal outcome was a composite of complications (continuous positive airway pressure or high-flow nasal cannula for ≥2 consecutive hours, inspired oxygen ≥30% for ≥4 consecutive hours, mechanical ventilation, stillbirth, or neonatal death ≤72 hours after birth). Secondary outcomes were 5-minute Apgar score <7 and a composite of maternal morbidity (bladder injury, bowel injury, and extension of hysterotomy). Bivariable and multivariable analyses were used to compare outcomes. RESULTS: Two hundred eighteen maternal-perinatal dyads were analyzed. They were dichotomized based on I-D ≤4 minutes (those in the tertile with the shortest duration) or >4 minutes. Women with I-D >4 minutes were more likely to have prior abdominal surgery and less likely to have labored prior to CD. I-D >4 minutes was associated with significantly increased frequency of the primary perinatal outcome. This persisted after multivariable adjustment. In bivariable analysis, 5-minute Apgar <7 was more common in the group with I-D >4 minutes, but this did not persist in multivariable analysis. Frequency of maternal morbidity did not differ. CONCLUSION: When CD is performed at term using GETA without evidence of nonreassuring fetal status prior to delivery, I-D interval >4 minutes is associated with increased frequency of perinatal complications. KEY POINTS: · Cesarean delivery under general anesthesia is associated with increased perinatal complications.. · Perinatal complications are increased with increasing duration of exposure to general anesthetics.. · Maternal complications were not increased with shorter duration of exposure to general anesthesia..

Airway management during left-sided gastrobronchial fistula repair after esophagectomy for esophageal carcinoma: A case report.

RATIONALE: Gastrobronchial fistula (GBF) is a rare but life-threatening complication of esophagectomy with gastric conduit reconstruction, and airway management during fistula repair is challenging. Here, we describe airway management in a patient undergoing left-sided GBF repair using video-assisted thoracoscopic surgery. PATIENT CONCERNS: A 63-year-old man diagnosed with esophageal carcinoma underwent esophagectomy with reconstruction by gastric pull-up and tabularization of the gastric conduit. Subsequently, about 8 weeks later, the patient presented with repeated pneumonia and a 1-week history of cough with significant sputum, dysphagia, and repeated fever. DIAGNOSIS: GBF, a rare postoperative complication, was located on the left main bronchus at 2 cm below the carina and was diagnosed based on findings from gastroscopy, flexible bronchoscopy, and thoracic computed tomography scan with contrast. INTERVENTIONS: We performed left-sided one-lung ventilation (OLV) under total intravenous anesthesia instead of inhalational anesthetics. The left-sided OLV, with positive end-expiratory pressure (PEEP) and nasogastric tube decompression, generated positive pressure across the fistula. It prevented backflow into the left main bronchus. Total intravenous anesthesia preserved hypoxic pulmonary vasoconstriction and prevented adverse effects associated with inhalational anesthetics. A right-sided, double-lumen endotracheal tube was inserted after anesthesia induction, and surgical repair was performed through a right-sided video-assisted thoracoscopic surgery. OUTCOMES: Intraoperative hemodynamics remained relatively stable, except for brief tachycardia at 113 beats/min. Arterial blood gas analysis revealed pH 7.17 and PaO2 89.1 mmHg upon 100% oxygenation, along with hypercapnia (PaCO2 77.1 mmHg), indicating respiratory acidosis. During OLV, pulse oximetry remained higher than 92%. The defect in the left main bronchus was successfully sutured after dissecting the fistula between the left main bronchus and the gastric conduit, and subsequently, OLV resulted in ideal ventilation. LESSONS: A left-sided GBF could lead to leakage from the OLV during surgery. Possible aspiration or alveolar hypoventilation due to this leakage is a major concern during airway management before surgical repair of the main bronchus.

Aerosol Generation During Laryngology Procedures in the Operating Room.

OBJECTIVE: Severe acute respiratory syndrome coronavirus-2 spreads through respiratory fluids. We aim to quantify aerosolized particles during laryngology procedures to understand their potential for transmission of infectious aerosol-based diseases. STUDY DESIGN: Prospective quantification of aerosol generation. METHODS: Airborne particles (0.3-25 µm in diameter) were measured during live-patient laryngology surgeries using an optical particle counter positioned 60 cm from the oral cavity to the surgeon's left. Measurements taken during the procedures were compared to baseline concentrations recorded immediately before each procedure. Procedures included direct laryngoscopy with general endotracheal anesthesia (GETA), direct laryngoscopy with jet ventilation, and carbon dioxide (CO2 ) laser use with or without jet ventilation, all utilizing intermittent suction. RESULTS: Greater than 99% of measured particles were 0.3 to 1.0 µm in diameter. Compared to baseline, direct laryngoscopy was associated with a significant 6.71% increase in cumulative particles, primarily 0.3 to 1.0 µm particles (P < .0001). 1.0 to 25 µm particles significantly decreased (P < .001). Jet ventilation was not associated with a significant change in cumulative particles; when analyzing differential particle sizes, only 10 to 25 µm particles exhibited a significant increase compared to baseline (+42.40%, P = .002). Significant increases in cumulative particles were recorded during CO2 laser use (+14.70%, P < .0001), specifically in 0.3 to 2.5 µm particles. Overall, there was no difference when comparing CO2 laser use during jet ventilation versus GETA. CONCLUSIONS: CO2 laser use during laryngology surgery is associated with significant increases in airborne particles. Although direct laryngoscopy with GETA is associated with slight increases in particles, jet ventilation overall does not increase particle aerosolization. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2759-2765, 2021.

Manejo anestésico de la tiroidectomía endoscópica transoral. Reporte de un caso / Anaesthetic management of transoral endoscopic thyroidectomy. A case report

La tiroidectomía endoscópica transoral por abordaje vestibular (TOETVA) constituye un procedimiento novedoso y mínimamente invasivo, libre de cicatrices visibles y que presenta resultados alentadores en cuanto a la rápida recuperación y menor dolor posoperatorio. Consiste en realizar la tiroidectomía a través de su orificio natural, empleando tres puertos en el área oral vestibular y llevando a cabo una disección cuidadosa hasta la muesca esternal y los bordes de ambos músculos esternocleidomastoideos. El objetivo es describir las diferentes implicaciones anestésicas que conlleva esta técnica quirúrgica, dado que la evidencia publicada hasta la fecha en la literatura es muy limitada. Se considera esencial la monitorización del nervio laríngeo recurrente mediante tubo endotraqueal con electromiografía para garantizar su identificación e integridad, así como la utilización de otros monitores como el TOF-watch o el índice biespectral para asegurar una adecuada profundidad anestésica y un óptimo nivel de relajación muscular.(AU)

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel and minimally invasive procedure, free of visible scars and showing encouraging results in terms of rapid recovery and less postoperative pain. It consists of performing the thyroidectomy through its natural orifice, using three ports in the oral vestibular area and carrying out a careful dissection to the sternal notch and the edges of both sternocleidomastoid muscles. The objective of this article is to describe the different anesthetic implications that this surgical technique entails, given that the evidence published to date in the literature is very limited. It is considered essential to control the recurrent laryngeal nerve using an endotracheal tube with electromyography to ensure its identification and integrity, as well as the use of other monitors such as the TOF watch or the bispectral index to ensure adequate anesthetic depth and an optimal level of muscle relaxation.(AU)

Evaluación de la relajación neuromuscular y predictores de vía aérea difícil en pacientes programados para cirugía general Hospital Central Universitario Dr. Antonio María Pineda / Evaluation of muscle relaxation and predictors of difficult airway in patients programmed for general surgery Hospital Central Universitario Dr. Antonio María Pineda

Se realizó una investigación experimental tipo ensayo clínico controlado simple ciego con el fin de evaluar la relajación muscular y los predictores de vía aérea difícil en pacientes programados para cirugía general en el Hospital Central Universitario Dr. Antonio María Pineda. La muestra estuvo conformada por 100 pacientes distribuidos aleatoriamente en cuatro grupos de 25 pacientes cada uno. En los grupos Experimental-1 (E-1) y Control-1 (C-1) se utilizó una dosis del bloqueante neuromuscular Bromuro de Rocuronio de 0,6 mg/kg y en los grupos Experimental-2 (E-2) y Control-2 (C-2) de 1 mg/kg. La edad promedio de los pacientes fue de 34,8 ± 9,8 años; en los grupos E-1 y E-2, los predictores de vía aérea difícil predominantes fueron distancia esternomentoniana (32% y 42%), distancia tiromentoniana (24% y 40%), distancia interincisivos clase I (88% y 92 %), circunferencia de cuello  40 cm (16% y 8 %), Mallampati (88% y 40%), extensión atlanto-occipital (28% y 20%) y protrusión mandibular (28% y 20%). En el 72% y 80% de los pacientes de los grupos experimentales y control no hubo intento adicional de intubación orotraqueal (IOT); el tiempo invertido para alcanzar la IOT fue < 1 minuto en el grupo C-2 (64%) y E-2 (72%). Existen diferencias estadísticamente significativas entre el número de intentos para alcanzar la IOT, la presencia de predictores de vía aérea difícil y la dosis de bloqueante neuromuscular utilizada lo que evidencia de que a medida que se aumenta la dosis del medicamento hay mayor posibilidad de éxitos en la IOT, aun cuando estén presentes predictores de vía aérea difícil(AU)

An experimental simple blind controlled clinical trial was carried out to evaluate muscle relaxation and predictors of difficult airway in patients scheduled for general surgery at the Hospital Central Universitario Dr. Antonio María Pineda. The sample consisted of 100 patients randomly distributed into four groups of 25 patients each. Patients from the Experimental-1 (E-1) and Control-1 (C-1) groups received 0.6 mg/kg of the neuromuscular blocking agent Rocuronium Bromide while Experimetal-2 (E-2) and Control-2 (C-2) patients received a dosage of 1 mg/kg. Average age of participants was 34.8 ± 9.8 years. Predictors of difficult airway in E-1 and E-2 were sternomental distance (32% and 42%, thyromental distance (24% and 40%), interincisive distance class 1 (88% and 92%), neck circumference  40 cm (16% and 8%), Mallampati (88% and 40%), atlanto-occipital extension (28% and 20%) and mandibular protrusion (28% and 20%). In 72% and 80% of patients from the E and C groups there was not an additional attempt of orotracheal intubation (OTI); the time invested to reach the OTI was less than one minute in 64% of patients from the C-2 and 72% of the E-2. There are statistically significant differences between the number of attempts to reach the OTI, presence of predictors of difficult airway and the dose of Rocuronium Bromide which means that as the drug dosage increases, there is a greater possibility of success in the OTI, even when predictors of difficult airway are present(AU)

Anestesia para cirugía abdominal urgente en síndrome de Down y tetralogía Fallot no reparada / Anesthesia for urgent abdominal surgery in Down syndrome and unrepaired Fallot tetralogy

Introducción: la cirugía en pacientes con síndrome de Down y tetralogía de Fallot no reparada es infrecuente, pero en ocasiones el anestesiólogo debe prestar servicio a estos pacientes para cirugías de urgencia no cardiaca. Presentación de caso: paciente blanco, masculino, 36 años de edad, con antecedentes de síndrome de Down y tetralogía de Fallot no reparada, con dolor abdominal de tres días de evolución en epigastrio e irradiación a fosa ilíaca derecha, sin alivio al reposo ni a la administración de analgésicos; acompañado de náuseas, vómitos y síntomas catarrales. Discusión: fue valorado por cirugía y se diagnosticó abdomen agudo quirúrgico por posible apendicitis aguda y mediante anestesia general orotraqueal fue intervenido con resultados favorables. Conclusiones: la administración de anestesia general en la conducción anestesiológica del paciente con síndrome de Down y tetralogía de Fallot no reparada para cirugía abdominal urgente, permite resultados satisfactorios durante el proceder(AU)

Introduction: surgery in patients with Down syndrome and unrepaired tetralogy of Fallot is infrequent, but sometimes the anesthesiologist must provide services to these patients for non-cardiac emergency surgeries. Case presentation: white male patient, 36 years old, with a history of Down syndrome and unrepaired Fallot's tetralogy, with abdominal pain of three days of evolution in the epigastrium and irradiation to the right iliac fossa, without relief at rest or at rest administration of analgesics; accompanied by nausea, vomiting and catarrhal symptoms. Discussion: it was evaluated by surgery and an acute surgical abdomen was diagnosed for possible acute appendicitis and under general or tracheal anesthesia it was operated with favorable results. Conclusions: the administration of general anesthesia in the anesthesiological conduction of the patient with Down syndrome and unrepaired tetralogy of Fallot for urgent abdominal surgery allows satisfactory results during the procedure(EU)

A simple screening test of filtration efficiency for protecting the gas sampling line from coronavirus using fluorescent microspheres.

BACKGROUND: During the coronavirus pandemic, preventing contamination of the anesthesia machine, critical to avoid cross-contamination between patients, has proven challenging when treating premature infants and neonates. While attaching a HEPA filter to the endotracheal tube will protect the anesthesia machine and the gas sampling line from contamination, this contribution to the dead space makes ventilation of these small patients challenging. Direct filtration of the gas sampling line eliminates this problem; however, appropriate filters are not readily available. AIMS: Identify a small filter capable of filtering out particles of a size similar to the SARS-CoV-2 virus for the gas sampling line. METHODS: We used fluorescence microspheres suspended in a solution for a challenge test to determine the filtration efficiency of various filters. The microspheres varied in diameter (0.02 µm, 0.042 µm, 0.109 µm, and 0.989 µm). A fluorescence plate reader was used to evaluate the degree of fluorescence intensity in the flow-through from various filters and referenced to the fluorescence intensity of the input. RESULTS: AHEPA filter, as recommended as an anti-viral filter, effectively filtered all the particles tested. The B. Braun PERIFIX Flat Epidural Filter was the second most effective filter, filtering particles larger than 0.042 µm. Other filters tested did not filter fluorescence microspheres equivalent in size to a single coronavirus particle (0.07 µm). CONCLUSIONS: Although the Food and Drug Administration (FDA) has not approved the Flat Epidural Filter for use as an anesthesia machine gas filter, our simple challenge test suggests that it could be used to effectively filter the anesthesia gas sampling line.

Recomendaciones para la evaluación y manejo de la vía aérea difícil prevista y no prevista de la Societat Catalana d'Anestesiologia, Reanimació I Terapèutica del Dolor, basadas en la adaptación de guías de práctica clínica y consenso de expertos / Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació I Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

La Sección de Vía Aérea de la Sociedad Catalana de Anestesiología, Reanimación y Terapéutica del Dolor (SCARTD) presenta la actualización de las recomendaciones para la evaluación y manejo de la vía aérea difícil con el fin de incorporar los avances técnicos y los cambios observados en la práctica clínica desde la publicación de la primera edición en 2008. La metodología elegida fue la adaptación de 5 guías internacionales recientemente publicadas, cuyo contenido fue previamente analizado y comparado de forma estructurada, y el consenso de expertos de los 19 centros participantes. El documento final fue sometido a la valoración de los miembros de la SCARTD y a la revisión por parte de 11 expertos independientes. Estas recomendaciones están pues sustentadas en la evidencia científica actualmente disponible y en un amplio acuerdo de los profesionales de su ámbito de aplicación. En esta edición se amplía la definición de vía aérea difícil, abarcando todas las técnicas de manejo, y se hace mayor hincapié en la valoración de la vía aérea y en la clasificación en 3 categorías según el potencial grado de dificultad y las consideraciones de seguridad adicionales, que guiarán la planificación de la estrategia a seguir. La preparación previa al manejo de la vía aérea, no solo relativa al paciente y al material, sino también a la comunicación e interacción entre todos los agentes implicados, ocupa un lugar destacado en todos los escenarios incluidos en el presente documento. El texto refleja el aumento progresivo del uso de los videolaringoscopios y de los dispositivos de segunda generación en nuestro entorno y promueve tanto su uso electivo como el uso precoz en la vía aérea no prevista. También recoge la creciente utilización de la ecografía como herramienta de apoyo en la exploración y toma de decisiones. Se han abordado nuevos escenarios como el riesgo de broncoaspiración y la extubación considerada difícil. Finalmente, se trazan las líneas maestras de los programas de entrenamiento y formación continuada en vía aérea necesarios para garantizar la implementación efectiva y segura de las recomendaciones

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines

Implementation of an Anaesthesia Quality Improvement Programme to Reduce Fibreoptic Bronchoscope Repair Incidents.

BACKGROUND: This study was aimed at investigating the effectiveness of the implementation of a comprehensive quality improvement programme (QIP) for reducing the repair rate of the fibreoptic bronchoscope (FOB). METHODS: A three-stage improvement strategy was implemented between January 2013 and December 2016. Stage one is the acquisition of information on violations of practice guidelines, repair rate, cost of repair, and incidence of unavailability of FOB during anaesthesia induction of the previous year through auditing. Stage two is the implementation of a quality improvement campaign (QIC) based on the results of stage one. Stage three is the programme perpetuation through monitoring compliance with policy on FOB use by regular internal audits. The effectiveness was retrospectively analyzed on a yearly basis. RESULTS: The annual repair rate, repair cost, and incidence of FOB unavailability before the QIP implementation were 1%, 18,757 USD, and 1.4%, respectively. After QIC, the repair rate in 2013 dropped by 81% (from 1% in 2012 to 0.19% in 2013, p < 0.05). The annual repair cost fell by 32% from 18,758 USD (2012) to 12,820 USD (2013). Besides, the incidence of FOB unavailability plummeted by 71% from 1.4% to 0.4% during the same period. The annual repair rates and incidence of FOB unavailability remained lower in subsequent three years than those before QIP implementation. CONCLUSION: Implementation of a quality improvement programme was effective for reducing the rate and cost of FOB repair as well as unavailability rate, highlighting its beneficial impact on cost-effectiveness and patient safety in a tertiary referral center setting.

Factores asociados a la extubación temprana en pacientes con cirugía correctora de tetralogía de Fallot / Factors associated with early extubation of patients after corrective tetralogy of Fallot

Objetivo: Analizar el manejo intraquirúrgico y los resultados posquirúrgicos asociados a la extubación temprana en los pacientes sometidos a cirugía reparadora de tetralogía de Fallot en un hospital público argentino. Métodos: Se realizó una revisión retrospectiva de los expedientes clínicos de los pacientes a quienes se les practicó cirugía para corrección de tetralogía de Fallot. Se incluyeron en el análisis un total de 38 expedientes que cumplieron con los criterios de inclusión establecidos en el protocolo para la revisión retrospectiva. Resultados: El 16% fue extubado de manera temprana. Milrinona fue la única droga que mostró diferencias en los pacientes a quienes se extubó de manera temprana (p = 0,01). El tiempo de circulación extracorpórea, el de clampaje aórtico, la transfusión con crioprecipitados, la saturación de la presión de oxígeno, y el hematocrito al finalizar el procedimiento quirúrgico no evidenciaron diferencias (p > 0,05). En el período posquirúrgico, la estadía en UTI fue más corta en los pacientes que fueron extubados de manera temprana (p = 0,0007), pero no hubo diferencias en la estadía hospitalaria total (p = 0,26). Conclusiones: La extubación temprana en la institución si bien resultó de baja frecuencia ha demostrado ser una alternativa segura y eficaz para disminuir la estancia en UTI de estos pacientes

Objective: To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina. Methods: A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis. Results: 16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p = 0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p > .05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p = 0.0007), but there were no differences in the total hospital stay (p = 0.26). Conclusions: Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients’ stay in ICU

Arthur Guedel and the Ascendance of Anesthesia: A Teacher, Tinkerer, and Transformer.

At the beginning of the twentieth century, anesthesia was an emerging field without permanent departments, exclusive practitioners, or academic residency programs. Instead, surgeons and nurses administered anesthetic gases in an ad-hoc fashion, exposing patients to the perilous risks of general anesthesia. Dr. Arthur Guedel was a general practitioner from rural Indiana who unexpectedly became an integral part of anesthesia's evolution into a safety conscience and formally recognized expertise. Beginning during his military service in World War I, he refined the stages of ether anesthesia and produced the definitive textbook on inhalational anesthetics. During the prolific career that followed, Guedel also introduced ground-breaking devices for patient-controlled analgesia, cuffed endotracheal intubation, and oral airway patency. His inclusive mentorship, collaborative research, and innovative instruments exemplify his role as a multitalented tinkerer, teacher, and transformative leader. This essay examines Guedel's pioneering contributions and the scope of his influence, all of which revolutionized anesthesia and expanded surgeons' operative capability. Through the lens of Guedel's personal and professional life, this essay further illustrates how the diverse, interdisciplinary, and cutting edge characteristics of the practice itself contributed to anesthesia's increased importance in modern medicine.

Capacidad del índice de El-Ganzouri para predecir el grado de dificultad en la intubación traqueal / El-Ganzouri index effectiveness for predicting the degree difficulty in tracheal intubation

Introducción: La intubación de la vía respiratoria difícil constituye un problema de salud. Para prevenirla, se han utilizado diferentes índices. Objetivo: Evaluar la utilidad del índice de El-Ganzouri en la predicción del grado de dificultad en la intubación traqueal mediante laringoscopia convencional. Método: Se realizó un estudio descriptivo de corte transversal, en pacientes que requirieron intubación traqueal, en el Hospital Hermanos Ameijeiras, entre febrero de 2014 y 2017. Esta prueba combina y estratifica siete variables derivadas de parámetros observacionales asociadas individualmente. Se estratificó sus valores y se interpretó < 4 vía respiratoria de fácil acceso y ; 4 vía respiratoria de difícil acceso. Resultados: Se estudiaron 94 pacientes en los que se evaluó el índice de El-Ganzouri. Predominó el grupo etáreo de 50 a 59 años (29,8 por ciento) y el sexo masculino 52,1 por ciento. ASA II fue más frecuente en 66 por ciento. El índice de El Ganzouri primó la apertura oral lt; 4 cm, la distancia tiromentoniana gt; 6.5 cm, El Mallamapati I en 91,5 por ciento, los movimientos del cuello gt; 90°, el peso corporal < 90 kg y ningún antecedente de historia de dificultad en la intubación 67,0 por ciento. Al corroborar las pruebas predictivas con la de Cormack y Lehane, se observó que 92,6 por ciento de los pacientes presentaron una vía respiratoria fácil y esta condición se obtuvo en el 78,7 por ciento con el Índice El Ganzouri. La sensibilidad fue de 71,43 por ciento y la especificidad fue de 20,69 por ciento. El valor predictivo positivo de 6,76 y 90,0 de predictivo negativo. Conclusiones: Se confirmó la utilidad del índice de riesgo multivariado de El-Ganzouri en la predicción del grado de dificultad en la intubación traqueal mediante laringoscopia convencional. Se identificó la sensibilidad, especificidad, valores predictivos positivos y negativos los cuales mostraron buena predicción de vía respiratoria anatómicamente difícil(AU)

[Angioedema of the upper airways during a routine surgery]. / Angionevroticheskii otek verkhnikh dykhatel'nykh putei, razvivshiisia u bol'noi vo vremia planovoi operatsii.

The article describes a rare clinical case of the development of angioedema of the larynx and pharynx in a patient during a surgery under endotracheal anesthesia. The authors of the article indicate that in the practice of clinic is 1 case for 32011 people, which is 0.003% of all hospitalized in the hospital for the elective surgical treatment of diseases of the upper respiratory tract. After removal of the tonsils and cyst of the nasopharynx, the surgeon noted a pronounced edema of the uvula, the mucous membrane of the soft palate, the lateral walls of the laryngopharynx and larynx. The patient was not taken out of the anesthesia. The mechanical ventilation was continued and the patient was transferred to the intensive care unit and intensive care unit where antiedematous and symptomatic therapy was conducted. On the 3rd day of treatment, the upper respiratory tract edema reduced, the patient was extubated. The authors present an algorithm for the examination and treatment of patients with angioedema.