Intubation Research Articles

Airway management and ventilation strategy among obese adult patients: a comprehensive review and analysis

Background: Difficulties with mask ventilation and intubation are more prevalent in obese patients. Hence, health care practitioners engaged in airway management of obese individuals must exercise particular vigilance and care. Ventilation strategies can potentially have a detrimental impact on postoperative pulmonary function, prolong hospital stays, and increase costs. As a result, the aim of this review was to investigate airway management technique and ventilation strategies in obese adult patients. Methods: The PubMed, HINARI, Google Scholar, and Cochrane Review databases were searched using appropriate keywords and search engines for adequate evidence from studies meeting the inclusion criteria to reveal the endpoint, which was ventilation strategy and airway management in adult obese patients. Duplicate entries were eliminated through EndNote software. Screening of literature was conducted with proper appraisal checklist. This review was reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 statement. Results: The included literature covers a wide range of topics, including preoxygenation, making the patient in a 25° head-up position, use of 10–12cmH2O of positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP) during induction, placing the patient in a ramping posture during intubation, high-flow oxygenation (15 L/min) through the nasopharyngeal airway or nasal cannula during laryngoscopy, using low tidal volume during surgery, a 1:1/1.5:1 I:E ratio, PEEP of 10–20 cmH2O, Fio2 reduced to make SpO2 > 90, pressure-controlled (PC)/volume-controlled (VC) ventilation mode, and recruitment maneuver (RM). Following surgery, it was essential to provide oxygen therapy to maintain preoperative levels, provide CPAP/non-invasive positive pressure ventilation, place patients in semi-sitting positions, and provide thorough postanesthesia care unit monitoring in order to enhance patient outcomes with regard to morbidity and mortality among obese patients. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. Conclusions: Positioning the patient in a head-up position (semi-sitting), utilizing CPAP during preoxygenation, and administering oxygen via nasal cannula during intubation to prolong apnoea time and awake fibrotic for suspected difficult airway. Additionally, selecting appropriate ventilation modes (PC/VC), PEEP + RM, and positions during the intraoperative phase is crucial to improving outcomes in obese surgical patients.

Artificial intelligence in triage of COVID-19 patients

In 2019, COVID-19 began one of the greatest public health challenges in history, reaching pandemic status the following year. Systems capable of predicting individuals at higher risk of progressing to severe forms of the disease could optimize the allocation and direction of resources. In this work, we evaluated the performance of different Machine Learning algorithms when predicting clinical outcomes of patients hospitalized with COVID-19, using clinical data from hospital admission alone. This data was collected during a prospective, multicenter cohort that followed patients with respiratory syndrome during the pandemic. We aimed to predict which patients would present mild cases of COVID-19 and which would develop severe cases. Severe cases were defined as those requiring access to the Intensive Care Unit, endotracheal intubation, or even progressing to death. The system achieved an accuracy of 80%, with Area Under Receiver Operating Characteristic Curve (AUC) of 91%, Positive Predictive Value of 87% and Negative Predictive Value of 82%. Considering that only data from hospital admission was used, and that this data came from low-cost clinical examination and laboratory testing, the low false positive rate and acceptable accuracy observed shows that it is feasible to implement prediction systems based on artificial intelligence as an effective triage method.

Factors influencing confidence in tracheal intubation among neonatal trainees: A questionnaire-based study.

Tracheal intubation (TI) is pivotal in managing critically ill neonates. This study aims to investigate the disparities in exposure and training techniques that affect self-perceived confidence in neonatal fellows concerning TI. A comprehensive, structured questionnaire-based survey was conducted among neonatal trainees from October to November 2022. Self-perceived confidence in TI was evaluated using a Likert scale, ranging from 1 to 10. The trainees who scored below seven were categorised as under-confident, while those who scored seven or more were considered confident in TI. An analysis was done to assess the differences in exposure, training and clinical policies related to TI in both groups. A P-value <0.05 was considered significant. The final dataset consisted of 93 trainees. Confidence was higher among those who had independently performed TI on more than 30 neonates during their postgraduate training (relative risk (RR) 1.5 (1.03-2.1), P = 0.02) and super-specialty training (RR 1.5 (1.20-1.93), P = 0.0004). Confidence was also significantly associated with training programmes that incorporated written checklists for intubation instruments and policies (RR 1.4 (1.1-1.8), P = 0.006), conducted debriefing sessions after each TI attempt (RR 1.3 (1.03-1.6), P = 0.005), and implemented regular simulation programmes (RR 1.4 (1.1-1.8), P = 0.0006). Trainees with increased opportunities for intubation and training programmes featuring regular simulations and debriefing sessions tend to possess higher self-perceived confidence in TI.

Outcomes Associated With Airway Management of Adult Trauma Patients Admitted to Surgical Intensive Care.

Advanced airway management and ventilation of trauma patients are often needed during acute stabilization and resuscitation and later, in those admitted. In addition to endotracheal intubation for advanced airway management, tracheostomy is commonly used in critically ill patients when prolonged mechanical ventilation is required. However, the outcomes associated with airway management approaches and the timing of a tracheostomy in critically ill patients are mixed. This protocol intended to compare the effect of tracheostomy in major trauma patients vs. management with non-invasive techniques and endotracheal intubation during admission, examine complications and outcomes associated with the three types of airway management approaches, and explore the association of clinical and social determinants of health variables with complications in patients requiring advanced airway management. A total of 911 adult trauma patients admitted to a Level 1 trauma center surgical intensive care unit (SICU) were included in this retrospective, single-center, quantitative study from 2019 to 2021. Descriptive and correlational analyses were used to examine outcomes of ventilator days, length of stay, pneumonia, readmission, mortality, and associations with the airway management approach. The outcomes of ventilator days and length of stay were compared between groups with a one-way ANOVA, and differences between groups on outcomes of pneumonia, readmission, and mortality were estimated using crosstabulations and chi-square (x²) statistics. Hypothesized relationships of clinical and social determinants of health variables associated with outcomes of ventilator days, hospital length of stay, pneumonia, readmission, and mortality in patients requiring advanced airway management ≥ four days were estimated. There was no significant difference in outcomes of pneumonia and mortality between the advanced airway management groups (p=0.856 and p=0.167, respectively). There were significant differences in ventilator days, length of stay (LOS), and readmission. Between the groups: endotracheal intubation only, early (<10 days post-intubation) tracheostomy, and late (>10 days post-intubation) tracheostomy in SICU patients (p <0.001, p=0.028, and p=0.003, respectively). Specifically, patients in the early tracheostomy group had a higher readmission rate (33.3%) as compared to endotracheal tube patients (2.3%) and late tracheostomy patients (0.0%). Social determinants of health variables (smoking and functional dependence) were also significantly correlated with readmission in the early tracheostomy and endotracheal tube airway management groups (p=.047 and p=.022, respectively). Additionally, clinical variables of injury severity scores, ED arrival systolic blood pressure (SBP), and presence of pre-existing comorbidities were found to be significantly associated with complications of pneumonia, readmission, and mortality within the patients (n=229) requiring advanced airway approaches. Adult trauma patients with early tracheostomy airway management may experience a higher readmission rate related to the complexity of their injuries than patients managed with endotracheal intubation or late tracheostomy. Clinical and social determinants of health factors may be associated with complications. Further studies examining these associations in larger samples are needed to examine the validity of these findings.

High velocity nasal insufflation vs non-invasive positive pressure ventilation in the management of acute hypercapnic respiratory failure

ABSTRACT Introduction High-velocity nasal insufflation (HVNI) is a type of high-flow nasal cannula that depends on the dead-space clearance. HVNI utilizes small-bore nasal cannulae resulting in high velocity flow greater than the flow of the wider bore cannulae that were previously in use. Aim Assess the efficacy of high-velocity nasal insufflation in managing acute hypercapnic respiratory failure and compare between high-velocity nasal insufflations and noninvasive positive pressure ventilation (NIPPV) regarding efficacy and outcome in managing acute hypercapnic respiratory failure. Patients and Methods Over 12 months 48 patients admitted with a diagnosis of acute hypercapnic respiratory failure were enrolled in the study. Twenty-four patients were managed with HVNI, and the other 24 patients were managed with non-invasive ventilation. Patients were closely monitored in the respiratory intensive care unit (RICU). Oxygen saturation, respiratory rate, and Arterial Blood Gases (ABG) were measured before the start of treatment, then 1 hour, 4 hours, 2 days, and 3 days after treatment. Patients were allowed to crossover to the other arm of treatment or endotracheal intubation according to the clinical situation. Results pH, P Co2 levels showed similar changes in the two studied groups and improved with time. Treatment failure and mortality rates were also comparable in the two groups. Failure of treatment occurred in 16% in the group managed with HIVNI and in 33% in the group managed with NIPPV. Intubation at the end of 72 hourswas 16.7% in the group managed with HVNI and 25% in the group managed with NIPPV. Conclusion High velocity nasal insufflation is effective in managing acute hypercapnic respiratory failure. HVNI offers an effective way alternative to NIPPV in managing acute hypercapnic respiratory failure.

Posterior cricoid plate drill enlargement in idiopathic subglottic stenosis.

Idiopathic subglottic stenosis(ISS) is an airway stricture between larynx and trachea, within 1 cm from the vocal cords. Resection-reconstruction presents technical issues because of the need to resect the anterior portion of the cricoid cartilage, but not the posterior plate beyond which the recurrent laryngeal nerves access the vocal cords. The main surgical challenge consists of the minute airway caliber short below the cords, ensuing after the resection. We propose drill posterior cricoid plate molding to obtain antero-posterior and lateral amplification of the laryngo-tracheal anastomosis. This is a retrospective study of patients who underwent laryngo-tracheal resection with drill enlargement between January 2023 and June 2024. Laryngo-tracheal resection was performed according to Pearson. At this point airway caliber is gauged by endotracheal tubes of increasing size. To enlarge the air space, the inner surface of the posterior plate was molded by drill. Breathing, complications, voice and swallowing function were recorded. Our study includes 23 consecutive patients with ISS. No mortality described. Fifteen patients(65.2%) described voice alteration and 7(30.4%) experienced transient swallowing impairment. The mean operative time was 94.56(±28.72) min. All patients breathed well at discharge. Overall early success rate was excellent (no sequelae) in 7(30.4%) patients, and good(grade A: voice/breathing changes not influencing the quality of life; grade B: abnormal voice and shortness of breath, not hindering normal activities) in 15(65.2%). At the mean follow-up of 10.5 ± 5.5 months definitive success was achieved. This is the first study describing this technique. The results of our early experience with drill molding of the posterior cricoid plate are promising. It is an innovative, simple, safe, and effective method for subglottic airway enlargement in ISS, resulting in low post-operative complications, and in good to excellent results. Prot. n. Prot. n. C. 139/December 2023.

EVALUATION OF ETORPHINE-MEDETOMIDINE-MIDAZOLAMAZAPERONE FOR IMMOBILIZATION IN CAPTIVE PRONGHORN (ANTILOCAPRA AMERICANA).

Etorphine based immobilization protocols are reported to be effective in pronghorn; however, information on cardiorespiratory effects is limited. The objective of this study was to evaluate the efficacy and cardiopulmonary effects of etorphine, medetomidine, midazolam, and azaperone for immobilization in captive pronghorn. Additionally, the effects of endotracheal intubation and manual ventilation on cardiopulmonary variables were assessed. A combination of 5 mg etorphine, 10 mg medetomidine, 2.5 mg midazolam, and 5 mg azaperone was administered by hand or via dart to 10 pronghorn. Five pronghorn were endotracheally intubated once recumbent and manually ventilated. Oxygen at a flow of 6 L/min was supplemented to all animals. Induction and recovery times were recorded, and during recumbency vital parameters and arterial blood samples were collected. Time to lateral recumbency was 3.8 ± 1.25 min. Marked hypoxemia and hypercapnia was observed in both spontaneously breathing and manually ventilated pronghorn. Hypercapnia improved significantly in manually ventilated pronghorn compared to spontaneously breathing animals. All pronghorn recovered rapidly after reversal with 150 mg naltrexone and 30 mg atipamezole. Administration of etorphine, medetomidine, midazolam, and azaperone resulted in excellent chemical immobilization in pronghorn. Significant hypoxemia and hypercapnia occurred and oxygen supplementation, endotracheal intubation, and manual ventilation is recommended.

Successful Treatment of Unilateral Pulmonary Edema as Minimally Invasive Mitral Valve Surgery Complication—Case Presentation

Background/Objectives: In recent decades, the advantages of minimizing surgical trauma have led to the development of minimally invasive surgical procedures. While the benefits often outweigh the risks, several challenges are encountered that are not present in conventional surgical approaches. Unilateral pulmonary edema (UPE) after mitral interventions performed through a right-sided approach is a rare but potentially life-threatening event. Methods: We present the case of a 49-year-old patient who underwent endoscopic mitral valve repair. Immediately following ICU admission, the patient’s oxygen saturation suddenly dropped, and serous discharge was exteriorized from the endotracheal tube, with a thoracic X-ray revealing right-sided unilateral pulmonary edema. Results: The therapeutical course was complex. The patient developed hemodynamic instability, leading to cardiac arrest, which required cardiopulmonary resuscitation and the initiation of peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The endotracheal cannula was replaced with a right-sided double-lumen cannula, and the patient was placed on two ventilators operating independently. The patient was weaned off extracorporeal membrane oxygenation (ECMO) on the fifth day and extubated on the sixth postoperative day. Conclusions: We successfully treated this patient using ECMO and independent lung ventilation. Several cases have been described in the literature, but the pathogenesis and risk factors of UPE remain unclear. Management depends on the severity of UPE, but a deeper understanding of its underlying mechanisms could provide cardiac surgeons with enhanced strategies for preventing UPE and implementing timely interventions.

Effect of inspiratory and expiratory muscle training on respiratory function and decannulation outcome in patients with tracheostomy after stroke: a randomized controlled trial

ABSTRACT Background This study aimed to evaluate the clinical efficacy and safety of inspiratory and expiratory muscle training (IEMT) for patients who underwent tracheostomy after stroke. Methods The study was an investigator-initiated, single-center, two-arm, evaluator-blinded, randomized clinical trial conducted at West China Hospital of Sichuan University, China, from January 2022 to June 2022. The patients were randomly divided into the intervention group and control group. Patients in both groups received conventional clinical, rehabilitation treatment and usual care. The intervention group also received IEMT for three weeks. There were three primary outcomes including maximal inspiratory pressure (MIP, cmH2O), maximal expiratory pressure (MEP, cmH2O) and decannulation outcome after intervention (n, %). The secondary outcomes were other respiratory function outcomes, motor function, activities of daily living (ADL), quality of life (QoL) and the new pulmonary infection rate after the intervention at three weeks. Results A total of 50 participants were enrolled [25 in each group; 39 (78%) were men; mean (SD) age, 55.94 (11.97) years]. At three weeks, significant differences were found in the MIP [control vs IEMT: 39.04 (6.21) vs 56.28 (10.41), p < 0.001]; MEP [43.48 (5.36) vs 62.16 (10.18), p < 0.001], and tracheal tube extraction success rate [2 (8%) vs 9 (36%), p = 0.019] between the two groups. In addition, the new pulmonary infection rate in the intervention groups were significantly different (all p < 0.05) from those in the control group. Conclusions IEMT can improve respiratory function, decannulation outcome, among patients with tracheostomy after stroke.

In Vitro Comparison of Inspiration-Synchronized and Continuous Vibrating Mesh Nebulizer During Adult Invasive Mechanical Ventilation.

Background: Aerosol delivery may be enhanced by utilizing an inspiration-synchronized nebulization mode, where nebulization occurs only during inspiration. This study aimed to compare aerosol delivery of albuterol via a prototype of an inspiration-synchronized vibrating mesh nebulizer (VMN) versus continuous VMN during invasive mechanical ventilation. Methods: A critical care ventilator equipped with a heated-wire circuit to deliver adult parameters was attached to an endotracheal tube (ETT), a collection filter, and a test lung. The nebulizer was placed at the humidifier's inlet, inspiratory limb at the Y-piece, and between the Y-piece and ETT. Conventional VMNs producing standard size aerosol particles (Solo; Aerogen Ltd) were compared with prototype small-particle VMNs (Aerogen Pharma) in both inspiration-synchronization and continuous modes. In each run, 1 mL of albuterol (2.5 mg) was used (n = 5). The drug was eluted from the collection filter and assayed with UV spectrophotometry (276 nm). Results: The inhaled dose with inspiration-synchronization mode was 1.4 to 3.6 times that with the continuous mode, regardless of nebulizer positions (all p < 0.001). The small-particle VMN delivered an 8%-69% greater inhaled dose than the conventional VMN (Solo), regardless of the nebulizer placement or aerosol generation mode (all p < 0.001). The highest inhaled dose (50%-60%) with the inspiration-synchronized VMN was observed when it was placed at the ETT (all p < 0.001), whereas the continuous VMN performed better when positioned near the humidifier, with an inhaled dose of 21%-37% (p < 0.001). Conclusion: The inspiration-synchronized VMN delivered a greater inhaled dose than continuous VMN, irrespective of nebulizer placement. The prototype VMN producing smaller aerosol particles resulted in a greater inhaled dose than the conventional VMN (Solo), regardless of placement or aerosol generation modes. The inspiration-synchronized VMN achieved the highest delivery when placed close to the airway, whereas the continuous VMN delivered the most when positioned near the ventilator.

Estudio sobre la eficacia de un gel que contiene betametasona al 0,05 %, lidocaína al 2 % y tetracaína al 1 % para reducir el dolor de garganta, la ronquera, la tos y la tos en el tubo durante la salida de la anestesia.

Postoperative sore throat is a common complaint and an undesirable outcome. It is often a side effect of general anesthesia, reported by 30% to 70% of patients following tracheal intubation. Despite advancements in laryngoscopy equipment, postoperative sore throat remains a common issue, requiring additional pharmacological interventions and negatively affecting patient satisfaction. This highlights the continued need for effective strategies to tackle this challenge in clinical practice. This study is a retrospective cohort analysis involving 101 patients who underwent elective plastic surgery with orotracheal intubation under general anesthesia. The research compares the incidence of postoperative sore throat, hoarseness, and cough, as well as coughing upon emergence from anesthesia, between two types of lubricated endotracheal tubes: one coated with a gel containing 0.05% betamethasone, 2% lidocaine, and 1% tetracaine, and another with 2% lidocaine jelly. At the 8-hour mark after extubation, the incidence of postoperative sore throat was significantly lower in the experimental group at 17.6%, compared to 58% in the 2% lidocaine jelly group (P&lt;0.001). Over the 24-hour evaluation, the experimental group consistently showed a lower incidence of postoperative sore throat at all measured time points. The 2% lidocaine group had an OR 2.0 CI 95% (1.48-2.93), 2.28 CI 95% (1.54-3.3), and 2.4 CI 95% (1.64-3.5) for postoperative sore throat at post-anesthesia care unit, 8 hours and 24 hours after surgery evaluation respectively. Our research highlights the potential benefits of applying a gel that contains corticosteroids and local anesthetics to the tracheal tube. This application may help reduce postoperative complications associated with tracheal intubation, including sore throat, coughing, irritation from the tube, and hoarseness.

Comparison of Hemodynamic Responses to Ketofol versus Etomidate During Anesthesia Induction in Elderly Patients

Background: Nausea While elderly patients are at an increased risk of perioperative morbidity and mortality; old age alone is not a contraindication for surgery. General factors that should be considered in preoperative risk assessments include age, functional status, cognition, nutritional status, and comorbidities, such as cardiac, pulmonary, renal, and endocrine disorders. Induction of anesthesia is a critical step in surgery, particularly for elderly patients and those with a high physical status. Commonly used drugs for this purpose include etomidate and propofol. Therefore, this study aimed to compare the impact of Ketofol versus etomidate alone on the hemodynamic status of patients who fall under the ASA class II or higher. Methods: The study was a prospective randomized double-blind clinical trial, with a study population of age of ≥65 years, ASA physical status class II or higher, that were randomized into two groups. Ketofol (n=45) and, Etomidate (n=45) groups. Patients followed for clinical outcomes including their hemodynamic status during the induction period. Results: The present study showed that, the examination of hemodynamic parameters up to 10 minute after laryngoscopy showed that none of these parameters were significantly different between the two groups, while immediately after anesthesia induction, heart rate and blood pressure were found to be significantly different. However, there was no significant difference in terms of SPO2 among the two groups in any given interval. Conclusion: The results of the present study revealed that Ketofol resulted in better regulation and stability of blood pressure and heart rate in patients undergoing endotracheal intubation, compared to etomidate alone.

Use of the high-flow helmet CPAP non-invasive ventilation device designed in Peru in patients with severe acute respiratory syndrome (COVID-19): A prospective multicenter study

High-flow non-invasive ventilation (NIV) devices reduce the morbidity and mortality of COVID-19. The objective was to evaluate the use of the non-invasive ventilation device with high-flow helmet CPAP designed in Peru in patients with severe acute respiratory syndrome (COVID-19) hospitalized in the emergency services of five hospitals. Prospective multicenter and cross-sectional observational study from five hospitals from July to August 2020. 19 patients were recruited and divided into two groups (G-1 n = 10; G-2 n = 9) applying clinical and gasometric parameters as indicators of disease evolution upon hospital admission and within 24 hours. A progressive increase in these parameters was observed in those patients who used the NIVCPAP helmet within the first 24 hours. In G-01, improvement was evident in 90% (n = 9/10): PaO2 (range 48–137; average: 82.49 ± 8.07; p-value = 0.008), CO2 (25.2–51.0; 36.62 ± 2.62; p-value p = 0.327), and the PaO2/FiO2 coefficient (87–318; 191.5 ± 18.68). 10% of patients did not progress optimally, being subjected to endotracheal intubation and invasive mechanical ventilation. In G-02 the values ​​were %SatO2 (range 92–98; 96 ± 0.76) and the SaO2/FiO2 coefficient (214–228; 223.2 ± 1.80), indicating significant improvement within 24 hours (p &amp;lt; 0.001). It is concluded that the use of the CPAP helmet non-invasive ventilation (NIV) device contributes to improving gasometric values ​​and clinical condition. Being an alternative to recover typical cases of COVID-19 in all hospitals in Peru.

Comparison between Fentanyl, Clonidine and Dexmedetomidine for Awake Fiberoptic Intubation

Background: Currently Awake fibreoptic intubation- (AFOI) is the gold standard for the management of patients with an anticipated difficult airway. Various medications have been used to perform intubation during AFOI. The ideal drug for AFOI must provide comfort, cooperation, amnesia and hemodynamic stability along with maintenance of spontaneous respiration. The study aimed to compare fentanyl, clonidine and dexmedetomidine in providing favourable intubating conditions along with hemodynamic stability during AFOI. Methods: This prospective and randomized trial was carried out in 90 patients who were scheduled for elective surgery and required awake fibreoptic intubation. The patients were randomly divided into three different groups; Group A: Received Injection Dexmedetomidine-1ug/kg over 10 minutes; Group B: Received Injection Clonidine-2ug/kg over 10 minutes; and Group C: Received Injection Fentanyl- 2ug/kg over 10 minutes. Cough score, post-intubation score, Ramsay sedation score (RSS) and the changes in hemodynamic, were used to evaluate the effectiveness of the intubation condition and the results were then compared among the groups. Results: Demographic variables such as gender, age, weight and American Society of Anaesthesiologists-Physical Status ASA-PS (I/II) were comparable among the three groups and not statistically significant. The cough score and the post intubation score were lower in Group A. RSS was noted to be higher in Group A and there was a lower incidence of desaturation. Hemodynamic parameters were also favourable in Group A. Conclusion: Dexmedetomidine was found to be more effective than clonidine and fentanyl in those undergoing awake fibreoptic intubation. There were fewer adverse effects such as coughing, discomfort, oxygen desaturation, and intolerance to intubation.

Successful Awake Fiberoptic Intubation and Ultrasound Guided Epidural Placement in Anaesthesia Management of a Case of Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy involving spine and sacroiliac joints resulting in characteristic bamboo spine (fused and rigid spine). A 41yr old male patient with Ankylosing spondylitis with history of Left THR presented with periprosthetic fracture posted for ORIF with plating. He had a classical bamboo spine with cervical involvement, MPC- 3 and restricted neck mobility. Preoperative Ultrasound scan (USG) of lumbar region done to identify spinal spaces. Awake Fiberoptic Nasal intubation done to secure difficult airway and induction done with Propofol and Vecuronium. Epidural catheter inserted at L1-L2 space using paramedian approach under USG under General Anesthesia in lateral position and Epidural analgesia given with 1% Ropivacaine. Extubation was done uneventfully with Sugammadex 2mg/kg used as reversal at end of surgery. Anaesthetic challenges in AS were both difficult airway and difficult regional anesthesia which was successfully managed with detailed evaluation and planning with USG

Changes in hemodynamic parameters with different anaesthesia induction agents in elderly patients with coronary heart disease

Background. Coronary heart disease (CHD) is one of the most common diseases in Ukraine and worldwide. Open myocardial revascularisation procedures require general anaesthesia with endotracheal intubation. Prevention of peri-intubation hypotension in elderly patients with CHD is relevant today. The purpose was to improve the safety of surgery in elderly CHD patients by determining the induction schedule for anaesthesia with minimal cardiodepressant and vasodilator effects. Materials and methods. A cohort prospective randomized study of 40 patients with ASA III–IV who underwent off-pump coronary artery bypass grafting. Their mean age was 67.00 ± 5.78 years. The participants were divided into 2 groups based on the type of induction agent: group 1 — propofol 1.5 mg/kg, fentanyl 2.0 μg/kg; group 2 — propofol 1.5 mg/kg, fentanyl 2.0 μg/kg, ketamine 0.5 mg/kg. Relaxation: pipecuronium bromide 0.1 mg/kg. Hemodynamic parameters were recorded at the following stages: 1) upon arrival to the operating room; 2) before it; 3) after intubation; 4) 25 minutes after intubation. Results. After the administration of induction drugs, a significant difference was observed only in mean arterial pressure (MAP): group 1 — 72.71 ± 4.76 %, group 2 — 81.29 ± 5.4 % of the baseline, p = 0.0001. At the third stage, a statistically significant difference between the groups was determined in three indicators: MAP (86.74 ± 8.82 %, 92.34 ± 7.26 %; p &lt; 0.05), stroke volume index (SVI) (99.91 ± 2.94 %, 109.63 ± 8.16 %, p &lt; 0.05), cardiac index (CI) (96.63 ± 11.77 %, 110.38 ± 12.37 %, p &lt; 0.05). At the fourth stage, a statistical difference between the groups was observed in MAP (74.87 ± 7.90 % in group 1 vs. 86.47 ± 6.07 % in group 2, p &lt; 0.05), SVI (87.09 ± 5.30 % in group 1 vs. 108.21 ± 8.32 % in group 2, p &lt; 0.05), ejection fraction (88.26 ± 3.58 % in group 1 vs. 106.89 ± 6.22 % in group 2, p &lt; 0.05), CI (79.59 ± 10.11 % in group 1 vs. 108.29 ± 9.95 % in group 2, p &lt; 0.05), systemic vascular resistance index (91.13 ± 9.34 % in group 1 vs. 77.86 ± 9.83 % in group 2, p &lt; 0.05). Conclusions. The addition of ketamine to the classic combination of propofol and fentanyl increases the effectiveness and reduces the percentage of possible potential complications by stabilizing hemodynamics during anaesthetic support for coronary artery bypass grafting in older patients with CHD.

Comparaison of effectiveness of flexible intubation fibersocope versus bonfils fiberoscope in tracheal intubation of paediatrics with midfacial hypoplasia

ABSTRACT Background Airway management is one of the fundamental skills of an anesthesiologist. When compared to adult patients, the pediatric patients have notable anatomical and physiological variations. These variations affect the methods and equipment the anesthesiologist will select to provide safe airway management. Purpose The purpose of the study aimed to compare the effectiveness of first intubation attempt while utilizing flexible intubation fiberoscope versus Bonfils fiberoscope in tracheal intubation of pediatrics with midfacial hypoplasia. Also, to estimate time to first intubation attempt, time to endotracheal insertion and to assess the occurrence of complications. Methods This randomized controlled trial was conducted over 30 children (aged 6 month up to 5 years) with midfacial hypoplasia planned to undergo elective surgery while under general anesthesia. The children were categorized in random to two equal groups: group I intubation was with Karl Storz flexible intubation fiberoscope 3.7 mm via AirQ-ILA, while group II intubation was with Storz Bonfils fiberoscope 3.5 mm. Success of first attempt of intubation, time to first attempt of intubation, time to endotracheal insertion, number of intubation attempt, complications were recorded. Results No notable variations were observed in the success of first attempt of intubation between the two groups. The time to first attempt of intubation and the time to endotracheal tube insertion were significantly less in group II than in group I where p > 0.001. Regarding the number of intubation attempt and the occurrence of complications, the two groups did not significantly differ from one another where p = 1.000. Conclusion The Bonfils fiberoscope and the flexible intubation fiberoscope are both appropriate tools for intubating pediatrics with midfacial hypoplasia. However, Bonfils fiberoscope was superior with regard to the time to first attempt of intubation and the time to endotracheal tube insertion.

Radiology resident proficiency in identifying misplaced lines, tubes, and devices: a simulation-based study using WIDI SIM.

Accurate placement of medical devices is crucial in critical care to prevent severe complications. This study aims to evaluate radiology residents' proficiency in identifying four specific critical misplacements of medical devices using the Wisdom in Diagnostic Imaging Simulation (WIDI SIM). A retrospective analysis was conducted on 1,102 responses from radiology residents who participated in the WIDI SIM between 2010 and 2022. The majority were first- and second-year residents from multiple institutions. The simulation presented four specific cases featuring misplacements of an endotracheal tube in the esophagus, an intrauterine device embedded in the myometrium, a peripherally inserted central catheter in the right internal jugular vein, and an umbilical venous catheter in the splenic vein. Residents provided free-text interpretations scored on a 0-10 scale by subspecialty radiologists. Errors were categorized as observational (failure to identify misplacement) or interpretive (misinterpretation of identified misplacement). Statistical analyses were performed using Kruskal-Wallis and Dunn's multiple comparisons tests. Across all cases, residents' average scores did not meet the acceptable standard of 7 points. Observational errors were predominant, indicating a failure to recognize these specific device misplacements. Effective report rates were low: 58% for the endotracheal tube case, 35% for the intrauterine device, 19% for the peripherally inserted central catheter, and 25% for the umbilical venous catheter. Significant performance improvements were observed between first- and second-year residents in three of the four cases (p-values ranging from < 0.0001 to 0.0238), but overall proficiency remained suboptimal even among senior residents. This study reveals gaps in radiology residents' ability to identify these specific misplaced lines, tubes, and devices accurately. The consistent pattern of underperformance, primarily due to observational errors, suggests a need for targeted educational interventions to improve resident proficiency in this aspect of emergency radiology.

Does the TruBlue Laser Set Microlaryngoscopy Equipment on Fire? A Systematic Evaluation.

The risk of fire during laser microlaryngoscopy is well known. However, limited information is available about fire risk with the novel TruBlue laser. This study systematically evaluates its interactions with common surgical supplies, offering valuable insights into safety considerations for surgeons. We used experimental conditions to test the extent to which TruBlue laser energy produces smoke, perforation, or fire in Rüsch®, Medtronic™ and microlaryngeal endotracheal tubes and in surgical pledgets. Only the Microlaryngeal Tube (MLT) caught fire. Notably, it happened only when the laser fiber shifted on the tube's surface. Smoke emerged solely from the laser fiber applied to the Medtronic™ shaft and only during continuous contact mode. Cuff perforation and smoke emanating from the shaft occurred in three-quarters of the Rüsch® trials. The pledgets' radiopaque segment exhibited a greater combustibility than other segments (p < 0.01). In many of the pledget trials, faster smoke emission occurred with shorter laser-to-target distances (p < 0.05). Water-soaked pledgets displayed a reduced rate of smoke production (p < 0.01) and string division. The Medtronic™ tube assures remarkable safety with a nonignitable shaft and low cuff ignition. The MLT poses the highest ignition risk. Cuff perforation risk is mitigated by maintaining a 0.3-cm distance from the laser fiber tip. Pledget fire risk is mitigated by positioning the radiopaque part away from the laser beam and by soaking the pledget with water. Laser division of the pledgets' string was common. NA Laryngoscope, 2024.

Cesarean section with operation on placental support as an adapted EXIT procedure for fetal thyroid goiter: A case report and literature review.

The ex-utero intrapartum treatment (EXIT) procedure is a specialized delivery strategy that extends utero-placental-fetal circulation to convert a potential neonatal emergency condition into a condition that is compatible with postnatal life. Cesarean section with operation on placental support is an EXIT technique that requires a relatively short duration of placental support and few skilled medical personnel and specialized instruments; it can successfully treat selected fetal indications. In the present study, we report a case of fetal thyroid goiter as an example of a fetal anomaly requiring the procedure. We then review all cases published in the medical literature that were similar to our procedure (15 cases including our new case). Twelve (80%) cases of fetal anomalies and three prophylactic cases of extremely low birth weight were delivered using a procedure adapted from the standard EXIT procedure. All 12 cases of fetal anomalies were treated by airway intervention. In 12 of the 15 cases (80%), direct laryngoscopy and endotracheal intubation were attempted; intubation was successful in seven of these 12 cases (58%). There was only one case of postpartum hemorrhage caused by uterine incisional bleeding, with a consequence of delayed hysterotomy closure. In summary, cesarean section with operation on placental support is a promising alternative delivery technique for neonates with airway obstructive lesions, especially in resource-limited settings.