General Endotracheal Anesthesia Research Articles

Effect of use of cuffed endotracheal tubes on the occurrence of postoperative extubation-related respiratory adverse events in pediatric patients with airway hypersensitivity: a retrospective cohort study.

Whether endotracheal tube (ETT) configuration (cuffed or uncuffed) influences the occurrence of respiratory adverse events (RAEs) in patients at risk remains largely unknown. We investigated the effects of cuffed ETTs on RAE occurrence after extubation in pediatric patients with airway hypersensitivity. Children aged < 8years with increased airway hypersensitivity (defined as upper airway symptoms, recent upper respiratory infection within 2weeks, or a history of asthma) who underwent general endotracheal anesthesia with inhaled agents between January 2021 and December 2022 were included. We retrospectively examined the patients' background and intraoperative anesthesia conditions by comparing the cuffed and uncuffed ETT groups. Multiple logistic regression analysis was performed to estimate the association between ETT configuration (cuffed vs. uncuffed) and the occurrence of RAEs or respiratory interventions (laryngospasm, peripheral capillary oxygen saturation < 92%, oxygen supplementation, epinephrine inhalation, or reintubation) after extubation. Cuffed ETTs were used in 163 patients and uncuffed ETTs in 143 patients. Apart from the frequency of upper airway surgery and intraoperative fluid balance, no significant differences in background characteristics were observed between the groups. RAEs after extubation were observed in 36 (22.1%) and 28 (19.6%) patients in each cuffed and uncuffed ETT groups. After adjusting for known RAE risk factors, no difference was observed in RAEs or respiratory interventions after extubation between both groups (odds ratio, 1.14; 95% confidence interval: 0.64, 2.06). In pediatric patients with airway hypersensitivity, the use of cuffed ETTs did not increase the occurrence of RAEs or respiratory interventions after extubation.

Safety and efficacy of the Tao facemask for positive pressure ventilation in morbidly obese patients

Purpose: Positive-pressure mask ventilation is an essential skill for individuals providing basic and advanced airway interventions in a variety of clinical settings. The C-E grip technique is most commonly used with standard facemasks to provide an effective seal that allows for positive pressure ventilation. The Tao mask is a novel facemask that utilises an ergonomic grip by using downwards pressure of the palm of the hand accompanied by midline jaw lift. Specifically, the technique to create a seal involves downwards pressure of the palm centred on the mask accompanied by a jaw lift with four fingers centred under the mandible. A previous comparison between the Tao and standard masks revealed superior performance across a cross-section of average patients. The purpose of this study was to evaluate the safety and effectiveness of the Tao mask compared to the standard mask in a subset of patients with morbid obesity as defined by a body mass index (BMI) greater than or equal to 40 kg/m2. Methods: This prospective crossover trial included 156 patients aged ⩾18 years at the Medical University of South Carolina who were scheduled for elective surgery under general endotracheal anaesthesia with a BMI of ⩾40 kg/m2 at the time of surgery. After the induction of general anaesthesia, but prior to the administration of a neuromuscular blocking drug (NMBD), each patient was ventilated with both the standard and Tao masks, and effectiveness was measured using both the Han and Warters scales. The process was repeated after the administration of an NMBD. Results: Data were collected and analysed from 153 individuals. The mean BMI was 50.7 ± 9.3 kg/m2. The Tao mask ventilation scores were significantly lower (more effective) than the standard mask scores on both the Han and Warters Scales before pre-NMBD ( p = 0.0002 and p &lt; 0.001, respectively) and after post-NMBD ( p = 0.002 and p &lt; 0.001, respectively). On the Warters Scale, it was significantly easier to ventilate with the Tao Mask pre-NMBD ( p = 0.0001). On the Han Scale, the Tao mask was significantly easier than the standard mask post-NMBD ( p = 0.03). With regard to mask sequence, the mean Warters scores were lower for the Tao mask pre-NMBD only when the standard mask was used first ( p = 0.002). Similarly, the difference in the mean Warters scores post-NBMD was significant only when the standard mask was used first ( p = 0.02). Conclusion: The Tao mask demonstrated equivalent safety and superior effectiveness in ventilating morbidly obese surgical patients despite a trial design that favoured the standard mask owing to anaesthetist experience. The use of the Tao mask may be particularly beneficial in clinical situations involving inexperienced operators or in patients for whom mask ventilation is likely to be difficult. ClinicalTrials.gov registration number: NCT03473366

Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features.

Background/Objectives: Prediction of a difficult airway during pre-anesthetic evaluation is of great importance because it enables an adequate anesthetic approach and airway management. As there is a scarcity of prospective studies evaluating the role of anthropometric measures of the face and neck in predicting difficult airways in infants with an apparently normal airway, we aimed to identify the aforementioned predictors of difficult facemask ventilation and intubation in infants. Methods: A prospective, observational study that included 97 infants requiring general endotracheal anesthesia was conducted. Anthropometric and specific facial measurements were obtained before ventilation and intubation. Results: The incidence of difficult facemask ventilation was 15.5% and 38.1% for difficult intubation. SMD (sternomental distance), TMA (tragus-to-mouth angle distance), NL (neck length) and mouth opening were significantly lower in the difficult facemask ventilation group. HMDn (hyomental distance in neutral head position), HMDe (hyomental distance in neck extension), TMD (thyromental distance), SMD, mandibular development and mouth opening were significantly different in the intubation difficulty group compared to the non-difficult group. HMDn and HMDe showed significantly greater specificities for difficult intubation (83.8% and 76.7%, respectively), while higher sensitivities were observed in TMD, SMD and RHSMD (ratio of height to SMD) (89.2%, 75.7%, and 70.3%, respectively). Regarding difficult facemask ventilation, TMA showed greater sensitivity (86.7%) and SMD showed greater specificity (80%) compared to other anthropometric parameters. In a multivariate model, BMI (body mass index), COPUR (Colorado Pediatric Airway Score), BOV (best oropharyngeal view) and TMA were found to be independent predictors of difficult intubation, while BMI, ASA (The American Society Physical Status Classification System), CL (Cormack-Lehane Score), TMA and SMD predicted difficult facemask ventilation. Conclusions: Preoperative airway assessment is of great importance for ventilation and intubation. Patient's overall condition and facial measurements can be used as predictors of difficult intubation and ventilation.

Couvelaire Syndrome: A Case Report and Literature Review

Introduction. Couvelaire syndrome is a rare complication of pregnancy involving the placenta and the uterine wall. It is caused by placental abruption, preeclampsia, or other disorders that compromise the blood supply to the placenta. Diagnosis is typically made through history, clinical evaluation, and ultrasound. This study aims to report a grave case of Couvelaire syndrome complemented by presenting a review of the relevant literature, to aid the meaning of a clinical path, as well as early and adequate diagnosis and treatment of Couvelaire syndrome, to prevent feto-maternal consequences. The treatment of Couvelaire syndrome depends on the severity of the condition and the well-being of both the mother and the fetus. If the condition is severe and poses a risk to the mother or fetus, immediate delivery may be recommended, mainly with urgent Cesarean section in general endotracheal anesthesia. If there is significant blood loss leading to a decrease in hemoglobin levels, blood transfusions may be necessary to restore normal blood volume and oxygen-carrying capacity. Part of the general treatment plan should also be the management of the underlying cause of placental abruption, for example, in cases of preeclampsia, medications are prescribed to control blood pressure and prevent seizures.

REDUCING RESPIRATORY VARIATIONS IN INTERNAL JUGULAR VEIN CROSS-SECTIONAL AREA USING PEEP AND TRENDELENBURG POSITION

Introduction: The respiratory cycle influences the size of the right internal jugular vein (RIJV). We evaluated the changes in RIJV size during the respiratory cycle in patients on positive pressure ventilation. Additionally, we investigated the impact of positive end-expiratory pressure (PEEP) and the Trendelenburg position on these respiratory fluctuations. Methods: The study involved 24 patients who underwent general endotracheal anesthesia. Images of the right internal jugular vein (RIJV) were captured in the supine position (baseline, S0) and during three randomized maneuvers: applying a positive end-expiratory pressure (PEEP) of 10 cmH2O (S10), positioning the patient in a 10° Trendelenburg tilt (T0), and combining the Trendelenburg tilt with PEEP (T10). The aim was to measure the cross-sectional area (CSA), anteroposterior diameter, and transverse diameter of the RIJV at both its smallest and largest observed sizes during each maneuver. Results: The study found that all maneuvers significantly reduced the fluctuation in the size of the right internal jugular vein (RIJV) (p = 0.0004). Specifically, compared to the supine position (S0), the maneuvers resulted in the following decreases in the cross-sectional area (CSA) from the smallest to the largest observed sizes: • S0: Decrease by 28.3% • S10: Decrease by 8.5% • T0: Decrease by 8.0% T10: Decrease by 4.4% Additionally, compared to S0, the combination of a 10° Trendelenburg tilt position with a positive end-expiratory pressure (PEEP) of 10 cmH2O significantly increased the CSA: • In the largest observed areas by 83.8% • In the smallest observed areas by 169.4% These findings suggest that the Trendelenburg tilt combined with PEEP was particularly effective in increasing the CSA of the RIJV, both at its largest and smallest observed sizes, compared to other maneuvers and the baseline supine position. Conclusions: A 10° Trendelenburg tilt position combined with a PEEP of 10 cmH2O not only increases the size of the RIJV but also reduces fluctuation by the respiratory cycle.

Hoarseness after general endotracheal anesthesia: A single-center retrospective analysis

BackgroundAfter the extubation of endotracheal tubes or removal of laryngeal masks in patients who underwent general anesthesia, complications such as hoarseness often occur, potentially leading to serious adverse effects on patients. Therefore, this study aimed to analyze the causes of hoarseness to provide improved prevention and treatment options. MethodsWe conducted a retrospective analysis of patients who underwent general anesthesia at the Renmin Hospital of Wuhan University from January 2017 to December 2021, excluding patients under 18 years of age, over 80 years old, with preoperative hoarseness and undergoing multiple surgeries. The incidence, duration, influencing factors and causes of hoarseness after tracheal intubation were analyzed. ResultsThe study found that the incidence of hoarseness after tracheal intubation was 11.77%. Of those patients experiencing hoarseness immediately after the operation, 79.56% could recover on the same day, 15.37% of patients could recover on the day after operation, 4.23% could recover within 3 days of the operation, and 0.83% of patients might need 5 or more days to recover. Patients aged 50 years and older, with an intubation time of more than 3 h, who underwent neck and cardiothoracic surgery, with a low BMI and with difficult airways exhibited a higher incidence of hoarseness after tracheal intubation. The main causes of hoarseness were vocal cord paralysis and arytenoid joint dislocation, with the number of patients at 8.97% (1106) and 7.32% (902) respectively. The incidences of hoarseness caused by psychological stress accounted for 4.15% of the cases. with a total of 512 patients affected. ConclusionsAge, intubation time, surgical site, low BMI and difficult airway were important factors affecting hoarseness after intubation. The vocal cord paralysis and arytenoid joint dislocation were major causes of hoarseness.

Inadequate Spinal Anesthesia in Lumbar Spine Surgery Is Related to Volume of the Thecal Sac

Spinal anesthesia (SA) is used in lumbar surgery but initial adequate analgesia fails in some patients. In these cases, spinal redosing or conversion to general endotracheal anesthesia is required, both of which are detrimental to the patient experience and surgical workflow. We reviewed cases of lumbar surgery performed under spinal anesthesia from 2017 - 2021. We identified 12 cases of inadequate first dose, then selected 36 random patients as controls. We used a measurement tool to approximate the volume of the dural sac for each patient using T2-weighted sagittal MRI sequences. Patients who had an inadequate first dose of anesthesia had a significantly larger dural sac volume, 22.8 ± 7.9 cm3 in the inadequate dose group, and 17.4 ± 4.7 cm3 in controls (p=0.043). The inadequate dose group was significantly younger, 54.2 ± 8.8 years in failed first dose, and 66.4 ± 11.9 years in control (p=0.001). The groups did not differ by surgical procedure (p=0.238), level (p=0.353), ASA score (p=0.546), or co-morbidities. We found that age, larger height, and dural sac volume are risk factors for an inadequate first dose of SA. The availability of spinal MRI in patients undergoing spine surgery allows the preoperative measurement of their thecal sac size. In the future, this data may be used to personalize spinal anesthesia dosing based on individual anatomic variables and potentially reduce the incidence of failed spinal anesthesia in spine surgery.

Risks of peri- and postoperative complications with glucagon-like peptide-1 receptor agonists.

To assess whether adults with diabetes on oral hypoglycaemic agents undergoing general endotracheal anaesthesia during nine common surgical procedures who are glucagon-like peptide-1 receptor agonist (GLP1-RA) users, compared with non-users, are at increased risk of six peri- and post-procedure complications. A retrospective observational cohort analysis of over 130 million deidentified US adults with diabetes (defined as being on oral hypoglycaemic agents) from a nationally representative electronic health dataset between 1 January 2015 and 1 April 2023 was analysed. Cohorts were matched by high-dimensionality propensity scoring. We compared the odds of six peri- and postoperative complications in GLP1-RA users and non-users. A sensitivity analysis compared these odds in GLP1-RA users to non-users with diabetes and obesity. We measured the odds of (a) a composite outcome of postoperative decelerated gastric emptying, including antiemetic use, ileus within 7 days post-procedure, gastroparesis diagnosis, gastric emptying study; (b) postoperative aspiration or pneumonitis; (c) severe respiratory failure; (d) postoperative hypoglycaemia; (e) inpatient mortality; and (f) 30-day mortality. Among 13 361 adults with diabetes, 16.5% were treated with a GLP1-RA. In the high-dimensionality propensity score-matched cohort, GLP1-RA users had a lower risk of peri- and postoperative complications for decelerated gastric emptying and antiemetic use compared with non-users. The risk of ileus within 7 days, aspiration/pneumonitis, hypoglycaemia and 30-day mortality were not different. A sensitivity analysis showed similar findings in patients with diabetes and obesity. No increased risk of peri- and postoperative complications in GLP1-RA users undergoing surgery with general endotracheal anaesthesia was identified.

Modified Mallampati Test in Supine versus Sitting Position as a Predictor for Difficult Intubation – An Observational Study

Abstract Background: The modified Mallampati test (MMT) is routinely employed to predict difficult laryngoscopy and tracheal intubation. This test, as a standard, when conducted with a patient in a sitting position, exhibits limited practicality due to its relatively low sensitivity and specificity in predicting difficult tracheal intubation (DTI). It is hypothesised that MMT, when performed with a patient lying supine, may improve its efficacy as a predictor of DTI. Methods: This single-centre prospective observational study was conducted involving 455 adult patients requiring general endotracheal anaesthesia. During preanaesthetic evaluation, MMT was performed in the sitting position as a standard (sitting MMT). Subsequently, independent observers recorded the MMT in the supine position (supine MMT) before administering general anaesthesia. The sitting and supine MMT were correlated with Cormack and Lehane grades using the Chi-square test. Diagnostic performance metrics, including the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive predictive values (PPV) and negative predictive values, were employed to assess the predictive capabilities of MMT in both positions. Results: Out of 455 patients, 72 (15.8%) experienced difficult intubation (defined as Cormack–Lehane Grade III and above). Both MMT in the sitting and supine positions demonstrated strong predictive capabilities for DTI, with areas under the ROC of 0.799 and 0.779, respectively. While sitting in the MMT position exhibited higher sensitivity (55.6% vs. 28.8%), supine MMT demonstrated a superior PPV (86.1% vs. 55.6%). Conclusion: MMT, when conducted with a patient in a supine position emerges as an alternative and a reliable predictor for predicting DTI.

Ultrasound Evaluation of Anterior Neck Soft-Tissue Thickness to Predict Difficult Intubation in Overweight Adult Patients Posted for Surgery under General Endotracheal Anesthesia – An Observational Study

Background: Ultrasonographic imaging has been recently become simple portable and non-invasive adjuvant for bedside assessment of anterior neck soft tissue thickness which when measured at different levels showed to have significant role in predicting difficult laryngoscopy. Aims and Objectives: Primary objective was Ultrasonographic measurement of anterior neck soft tissue thickness at 3 levels -Distance from skin to hyoid bone (DSHB) -Distance from skin to thyrohyoid membrane (DSTM) -Distance from skin to anterior commissure of vocal cord(DSAC) and to compare and correlate the findings with Cooks modification of Cormack-Lehane score in predicting difficult laryngoscopy. Secondary objective was to compare and correlate the ultrasonographic measurements with conventional airway assessment methods. Materials and Methods: After obtaining approval from the ethical committee, 90 Patients with BMI above 25 kg /m2 was enrolled for the study. A day before the surgery a thorough Preanaesthetic evaluation and assessment of the airway is done using conventional methods. Then on the day of surgery ultrasonographic measurement of anterior neck at 3 levels was done and after inducing the patients laryngoscopy was done and Cooks modification of Cormack-Lehane score assessed. Results: The optimal cut off values to predict difficult laryngoscopy was 1.26, 2 and 1.2 cms for DSHB, DSTM and DSAC respectively, and among the three skin to anterior commissure of vocal cord was observed to be best USG parameter with more area under the ROC curve. Conclusion: USG measurement of anterior neck soft tissue thickness can be useful in predicting difficult laryngoscopy in overweight and obese patients also it had more diagnostic accuracy than conventional methods like MMS in predicting difficult laryngoscopy.

Effects of operating room ventilation on particle exposure and removal during general endotracheal anesthesia

The operating room (OR) ventilation system is a primary method for reducing particle exposure in the OR. However, most ventilation studies in operating rooms were conducted using computational fluid dynamics (CFD) models, which may not be able to predict the complexity of real operating conditions. In this study, we recruited 40 patients undergoing general endotracheal anesthesia in a total of 13 operating rooms. We tested the effectiveness of OR ventilation on mitigating patient and nebulizer-generated particles during the preoxygenation, induction, and intubation phases of care. Sampling locations were selected close to the patient's face (reference), physician's head area, and medical assistant's standing location. A total of six sampling sessions characterizing patient and healthcare worker activities were included. We observed a significantly higher number of particles during endotracheal intubation compared to preoxygenation with deep breathing and coughing, suggesting potential disruptive effect of surgical activities (i.e., intubation) on airflow, which affected particle concentration. Particle decay rates measured at all three locations (reference 50 ± 20 h-1; physician 46 ± 22 h-1; medical assistant 33 ± 21 h-1) were considerably higher than the regulated operating room air exchange rate of 20 h-1, indicating highly effective overall ventilation function. Nevertheless, healthcare workers should still be cautious about particle exposure risks in operations that generate large number of particles. Results from this study reflect the effectiveness of OR ventilation on particle mitigation in real-world scenario and may facilitate the validation of future CFD studies as well as the establishment of effective OR regulation guidelines to protect healthcare workers from particle exposures.

Anestezija za kraniotomiju u budnom stanju - principi izvođenja

Awake craniotomy is a neurosurgical procedure that is used for the safe removal of intracranial lesions near Broca's and Wernicke's speech areas. During this procedure, speech mapping is done. Its use demands anesthesia for awake craniotomy, which includes different possibilities for the management of anesthesia with awake patients at the moment of tumor removal. There are two widely accepted concepts: "awake-awake-awake", when the patient is consciously sedated ("awake") throughout surgery, with lighter or deeper sedation (monitored anesthesia care), or "asleep-awake-asleep", when the patient is introduced into general endotracheal anesthesia while opening the skull, but is awake during lesion removal and asleep during closure. Our protocol is a form of "asleep-awake" concept, with general endotracheal anesthesia for craniotomy and awake patients during and after lesion removal (including skull closure).

Effect of oral clonidine premedication on perioperative hemodynamics and postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A prospective randomized double-blind placebo-controlled clinical trial

Abstract Background: Laryngoscopy, endotracheal intubation, and creation of pneumoperitoneum during laparoscopic cholecystectomy cause sympathetic stimulation manifesting as hypertension, tachycardia, arrhythmia, and myocardial ischemia. Methods: We undertook this study to determine the effect of oral clonidine premedication on perioperative hemodynamics, postoperative pain, and sedation for patients undergoing laparoscopic cholecystectomy. In this double-blinded randomized controlled trial, 100 American Society of Anesthesiologists Grades I and II patients scheduled for laparoscopic cholecystectomy were randomized into 2 groups to receive 100 μg tablet clonidine in Group I and ranitidine 150 mg tablet in Group II (control group) 90 min before induction of general endotracheal anesthesia. Effect on hemodynamic parameters, duration of analgesia, requirement of rescue analgesic, and sedation score was assessed. Data were expressed as mean ± standard deviation or number (proportion). Unpaired t-test and Chi-square test were applied wherever indicated. P &lt; 0.05 was considered statistically significant. Results: Patients in the clonidine group had lower systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate values as compared to control group at all measured time intervals (P &lt; 0.05). The duration of analgesia was prolonged in the clonidine group (256.6 ± 34.97 min vs. 103.4 ± 10.94 min, P = 0.000). Total amount (88.50 ± 29.11 mg vs. 165.00 ± 30.31 mg, P = 0.000) and number of doses (1.18 ± 0.39 vs. 2.20 ± 0.40, P = 0.000) of rescue analgesic requirement in 1st 24 h postoperative period were also lesser in clonidine group. The sedation score was higher in clonidine group just after extubation (2.24 ± 0.43) as compared to the placebo group (1.92 ± 0.40, P = 0.000) at 1 h of postoperative period. Conclusion: Premedication with 100 μg clonidine provides stable hemodynamics against stress response triggered by the creation of pneumoperitoneum, laryngoscopy, and endotracheal intubation in patients undergoing laparoscopic cholecystectomy and also prolongs the duration of postoperative analgesia with reduced requirement of rescue analgesics without causing prolonged postoperative sedation.

Characteristic dynamic functional connectivity during sevoflurane-induced general anesthesia

General anesthesia (GA) during surgery is commonly maintained by inhalational sevoflurane. Previous resting state functional MRI (rs-fMRI) studies have demonstrated suppressed functional connectivity (FC) of the entire brain networks, especially the default mode networks, transitioning from the awake to GA condition. However, accuracy and reliability were limited by previous administration methods (e.g. face mask) and short rs-fMRI scans. Therefore, in this study, a clinical scenario of epilepsy patients undergoing laser interstitial thermal therapy was leveraged to acquire 15 min of rs-fMRI while under general endotracheal anesthesia to maximize the accuracy of sevoflurane level. Nine recruited patients had fMRI acquired during awake and under GA, of which seven were included in both static and dynamic FC analyses. Group independent component analysis and a sliding-window method followed by k-means clustering were applied to identify four dynamic brain states, which characterized subtypes of FC patterns. Our results showed that a low-FC brain state was characteristic of the GA condition as a single featuring state during the entire rs-fMRI session; In contrast, the awake condition exhibited frequent fluctuations between three distinct brain states, one of which was a highly synchronized brain state not seen in GA. In conclusion, our study revealed remarkable dynamic connectivity changes from awake to GA condition and demonstrated the advantages of dynamic FC analysis for future studies in the assessments of the effects of GA on brain functional activities.

Modified anterior approach versus traditional posterior approach for ultrasound-guided superior laryngeal nerve block in awake endotracheal intubation: a randomized non-inferiority clinical trial

Study objective This study was undertaken to compare the effect of the modified ultrasound-guided anterior superior laryngeal nerve block (SLNB) with the traditional ultrasound-guided posterior SLNB in providing intubation conditions during awake tracheal intubation (ATI) in patients without difficult airway. Design Randomized, assessor-blind. Registration number: ChiCTR2200058086. Setting West China Hospital of Sichuan University, Chengdu, China. Patients 104 patients aged 18–65 years, of American Society of Anesthesiologists status I-III, posted for elective general surgery with general endotracheal anesthesia. Interventions The patients were randomized into two groups (modified group, n = 52; traditional group, n = 52). Modified anterior SLNB or traditional posterior SLNB was performed under ultrasound guidance. Measurements The primary outcome was the proportion of acceptable intubation condition (AIC), which was analyzed in both per-protocol (PP) and intention-to-treat (ITT) populations. The prespecified non-inferiority margin was −4.8%. Secondary outcomes included intubation success rate on the first attempt, hemodynamic parameters during ATI, time taken for airway anesthesia and intubation, recall of intubation, patient perception of comfort, and incidence and severity of postoperative complications. Main results In the PP population, the proportion of AIC in the modified group was 49/49 (100%) and that in the traditional group was 49/49 (100%), absolute difference 0, lower limit of 1-sided 95% CI, −0.3%. In the ITT population, the primary outcomes in the modified and traditional group were 52/52 (100%) and 51/52 (98.1%), respectively, with an absolute difference of 1.9% and a lower limit of 1-sided 95% CI of −1.2%. The non-inferiority of modified ultrasound-guided anterior SLNB was confirmed in both populations. Conclusions Among adults without difficult airways during videolaryngoscope-assisted ATI, the modified ultrasound-guided anterior SLNB, compared to the traditional posterior approach, showed a statistically non-inferior effect in terms of providing AIC.

QUALITY OF LIFE OF A PATIENT AFTER ENDARTERECTOMY OF THE INTERNAL CAROTID ARTERY (ICA) FOLLOWINGAN ACUTE ISCHEMIC STROKE (AIS) DURING COVID-19

The aim of the study was to evaluate the quality of life of a patient af- terendarterectomy (CEA) of the Internal Carotid Artery (ICA) following an Acute ischemic stroke (AIS) during COVID-19.A right-handed, 51-year-old patient, a visual artist, single, in good health and no chronic illnesses to date, became infected with SARS-CoV-2 and contracted COVID-19. The presence of SARS-CoV-2 virus was confirmed by a RT PCR antigen test. The patient was hospitalized, and required mechanical ventilation at an Intensive Care Unit (ICU) before an acute ischemic stroke (AIS) onset. Except for untreated hypertension, her medical history was unremarkable. Her blood pressure was 180/100 mm Hg; her pulse was 76 beats per minute and was regular. AIS from the left middle cerebral artery (MCA) has resulted primarily in damage to the left hemisphere, and secondary effects on the right side resulting in body weakness and mild anomic aphasia. Magnetic resonance imaging (MRI) confirmed stroke and detected brain tissue damaged by an AIS. It revealed hyperintense foci in the T2 and FLAIR sequences, 21 mm in size in the left hemisphere of the brain. In search of the cause of AIS, CT angiography was performed. It revealed a large (90%) ICA occlusion. The patient was admitted to the emergency room at the Vascular Surgery Clinic with an Endovascular Subunit. The revascularization procedure (CEA) was performed under general endotracheal anesthesia with the use of the protocol and techniques (elaborated at the Department of Vascular Surgery and Endovascular Procedures, The John Paul II Hospital in Krakow). The CEA procedure improved her general health: she regained the ability to name objects and her HRQOL also improved in her perception. The improvement achieved was statistically significant. She returned to painting and functions well in society.The patient’s perception of HRQoL measured by the SF-36 domains was better after the CEA: a significant improvement in self-reported overall health has occured. The HRQoL outcome measures may be valuable in future clinical trials of comparing different methods of treatment offered after AIS.

Efficacy of Dexmedetomidine Combined with Bupivacaine in Supraclavicular Block Versus Bupivacaine alone in Upper Limb Surgery

Objective: To compare the efficacy of Dexmedetomidine combined with Bupivacaine in supraclavicular block versus Bupivacaine alone in upper limb surgeries&#x0D; Study Design: Quasi-experimental study&#x0D; Place and Duration Of Study: Anaesthesia Department, Combined Military Hospital Quetta, Pakistan, from Sep to Feb 2022.&#x0D; Methodology: Patients planning to undergo plating of radius fractures were included. The patients were divided into two equal sets (n=20) by purposive sampling and marked as Group-A and Group-B. Patients in both groups received supraclavicular block under ultrasound guidance and general endotracheal anaesthesia followed by that. In the first Group,Bupivacaine plain (0.125%) was used to block the brachial plexus, and in the second Group, Bupivacaine (0.125%) with adjuvant Dexmedetomidine (1ug/kg) was given respectively. The visual analogue scale was used to measure pain perception in both groups. &#x0D; Results: The duration of analgesia in the Dexmedetomidine Group was 10 ±0.925 hours and 5.68 ±0.471hours in Bupivacaine Group, which holds statistical significance (p-value&lt;0.001). The demographics, surgery-related parameters (duration and type of surgery), block related parameters (onset of block and time taken to block) were similar in both study groups.&#x0D; Conclusion: We concluded that Dexmedetomidine prolongs the duration of analgesia significantly when used as an adjuvant Bupivacaine in supraclavicular brachial plexus block.

Remimazolam as an Adjunct to General Anesthesia in Children: Adverse Events and Outcomes in a Large Cohort of 418 Cases.

Remimazolam was first approved in 2020 as a general anesthetic for adults and still does not have pediatric labeling. Our study will be the first pilot program that administers remimazolam as an adjunct to a general endotracheal anesthetic in children. Between August 2020 and December 2022, electronic medical records were collected for all children who received remimazolam during anesthesia. The remimazolam dosing regimen was extrapolated from the adult package insert, with intravenous induction doses of 12 mg/kg/h administered until the desired effect was achieved. Subsequent infusions were given at a rate of 1-2 mg/kg/h, accompanied by intermittent boluses of 0.2 mg/kg, with all dosing adjustments made according to the anesthesiologist's clinical discretion. A total of 418 children (mean 4.6 yrs, 68.7% ASA 1 and 2) underwent surgeries which averaged 81.2 min. A total of 75.2% of patients had greater than a 20% change (increase or decrease) in MAP (lowest or highest) from baseline, and 203 (49.3%) patients had greater than a 30% change (increase or decrease) in MAP (lowest or highest) from baseline. A total of 5% received ephedrine to treat unanticipated hemodynamic variability. Discharge criteria were met within an average of 13.8 min after arrival at the post-anesthesia care unit. Remimazolam may offer the benefits of rapid recovery following general endotracheal anesthesia. The risk of hemodynamic variability which necessitates and responds to ephedrine should be anticipated.

PERIOPERATIVE CONCERNS OF VENTRICULOATRIAL SHUNT - A RETROSPECTIVE ANALYSIS OF 40 CASES

Background: Ventriculo -peritoneal [VP] shunt is the most commonly used cerebrospinal uid (CSF) diversion procedure for the management of hydrocephalus. However, when the absorption of CSF from the peritoneum is defective, it results in abdominal distension with CSF ascites. In such cases, an alternate diversion procedure - the ventriculo-atrial [VA] shunt – may be performed. However, this procedure is also associated with several perioperative problems like arrhythmias, air embolism and infection. Materials and methods: A retrospective analysis of 40 cases on the perioperative concerns of VA shunt procedures, performed in our institute, was done. Indication of the shunt, preoperative status &amp; work -up, intraoperative adverse events &amp; management and immediate post-operative complications were assessed. Out of the 40 patients, there were 25 male Results: s and 15 females and there were a total of 12 paediatric patients. Blocked shunt, abdominal infection and CSF ascites were common indications for VA shunt. All patients received general endotracheal anaesthesia with preoperative hypovolemia correction. Intraoperative tachycardia and arrhythmia were noted. Various Conclusion : preoperative concerns like distended abdomen and compromised respiration increase risk of VA shunt procedures. A better understanding of the underlying disease pathology and anticipation of related complications along with cautious and meticulous management can help prevent most of the complications of VA shunt procedure and thereby improve outcome

Lateral Decubitus Positioning For Shoulder Arthroscopy

Background: Lateral decubitus positioning is a frequently employed technique to perform shoulder arthroscopy. Proper patient positioning and equipment setup is crucial to ensure a safe and efficient surgery. Indications: The common indications for performing a shoulder arthroscopy in the lateral decubitus position include anterior shoulder stabilization, posterior shoulder stabilization, superior labrum anterior to posterior (SLAP) repair, diagnostic arthroscopy for internal impingement, and arthroscopic capsular release for adhesive capsulitis. Technique Description: After undergoing general endotracheal anesthesia in the supine position on a standard operating room table, the patient is rotated into the lateral decubitus position with the operative arm facing upward. The patient’s head is supported with a pillow to ensure a neutral position. The nonoperative arm is flexed forward and rests on a padded arm board. The sides of a bean bag are applied to the patient’s torso to maintain the lateral decubitus position, and the bean bag is deflated to remain rigid. An axillary roll is placed under the axilla, and foam pads are placed below the “down leg” and between both legs. A commercial arm jack is positioned on the anterior, proximal side of the operating room table to allow for 20° of shoulder abduction, which maximizes the glenohumeral joint space. Results: Advantages of the lateral decubitus position over the beach chair position include improved access to the anterior, inferior, and posterior glenoid; more ergonomic positioning for the operating surgeon; lower risk for patient cerebral hypoperfusion; and reduced rates of recurrent instability following arthroscopic stabilization in comparison to procedures performed in the beach chair position. Disadvantages of the lateral decubitus position include risk of traction-related neurovascular injury, requirement of an arm suspension device, and increased difficulty in rotating the shoulder intraoperatively. Discussion/Conclusion: Lateral decubitus positioning is commonly used to achieve a circumferential view of the glenohumeral joint in shoulder arthroscopy. This surgical position yields several advantages for the operating surgeon and has been shown to be associated with improved clinical outcomes after shoulder instability surgery. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.