Experience Of Anesthesiologist Research Articles

Difficult airway in a surgical patient with ankylosing spondylitis (Bechterew's disease): clinical case

A difficult airway is a life-threatening clinical situation in which a trained anesthesiologist experiences difficulty ventilating the upper airway with a tight mask, difficulty intubation the trachea, or both. This is an important socio-economic problem that makes a significant contribution to the structure of intraoperative mortality and disability of patients. A clinical observation of difficult airways in a patient with ankylosing spondylitis who was scheduled to have a brain tumor removed is presented.

Awake tracheal intubation in routine airway management: A retrospective analysis in a tertiary centre.

While awake tracheal intubation (ATI) is regarded as the gold standard for difficult airway management according to current guidelines, there seems to be a reluctance in its application. This retrospective cohort study, conducted at a German tertiary hospital over a 2-year period, aimed to demonstrate that integrating awake tracheal intubation using flexible bronchoscopy (ATI:FB) into routine airway management makes it a successful and safe approach. In 2019 and 2020, records from the data acquisition system (DAQ) and archived anesthesia records were screened to evaluate the specifics of ATI:FB procedures, focusing on overall success and safety. Analysis included complications, time required for ATI:FB, and potential influencing factors such as patient characteristics, indication, medical/operative specialty, sedation technique, route and experience of anesthesiologist. Logistic regression assessed the impact of various variables on occurrence of complications and linear regression, with log(time) as the dependent variable, evaluated median time required to perform ATI:FB. ATI:FB constituted 4.3 % (n = 1,911) of all airway management procedures, predominantly observed in dental, oral, and maxillofacial surgery (46.5 %) and otorhinolaryngology (38.4 %). The success rate for ATI:FB was notably high at 99.6 %, with only 5.4 % of cases experiencing complications, including technical issues, agitation, and visibility obstruction due to mucous secretion. Complication risk was influenced by the medical specialty and the experience of the anesthesiologist. A strong effect was observed in otorhinolaryngology (OR = 4.54, 95 % CI [1.64; 14.06]). The median time required for ATI:FB was 16 minutes (IQR: 11 to 23), with factors such as indication (p < 0.0001), experience of anesthesiologist (p < 0.0001), sedation technique (p = 0.0408), priority of the procedure (p = 0.0134), and medical/operative specialty (p < 0.0001) affecting the duration. The median time required for ATI:FB differed significantly based on the experience of the anesthesiologist (p < 0.0001). ATI:FB proves successful and safe, with low complications and manageable procedural time. Experience of the anesthesiologist is a modifiable factor enhancing safety, emphasizing the need for ATI:FB integration into routine airway management.

Magnitude, associated factors of difficult airway, and predictive value of airway examinations among maxillofacial surgery patients at public hospitals in public hospitals in Southern Ethiopia: A multicentre cross-sectional study

Background: “Difficult airway” is the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, laryngoscopy, and difficulty with tracheal intubation, or both. Associated factors and predictive value difficult airways, maxillofacial surgery study setup is under studied Objective: To determine the magnitude and associated factors of difficult airways and predictive value of airway examinations among adult patients who underwent maxillofacial surgery at public hospitals in Southern Ethiopia 2022. Methods and Materials: An institutional-based multicenter cross-sectional study was conducted among 250 maxillofacial patients from March to June 30, 2022 at selected hospitals. The data were entered into Epi_Data software version 4.3 and analyzed by STATA software version 14. All variables that were statistically significant in bivariate analysis, at the P &lt; 0.25, were included in the multivariate logistic regression analysis. The predictive value or the effectiveness of airway examinations in predicting difficult airways was analyzed by ROC. Results: In the current study, the magnitude of difficult airways was 21.2%( 95% CI = 16.3%-26.1%) and the magnitude of difficult intubation, difficult laryngoscopy, and difficult mask ventilation was 6.4% ( 95% CI3.3%-9.4%), 9.6% ( 95% CI6.1%-13%), and 13.6% ( 95% CI (9.1%-16.8%), respectively. History of head and neck surgery AOR=6.3, 95%CI (2.85-14.34), cervical collar AOR=4.9, 95%CI (1.96-12.49), and cervical spine injury AOR=2.4, 95%CI (1.07-5.38)] were independently and significantly associated with difficulty of airway. Modified Mallampati class and sternomental distance were identified as good preoperative tests to predict difficult laryngoscopy, intubation, and mask ventilation Conclusion and recommendation: The magnitude of difficult airways was maxillofacial surgery. Among various airway assessment tests, no single test was perfectly accurate. Anesthesia professionals are recommended to use a combination of pre-operative airway assessments.

QUALITY AND EFFICACY OF GENERAL ANESTHESIA VERSUS SEGMENTAL THORACIC SPINAL ANESTHESIA IN MODIFIED RADICAL MASTECTOMY SURGERY: A SINGLE-CENTER OBSERVATIONAL STUDY

Objective: Surgical resection remains the most important treatment modality for breast cancers. Recent research suggests that the choice of anesthesia technique might also have a role in the recurrence of the disease. We compared quality and efficacy of the conventional general anesthesia technique with segmental thoracic spinal (STS) anesthesia technique used in modified radical mastectomy. Methods: 60 American Society of Anesthesiologists II/III patients were divided into two groups Group C (Control group) and Group S (Study group). Group C patients were induced with standard anesthesia regimen while Group S patients were given STS at T4–T5 inter space with 1.5 mL of 0.5% hyperbaric levobupivacaine along with 15 µg of fentanyl with conscious sedation. Hemodynamics, pain score, time for first rescue analgesia, experience of anesthesiologist, surgeon, and patients were recorded. Results: Time for induction in group S is significantly longer (Group C 17.4±3.8 vs. 36.2±7.2 min, in Group S). The duration of surgery (56±13.6 min vs. 76.4±15.9 min) was also significantly longer, while reversal period was shorter in Group S (9.2±6.2 and 6.3±5.7 min). Modified Aldrete’s recovery score achieved quickly in Group C (16.8±4.9 vs. 29.7±9.8 min), but postoperative analgesia was better in Group S as first rescue analgesic sode required after 6.2±1.9 h in Gr. S while in Gr. C time duration was 4.9±1.3 h. Length of stay in hospital was more in Group S, (Group C 45.4±4.8 vs. Group S 56.3±8.5 [h]) while ease and comfort of surgeon anesthesiologist and patient satisfaction score were more in Group C. Conclusion: STS anesthesia is feasible for breast carcinoma surgeries but it is easier for surgeon and anesthesiologist to manage patient under general anesthesia. STS anesthesia has advantage in terms of early post-operative analgesia and will definitely be helpful in cases where patient is not fit for general anesthesia.

A retrospective cohort study of the anesthetic management of postpartum tubal ligation

BackgroundNeuraxial anesthesia with reactivation of a labor epidural catheter is commonly utilized for postpartum tubal ligations (PPTL), although the optimal anesthetic approach is unknown. We assessed institutional anesthesia practices for PPTL, and evaluated the failure rates of reactivation of labor epidural catheters, de novo spinal anesthesia, and spinal anesthesia after failed blocks. MethodsWe conducted a single-center retrospective cohort analysis of 300 consecutive patients who underwent a PPTL and 100 having spinal anesthesia for cesarean delivery. Anesthetic management data (existing labor epidural catheter reactivation, de novo spinal anesthesia or general anesthesia) were collected from electronic medical records. Anesthetic block failure rates were determined for each anesthetic technique. ResultsThe failure rate was 15% for de novo spinal anesthesia and 23% after failed reactivation of a labor epidural catheter or spinal anesthesia. The epidural catheter reactivation failure rate was 35%. The failure rate of spinal anesthesia for cesarean delivery was 4%. Drug dosage, epidural catheter use in labor, time since epidural catheter placement or delivery, labor neuraxial technique (combined spinal-epidural, epidural), supplemental top-up doses during labor, and anesthesiologist experience did not predict neuraxial anesthesia failures. ConclusionsOur analysis revealed an unexpectedly high neuraxial anesthesia failure rate even when de novo spinal anesthesia was used for PPTL. The results are consistent with other institutions' recent findings, and are higher than spinal anesthesia failure rates associated with cesarean delivery. Further studies are required to determine optimal anesthesia dosing strategies, and to understand the mechanisms behind high neuraxial anesthesia failures for PPTL.

Does Anesthesiologist Experience Influence Early Postoperative Outcomes Following Orthognathic Surgery?

Anesthesia provider experience impacts nausea and vomiting in other surgical specialties but its influence within orthognathic surgery remains unclear. The study purpose was to evaluate whether anesthesiologist experience with orthognathic surgery impacts postoperative outcomes, including nausea, emesis, narcotic use, and perioperative adverse events, for patients undergoing orthognathic surgery. This is a retrospective cohort study of subjects aged 12 to 35years old who underwent orthognathic surgery, including Le Fort 1 osteotomy±bilateral sagittal split osteotomy, at Boston Children's Hospital from August 2018 to January 2022. Subjects were excluded if they had incomplete medical records, a syndromic diagnosis, or a hospital stay of greater than 2days. The predictor variable was attending anesthesia provider experience with orthognathic surgery. Providers were classified as experienced or inexperienced, with experienced providers defined as having anesthetized ≥10 orthognathic operations during the study period. The primary outcome variable was postoperative nausea. Secondary outcome variables were emesis, narcotic use in the hospital, and perioperative adverse events within 30days of their operation. Study covariates included age, sex, race, comorbidities (body mass index, history of psychiatric illness, cleft lip and/or palate, chronic pain, postoperative nausea/vomiting, gastrointestinal conditions), enhanced recovery after surgery protocol enrollment, and intraoperative factors (operation performed, anesthesia/procedure times, estimated blood loss, intravenous fluid and narcotic administration, and anesthesiologist's years in practice). χ2 and unpaired t-tests were used to compare primary predictor and covariates against outcome variables. A P-value <.05 was considered significant. There were 118 subjects included in the study after 4 were excluded (51.7% female, mean age 19.1±3.30years). There were 71 operations performed by 5 experienced anesthesiologists (mean cases/provider 15.4±5.95) and 47 cases by 22 different inexperienced providers (mean cases/provider 1.91±1.16). The nausea rate was 52.1% for experienced providers and 53.2% for inexperienced providers (P=.909). There were no statistically significant associations between anesthesiologist experience and any outcome variable (P>.341). Anesthesia providers' experience with orthognathic surgery did not significantly influence postoperative nausea, emesis, narcotic use, or perioperative adverse events.

Design and Assessment of a Bimanual Haptic Epidural Needle Insertion Simulator.

The case experience of anesthesiologists is one of the leading causes of accidental dural punctures and failed epidurals-the most common complications of epidural analgesia used for pain relief during delivery. We designed a bimanual haptic simulator to train anesthesiologists and optimize epidural analgesia skill acquisition. We present an assessment study conducted with 22 anesthesiologists of different competency levels from several Israeli hospitals. Our simulator emulates the forces applied to the epidural (Touhy) needle, held by one hand, and those applied to the Loss of Resistance (LOR) syringe, held by the other one. The resistance is calculated based on a model of the epidural region layers parameterized by the weight of the patient. We measured the movements of both haptic devices and quantified the results' rate (success, failed epidurals, and dural punctures), insertion strategies, and the participants' answers to questionnaires about their perception of the simulation realism. We demonstrated good construct validity by showing that the simulator can distinguish between real-life novices and experts. Face and content validity were examined by studying users' impressions regarding the simulator's realism and fulfillment of purpose. We found differences in strategies between different level anesthesiologists, and suggest trainee-based instruction in advanced training stages.

Intubation challenges in surgeries of thyroid swellings

Background: Difficult airway is when a trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway or tracheal intubation or both. It has always been a challenging issue for anesthesiologists. Aims and Objectives: The objective was pre-operative assessment of airway in patients with goiter and to find the incidence of difficult intubation and its management. Materials and Methods: A prospective study was done in 32 patients presenting with goiter of various sizes. Routine airway examination includes mouth opening, Mallampati grading, neck circumference, neck mobility, thyromental distance, tracheal deviation on chest X-ray, AP and lateral views of neck, and Cormack-Lehane grading on laryngoscopy. The technique followed in each case was noted. Results: Out of 32 cases, difficult intubation was experienced in five cases. Among the studied parameters, neck mobility (66.7%) followed by neck circumference (44.4%) and Mallampati grading (37.5%) was found to be more predictive in assessing the airway. 62.5% patients were intubated through direct laryngoscopy, followed by bougie in 21.9% patients. Due to difficulty in intubation, 15.6% patients were intubated through videolaryngoscopy. Conclusion: We conclude that induction of anesthesia can be challenging for patients with goiter. A thorough history and examination are mandatory pre-operatively in these patients. Neck circumference and neck mobility are the most crucial factors as evident in our study. Videolaryngoscopy plays an important role in patients with difficult airway.

Epidural Catheter Replacement Rates With Dural Puncture Epidural Labor Analgesia Compared With Epidural Analgesia Without Dural Puncture: A Retrospective Cohort Study

(Int J Obstet Anesth. 2022;52:103590) Lumbar epidural analgesia (LEA) is a common method of labor analgesia. Traditional LEA, dural-puncture epidural (DPE), and combined spinal-epidural analgesia (CSE) are approaches to epidural catheter placement. Epidural catheters are known to malfunction following placement (12% to 13%), requiring replacement or conversion to general anesthesia (GA) if failure occurs during emergency intrapartum cesarean delivery (CD). Factors contributing to placement failure include body mass index (BMI) or weight, procedure type (CSE vs. LEA), gestational age, anesthesiologist experience, type of epidural catheter, patient age, and mode of delivery. Few studies have compared catheter failure rates between LEA and CSE. This retrospective analysis compares epidural catheter failure rates of DPE or LEA.

Equity, Diversity, and Inclusion in anesthesiology: a primer.

This continuing professional development module aims to elucidate the current demographics of anesthesiology in Canada and the experience of anesthesiologists from equity-seeking groups. This module will also identify and describe factors impacting the health care experience of patients from equity-seeking groups who receive perioperative, pain, and obstetric care. In recent years, discrimination based on sex, gender, race, ethnicity, sexual orientation, ability, other demographic factors, and the intersection of these identities have gained greater attention not only in our society at large but also within medicine and anesthesiology. The stark consequences of this discrimination for both anesthesiologists and patients from equity-seeking groups have become clearer in recent years, although the full scope of the problem is not fully understood. Data regarding the demographics of the national anesthesia workforce are lacking. Literature describing patient perspectives of various equity-seeking groups is also sparse, although increasing. Health disparities impacting people who are racialized, women, LGBTQIA+, and/or living with disability are also present in the perioperative context. Discrimination and inequity persist in the Canadian health care system. It is incumbent upon us to actively work against these inequities every day to create a kinder and more just health care system in Canada.

Emergency endotracheal intubation in critically ill patients with COVID-19: management and clinical characteristics

PurposesSARS-CoV-2 have become widespread worldwide since the outbreak. Respiratory function deteriorates rapidly in critically ill patients infected with SARS-CoV-2. Endotracheal intubation is an indispensable therapeutic measure during the development of the disease. This study was intended to describe the experience of endotracheal intubation from front-line anesthesiologists and clinical prognosis of patients infected with Coronavirus disease-19 (COVID-19).MethodsFourteen critical patients infected with COVID-19 who underwent endotracheal intubation were included in this study. We collate and analyze the blood gas results before and after tracheal intubation of patients and clinical prognostic indicators such as length of stay and. mortality. The experience of anesthesiologists who intubated patients has also been recorded in detail.ResultsPatients had a mean time of 10.6 days from initial symptoms to endotracheal intubation. Most intubated patients had one or more underlying conditions: hypertension (8, 57.14%), diabetes (5, 35.71%), and cardiovascular and cerebrovascular diseases (2, 14.29%). The oxygenation index increased significantly after intubation compared with before intubation (148.80 ± 42.25 vs 284.43 ± 60.17 p < 0.001). 85.72% of patients required extra-corporeal membrane oxygenation (ECMO) due to inability to maintain oxygen saturation with standard therapeutic measures. Two patients underwent lung transplantation because their lungs were essentially nonfunctional, and they recovered well after surgery. As of this writing, all patients were discharged after satisfactory recovery.ConclusionsReasonable selection of intubation timing is particularly important. It is crucial to increase the patient's oxygen supply and reduce oxygen consumption as much as possible during endotracheal intubation. In addition, the personal protective measures of medical personnel participating in treatment should be scientific and standardized.Graphical

What We Knew and What's New: 10 Years of Managing the Difficult Airway

Committee News| July 2022 What We Knew and What's New: 10 Years of Managing the Difficult Airway Brittany Reardon, MD; Brittany Reardon, MD Search for other works by this author on: This Site PubMed Google Scholar Loren Smith, MD, PhD Loren Smith, MD, PhD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2022, Vol. 86, 32. https://doi.org/10.1097/01.ASM.0000842076.17065.9f Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Brittany Reardon, Loren Smith; What We Knew and What's New: 10 Years of Managing the Difficult Airway. ASA Monitor 2022; 86:32 doi: https://doi.org/10.1097/01.ASM.0000842076.17065.9f Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: intubation, difficult Airway management is a cornerstone of anesthesiology, particularly management of potentially difficult airways, as anesthesiologists are the foremost experts in this arena. Anesthesiologists are acutely aware of how important it is to recognize a potentially difficult airway before administering sedation or anesthesia in order to avoid adverse events, including extended periods of hypoventilation, hypoxic brain injury, and death. The 2012 ASA Practice Guidelines for Management of the Difficult Airway defined a difficult airway as “the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both” (Anesthesiology 2013;118:251-70). These practice guidelines divided difficult airways into five categories: difficult facemask or supraglottic airway ventilation, difficult supraglottic airway placement, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. Given the elevated risk of failed ventilation and/or intubation after induction of anesthesia in a suspected or known difficult airway,... You do not currently have access to this content.

Anesthetic experience does not reduce accidental dural puncture in surgical patients: a retrospective case-controlled study

BackgroundAccidental dural puncture (ADP), which is a complication of epidural anesthesia, still exists and leads to worse outcomes in surgical patients. While residency training is important for epidural competency, it remains unknown whether anesthetic experience reduces ADP in surgical patients. Using an incident reporting system along with anesthetic records, this case-controlled study retrospectively investigated risk factors associated with ADP in surgical patients.MethodsPatients who experienced ADP during epidural anesthesia who were registered in the incident reporting system of our institution between April 2012 and March 2019 were enrolled. Patients with ADP were control-matched with those who without ADP in a 1:3 ratio, to compare the potential risk factors and calculated odds ratios (ORs) for ADP. The primary hypothesis was that anesthesiologists’ experience reduces the incidence of ADP. The secondary hypothesis was that there are risk factors for ADP. Between-group differences in anesthesiologists’ experience were compared using the Mann–Whitney U test. Significance was set at P < 0.05.ResultsThirty-five patients who experienced ADP were identified from the incident reporting system. These were matched with 69 patients who did not experience ADP. There was no difference in the years of experience of anesthesiologists between the groups that did and did not experience ADP (8 [3–20] vs. 9 [3–18] years, respectively; P = 0.65).ConclusionsHaving an experienced anesthesiologist did not guarantee the prevention of ADP. Daily individual training and briefings would be needed to reduce the incidence of ADP.

Impact of Anesthesiologist Experience on Early Outcomes in Adult Orthotopic Liver Transplantation

Liver transplantation is a complex surgical procedure. The experience of the anesthesiologist, and its potential relationship to patient morbidity and mortality, is yet to be determined. We sought to explore this possible association using our institutional training patterns as the subject of study. This is a single center retrospective analysis investigating the association of an anesthesiologist's experience with liver transplantation and its potential effect on early patient outcomes in adult liver transplant recipients from January 2010 to September 2016. Training of team members consisted of a 6-month period of clinical shadowing with a senior anesthesiologist and co-staffing 8 liver transplant procedures before solo staffing a liver transplant. Specifically, patient outcomes for the first 5 transplants after this training were investigated. The only independent risk factor for early death or early graft loss was the amount of packed red blood cells administered during transplantation. With respect to secondary outcomes, the amount of packed red blood cells and hospitalization at the time of transplant were associated with the number of days on a ventilator, length of intensive care unit stay, and overall hospital length of stay. The results of this study conclude that the training model currently in place for our new team members has no negative impact on patient outcomes after liver transplantation.

Association Between Anesthesiologist Volume and Short-term Outcomes in Complex Gastrointestinal Cancer Surgery

Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes. To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery. This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded. Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point. The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders. Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates. This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.

A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade.

Although the package insert clearly states that "the safety and efficacy of sugammadex in pediatric patients have not been established," we hypothesized that sugammadex is used widely in pediatric anesthetic practice supplanting neostigmine as the primary drug for antagonizing neuromuscular blockade (NMB). Additionally, we sought to identify the determinants by which pediatric anesthesiologists choose reversal agents and if and how they assess NMB in their practice. Finally, because of sugammadex's effects on hormonal contraception, we sought to determine whether pediatric anesthesiologists counseled postmenarchal patients on the need for additional or alternative forms of contraception and the risk of unintended pregnancy in the perioperative period. We e-mailed a questionnaire to all 3245 members of the Society of Pediatric Anesthesia (SPA) requesting demographic data and attitudes regarding use of NMB agents, monitoring, and antagonism practices. To address low initial response rates and quantify nonresponse bias, we sent a shortened follow-up survey to a randomly selected subsample (n = 75) of SPA members who did not initially respond. Response differences between the 2 cohorts were determined. Initial questionnaire response rate was 13% (419 of 3245). Overall, 163 respondents (38.9%; 95% confidence interval [CI], 34.2-43.8) used sugammadex as their primary reversal agent, and 106 (25.2%; 95% CI, 21.2-30.0) used it exclusively. Respondents with ≤5 years of practice used sugammadex as their primary reversal agent more often than those with ≥6 years of practice (odds ratio [OR]: 2.08; 95% CI, 1.31-3.31; P = .001). This increased utilization remained after controlling for institutional restriction and practice type (adjusted OR [aOR]: 2.20; 95% CI, 1.38-3.54; P = .001). Only 40% of practitioners always assess NMB (train-of-four), and use was inversely correlated with years of practice (Spearman ρ = -0.11, P = .04). Anesthesiologists who primarily used sugammadex assess NMB less routinely (OR: 0.56; 95% CI, 0.34-0.90; P = .01). A slim majority (52.8%) used sugammadex for pediatric postmenarchal girls; those with less experience used it more commonly (P < .001). Thirty-eight percent did not discuss its effects on hormonal contraception with the patient and/or family, independent of anesthesiologist experience (P = .33) and practice location (P = .38). No significant differences were seen in demographics or practice responses between initial and follow-up survey respondents. Sugammadex is commonly used in pediatric anesthesia, particularly among anesthesiologists with fewer years of practice. Failure to warn postmenarchal adolescents of its consequences may result in unintended pregnancies. Finally, pediatric anesthesia training programs should emphasize objective monitoring of NMB, particularly with sugammadex use.

A case of the unanticipated difficult airway where bougie was used as a conduit over I gel as a rescue airway for one-lung ventilation under direct vision of fiberoptic bronchoscopy

The basic foremost step for any surgery done under general anesthesia is to place an endotracheal tube (ETT) into the trachea. Placement of a definitive airway is vital to maintain a critical level of oxygen in the end organ during apnea time. There are multiple ways revealed in the literature to place ETT into the trachea. Sometimes, placement can be achieved speedily at the critical time with the experience of anesthesiologist and availability of different airway adjutants. Here, we describe a case of ETT intubation using bougie as a conduit over I gel under direct vision of fiberoptic bronchoscopy in a thymic enhancing mass.

Experience as anesthesia resident in intensive care unit during COVID-19 pandemic

Anesthesiologists’ skills are successfully used in the process of distributing care in the COVID-19 pandemic. The first case of COVID-19 in India was reported on January 30, 2020. Since then, this disease placed the entire health system of the world under immense pressure. Approximately 4% of patients with coronavirus disease required ICU admissions. The government had canceled all elective procedures and ordered new ventilators and built new hospitals to meet this unprecedented challenge. The importance and the experience of anesthesiologists were greatly increased as they rose to the occasion and played an important role in handling the crisis. Residents were introduced to this new world of ICU. This time anesthesiologists acted as the specialized physicians with knowledge of the pathophysiology of organ systems both under normal and stress conditions. The virus is known to spread by aerosol or respiratory secretions of symptomatic patients where viral load is higher. So as health professionals, we were also at high risk; no matter how many precautions we took. Personal care of every affected person was very important. Management took proper care in providing us with all necessary paraphernalia for personal protection. The most significant emotional challenge was dealing with the families of the patients and making them understand that everything was done to offer their loved ones the best possible care.

Comparison of remifentanil consumption in pupillometry-guided versus conventional administration in children: a randomized controlled trial.

Remifentanil is a commonly used opioid analgesic during anesthesia in children. Objective measurement of pain is required for adequate dosing of remifentanil. We investigated whether pupillometry-guided remifentanil administration can reduce intraoperative consumption of remifentanil in children. We performed a single-blinded, prospective, randomized controlled trial from December 2018 through June 2019. Children who were 3-12 years of age and classified as having an American Society of Anesthesiologists physical status I-II and undergoing elective surgery under general anesthesia were included. Fifty-six fulfilled the inclusion criteria, and fifty-four completed the study. Participants were randomly assigned to either a pupillometry or conventional group. Patients in both groups received target-controlled infusion of remifentanil. In the pupillometry group, the adjustment of the remifentanil effect site concentration was determined by the pupillary diameter, whereas in the conventional group, the adjustment was based on the anesthesiologist's experience. Primary outcome was intraoperative remifentanil consumption, divided by patient weight and infusion time (ng kg-1 min-1). Remifentanil consumption was reduced by 25% in the pupillometry group compared to the conventional group (116.7±56.0 ng kg-1 min-1 vs. 155.8±64.9 ng kg-1 min-1, respectively; P=0.02). There were no differences in intra- and postoperative blood pressure and heart rate. The incidences of postoperative desaturation or nausea/vomiting were not significantly different. Pupillometry-guided remifentanil administration in children undergoing general anesthesia can reduce the intraoperative remifentanil consumption.

Airway management of a huge thyroid mass: A case report

In large thyroidal masses with excessive tracheal shift, the laryngeal opening is usually in the normal position and intubation may not be difficult. However, in some cases, such as retrosternal big thyroid glands, airway management can get challenging. Failure to successfully manage difficult airways is responsible for 30% of deaths attributed to anesthesia, with approximately 600 deaths annually. Successful awake intubation can be performed in 88-100% by considering the appropriate position and experience of anesthesiologist with a fiberoptic bronchoscope. However, the path to be followed should be determined according to each patient.