Airway Management: The Current Role of Videolaryngoscopy

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.

Assessing the concern for airway complications introduced by Wendler's glottoplasty

Objective

Wendler's glottoplasty (WG) is a pitch-elevating surgery performed by laryngologists providing gender-affirming care. The surgery creates an anterior glottic web that could theoretically cause airway concerns, either perioperatively or at the time of future procedures; such concerns are not well-described in the literature. We seek to assess surgeon opinions on airway concerns regarding WG.

Method

A survey of laryngologists assessing opinions on airway considerations in glottoplasty.

Results

A total of 19 physicians responded, representing approximately 193 surgeries. 52.6% performed glottoplasty and the remainder responded based on experience with anterior glottic webs. Two perioperative airway complications were reported, both mild stridor that did not prevent same-day discharge. No long-term sequela was reported. All surveyed laryngologists endorsed an altered general anesthetic approach for future procedures, with 73.7% advocating for use of a smaller endotracheal tube. 72.2% did not have "major concerns" about future intubations, and only 5.3% thought the immediate risk of airway compromise was a "real concern." 91.9% counsel their patients routinely but briefly on airway concerns. Open-ended comments conveyed themes of concern for post-operative disruption of the web more than of airway compromise.

Conclusion

Because glottoplasty is performed in the anterior glottis and does not significantly impact airway patency, the risk of serious airway complications appears to be minimal. Laryngologists believe future intubations require a modified approach with a smaller tube, partly due to concern for glottic web trauma. Based on this pilot study, the topic deserves greater work to standardize care and anesthetic alterations for patients with WG.

Level of Evidence

5.

Acute paraplegia after aneurysmal subarachnoid hemorrhage: Case report of a rare complication with a 2‑year follow‑up

The current overall incidence of subarachnoid hemorrhage (SAH) is ~9/100,000 individuals/year and rupture of an intracranial aneurysm is the main cause of SAH, accounting for ~85% of cases. Only a small number of cases of paraplegia after intracranial aneurysmal SAH have so far been reported and its pathogenesis has remained to be fully elucidated. The present study reports the case of a patient with an aneurysm localized in the medial and inferior lateral wall of the C5 segment of the right internal carotid artery that was treated by coil interventional embolization. The muscle strength of both lower extremities of the patient was grade I and grade 0 before and after the operation, respectively. Lumbar and thoracic magnetic resonance imaging examinations revealed slight hematoma in the subarachnoid space below the L2 level. At two weeks after the operation, the muscle strength of both lower extremities was grade II, while the muscle strength was grade III and grade V at 30 and 60 days after the operation, respectively.

Intracranial Hypotension Syndrome: The Importance of Neurointensive Care

Surgical procedures involving the spine can result in various complications, including vascular, nerve root and dura mater injury, surgical wound infection, and hematoma formation. Unintentional durotomy is a frequent complication of these procedures (up to 17%). Two clinical cases are reported in which the occurrence of epileptiform activity in the form of generalized tonic-clonic seizures after instrumentation of the dorsal and lumbar spine raised suspicion of cerebrospinal fluid (CSF) fistula. In both cases, the diagnostic suspicion and early approach allowed for the adoption of a timely medical and surgical plan, with the aim of reducing the volume of lost CSF as well as the potential neurological dysfunction resulting from this surgical complication.

The Tritube: Facilitating Upper Airway Surgery With an Ultrathin Cuffed Airway Device

The Tritube is a narrow-bore cuffed tracheal tube (outer diameter 4.4 mm and inner diameter ~2.4 mm) that permits effective alveolar gas exchange using flow-controlled ventilation. Constant gas flow delivers physiological minute volumes, within preset pressure limits, and applies suction to the airway during expiration. The technique has attracted interest for laryngotracheal microsurgery as it provides superior surgical exposure and avoids many of the complications associated with high-frequency jet ventilation. Cuff inflation protects the lower airway and produces a motionless operating field. We describe the structure of the device, discuss its benefits, and suggest how it should be used clinically.

Unexpected Bradycardia Related to Surgical Manipulation During Thoracolumbar Spinal Surgery

BACKGROUND

Although spinal surgery can offer pain relief and functional improvements in daily life, it is often associated with various perioperative complications. The incidence of cardiac complications associated with spinal surgery is relatively low. We evaluated frequency and causes for bradycardia incidents in posterior thorocolumbar spinal surgeries.

METHODS

We retrospectively evaluated posterior thoracolumbar spinal surgeries between 2018-2022 for bradycardic events in our tertiary general hospital. Patients operated for degenerative changes or disk herniations are included, other cases for tumors, trauma, arteriovenous (AV) fistulae or previously operated are excluded.

RESULTS

The study reached 6 eligible patients (4 female and 2 male) aged between 45-75 years (mean: 63.3) among 550 patients operated between 2018-2022. The rate of bradycardia was 1.09%. Of these, 5 patients (lumbar discectomy: one; posterior stabilization:4) exhibited it following L2 and L3 root manipulation and one presented it following L4-5 discectomy. In each of these cases, bradycardia occurred during surgical manipulation and ceased upon removal of the insult. None of the cases exhibited accompanying hypotension. The patient's heart rates were seen to drop to lowest the of 30 beats/min, and all patients exhibited favorable outcomes and no postoperative cardiac complications over a mean follow-up period of 20 months (range: 10-40 months).

CONCLUSIONS

The current study examines the occurrence of unexpected bradycardia events associated with thoracolumbar spinal surgery during surgical handling of the dura mater. Awareness of such incidents among surgeons and anesthesiologists can help prevent catastrophic outcomes caused by adverse cardiac events.

Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach

Transgender and gender-diverse (TGD) people endure numerous physical and mental health disparities secondary to lifelong stigma and marginalization, which are often perpetuated in medical spaces. Despite such barriers, TGD people are seeking gender-affirming care (GAC) with increased frequency. GAC facilitates the transition from the sex assigned at birth to the affirmed gender identity and is comprised of hormone therapy (HT) and gender-affirming surgery (GAS). The anesthesia professional is uniquely poised to serve as an integral support for TGD patients within the perioperative space. To provide affirmative perioperative care to TGD patients, anesthesia professionals should understand and attend to the biological, psychological, and social dimensions of health that are relevant to this population. This review outlines the biological factors that impact the perioperative care of TGD patients, such as the management of estrogen and testosterone HT, safe use of sugammadex, interpretation of laboratory values in the context of HT, pregnancy testing, drug dosing, breast binding, altered airway and urethral anatomy after prior GAS, pain management, and other GAS considerations. Psychosocial factors are reviewed, including mental health disparities, health care provider mistrust, effective patient communication, and the interplay of these factors in the postanesthesia care unit. Finally, recommendations to improve TGD perioperative care are reviewed through an organizational approach with an emphasis on TGD-focused medical education. These factors are discussed through the lens of patient affirmation and advocacy with the intent to educate the anesthesia professional on the perioperative management of TGD patients.

When a Tooth Pulls the Heart Strings: Takotsubo Cardiomyopathy Post-dental Extraction

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a temporary left ventricular dysfunction caused by a catecholamine surge under severe stress. It's characterized by chest pain, non-specific ECG changes, and left ventricular apical ballooning observed during catheterization. We present a case of a 59-year-old postmenopausal female with a past medical history of asthma who arrived at the ED complaining of chest pain following dental extraction. The patient's abnormal ECG findings and elevated cardiac enzymes required cardiac catheterization, which revealed normal coronary vasculature but demonstrated left ventricular apical ballooning. Transthoracic echocardiogram (TTE) showed septal left ventricular hypertrophy, decreased ejection fraction (EF), and akinetic segments consistent with takotsubo cardiomyopathy. Secondary takotsubo cardiomyopathy induced by stress in the setting of dental procedures like a tooth extraction for a periapical dental abscess is rarely described in the literature. Our case serves as a reminder of the potential for stress-induced cardiomyopathy in postmenopausal women, especially those with undiagnosed underlying anxiety disorders, even following minimally invasive procedures.

Functional Neurological Symptom Disorder: A Continuing Conundrum for the Perioperative Physician

Functional neurological symptom disorder (FNSD) or functional neurological disorder (FND) or conversion disorder, is a syndrome of neurological complications unexplained by neuropathology. The term FNSD or FND is now preferred, as conversion disorder is not an etiologically neutral term and is thus falling from use by researchers and clinicians in the field. We report a case of new-onset postoperative neurological deficit in a patient who had undergone uneventful general anesthesia for a urology procedure. Postoperatively, in the post-anesthesia care unit, the patient was found to be unable to move her upper and lower limbs. Organic pathology was excluded and a diagnosis of FNSD was made. Four weeks after the surgery, the patient was only able to ambulate with the help of a mechanical walker device. It is now suggested that procedures involving anesthesia are relatively common triggers for the development of FNSD. The occurrence of FNSD in the postoperative period is increasingly being attributed to the effects of anesthesia, the hypothesis being that it arises from the abreactive or dissociative effects of anesthetic agents. Another theory is the vulnerability of the anesthetized state which may evoke previous traumatic experiences. Psychiatric co-morbidities such as anxiety and depression may be seen in these patients. Preoperative psychological assessment may help identify patients at risk for FNSD. If postoperative neurological deficit occurs, detailed neurological, metabolic, and psychiatric assessments should be done with FNSD being a diagnosis of exclusion. We present this case to increase awareness regarding this uncommon condition which can cause significant distress to the patient and healthcare team. Management should comprise honest disclosure, reassurance of recovery, and reinforcement of alternative coping strategies. The development of preoperative screening tools may help identify patients at risk for this disorder.

Saddle pulmonary embolism in the setting of COVID-19 infection: A systematic review of case reports and case series

Saddle pulmonary embolism (SPE) is a rare type of pulmonary embolism that can lead to hemodynamic compromise causing sudden deaths. Due to a dearth of large prospective studies in this area, little is known regarding the epidemiology, and prognosis and factors affecting the latter for COVID-19-associated SPE. We aimed to describe COVID-19-associated SPE and quantify and compare mortality and factors affecting mortality among the cases. We included a total of 25 publications with a total of 35 cases. The average age was 45 ± 16.3 years with 11 females and 24 males. Dyspnoea (82.5%), orthopnoea (43.5%), and cough (43.5%) were the most common symptoms, and obstructive shock was present in five (21.7%) patients. The average reported oxygen (O₂) saturation was 85.8% ± 11.9 mm Hg. Hypertension (26.1%), diabetes (21.7%), and deep vein thrombosis (21.7%) were the most commonly reported comorbidities. Right heart strain was recognized in seven (30%) patients on electroencephalogram (S1QIIITIII) and 12 (52.2%) patients on echocardiogram. Anticoagulation, thrombolysis, and percutaneous intervention were tried in 21 (91.3%), 13 (56.5%), and 6 (26.1%) cases, respectively. Despite the aggressive management, 2 of 25 (8.7%) patients died in our smaller case report cohort. We conclude that despite aggressive management modalities, the mortality of SPE remains high in COVID-19.

Anesthetic Management of a Patient With McArdle Disease: A Case Report and Review of the Literature

McArdle disease (glycogen storage disorder type V) is a rare inherited condition resulting in impaired energy metabolism. Challenges in anesthetized patients with McArdle disease include hypoglycemia, rhabdomyolysis, myoglobinuria, acute renal failure, and postoperative fatigue. We review the literature and discuss a successful anesthetic that had no perioperative complications for a patient with McArdle disease undergoing robotic-assisted lung wedge resection. Preoperatively, we obtained a complete blood count, chemistry panel, and creatine kinase level. Intraoperatively, we proceeded with general endotracheal anesthesia and monitored point-of-care electrolytes, hemoglobin, and blood glucose. The patient had an uneventful postoperative recovery and was discharged home on postoperative Day 3. Patients with McArdle disease can undergo safe surgery with appropriate perioperative planning and a well-managed anesthetic. Efforts should focus on mitigating the risks of hypoglycemia, rhabdomyolysis, myoglobinuria, acute renal failure, and postoperative fatigue.

Thromboelastography with platelet mapping to guide anesthetic management of emergency cesarean delivery in a patient with thrombasthenia: a case report

BACKGROUND

Perinatal management of congenital platelet dysfunction represents a challenge. One of the major concerns is whether neuraxial anesthesia can be applicable for cesarean delivery. We present a patient with thrombasthenia who underwent emergency cesarean delivery.

CASE PRESENTATION

A 34-year-old primipara was diagnosed with autosomal dominant thrombasthenia, which was not classified as any known type. A thorough examination revealed that adenosine diphosphate aggregation and collagen aggregation were suppressed. Platelet mapping of viscoelastic testing was used to observe the trajectory of platelet function during pregnancy, which was found to be normal to hypercoagulable until 38 weeks of gestation. On the basis of the results of testing and physiological status, we commenced spinal anesthesia and avoided prophylactic platelet transfusion.

CONCLUSION

The platelet mapping of viscoelastic testing was rapid and simple, allowing repeated examinations. We could choose the appropriate anesthesia method and determine the necessity of blood transfusion for a pregnant patient with thrombasthenia.

Utility of Electrical Stimulation for Correct Placement and Neuromodulation of the Erector Spinae Plane Block for Total Shoulder Arthroplasty: A Case Report

The role of neuromodulation in fascial plane blocks is unknown. This case report presents a complex patient who underwent shoulder arthroplasty with a high thoracic-erector spinae plane (HT-ESP) catheter that provided electrical and chemical neuromodulation, highlighting the potential of electrical stimulation in the identification of and therapy at the fascial plane level.

Novel use of continuous pericapsular nerve group (PENG) block technique for traumatic superior and inferior pubic rami fractures: a case report

BACKGROUND

Pubic rami fractures are painful injuries more commonly seen in the elderly with osteoporosis after high velocity trauma. In the most cases, management is conservative and non-operative with the goal to provide optimal pain relief to facilitate early mobilization and hospital discharge. Unfortunately, opioids remain the mainstay analgesic option and regional anesthesia techniques are limited but may include lumbar epidural anesthesia.

CASE PRESENTATION

A female patient in her 80s presented to the emergency department of a level 1 trauma center following a high-speed motor vehicle collision. The patient suffered multiple non-life-threatening injuries. Notably, the patient was experiencing severe right groin and leg pain secondary to superior and inferior pubic rami fractures. Due to the severity of this pain, the patient was unable to mobilize or participate with physiotherapy. A lumbar epidural anesthesia technique was not deemed suitable and instead, we inserted a continuous pericapsular nerve group (PENG) block with a programmed intermittent bolus regimen. Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize.

CONCLUSION

Analgesia options are limited in pubic rami fractures. We present the first published case of a novel use of the PENG block with a continuous catheter technique for the analgesic management of a traumatic superior and inferior pubic rami fracture. The clinical utility of this technique in pubic ramus fractures warrants further clinical investigation.

Management of vagus nerve simulation therapy in the peri-operative period: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Vagus nerve stimulation is a well-established treatment option for patients with drug-resistant epilepsy and has an expanding range of other clinical indications. Side effects of vagus nerve stimulation therapy include: cough; voice changes; vocal cord adduction; rarely, obstructive sleep apnoea; and arrhythmia. Patients with implanted vagus nerve stimulation devices may present for unrelated surgery and critical care to clinicians who are unfamiliar with their function and safe management. These guidelines have been formulated by multidisciplinary consensus based on case reports, case series and expert opinion to support clinicians in the management of patients with these devices. The aim is to provide specific guidance on the management of vagus nerve stimulation devices in the following scenarios: the peri-operative period; peripartum period; during critical illness; and in the MRI suite. Patients should be aware of the importance of carrying their personal vagus nerve stimulation device magnet with them at all times to facilitate urgent device deactivation if necessary. We advise that it is generally safer to formally deactivate vagus nerve stimulation devices before general and spinal anaesthesia. During periods of critical illness associated with haemodynamic instability, we also advise cessation of vagus nerve stimulation and early consultation with neurology services.

Airway nerve blocks for awake tracheal intubation: A meta-analysis of randomized control trials and trial sequential analysis

STUDY OBJECTIVE

This systematic review and meta-analysis aimed to assess the superiority of airway nerve blocks versus airway anesthesia without nerve blocks for awake tracheal intubation (ATI).

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

SETTING

All studies that assessed the superiority of airway anesthesia technique for awake tracheal intubation were searched in PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase and Chinese databases (including China National Knowledge Infrastructure, Wanfang database, and VIP databases) and trial registry databases from their inception to December 2022.

PATIENTS

Adult patients included in randomized controlled trials comparing airway anesthesia with or without airway nerve blocks for ATI.

INTERVENTIONS

Airway nerve (including superior laryngeal nerve, glossopharyngeal nerve, or recurrent laryngeal nerve) blocks for ATI.

MEASUREMENTS

The primary outcome was the intubation time. Secondary outcomes were quality of intubating conditions (including patient reaction to placement of the flexible scope and tracheal tube, coughing and gagging, and patient satisfaction) and overall complications during ATI.

MAIN RESULTS

Fourteen articles with 658 patients were identified for analysis. When compared with airway anesthesia without nerve blocks, airway nerve blocks significantly reduced intubation time (standardized mean difference [SMD] -2.57, 95% CI -3.59- -1.56, p < 0.00001), improved anesthesia quality of ATI with higher no reaction to placement of the flexible scope and tracheal tube (relative risk [RR] 9.87; 95% CI 4.10-23.75, p < 0.00001), lower cough or gag reflex during intubation (RR 0.35, 95% CI 0.27-0.46, p < 0.00001), higher excellent patient satisfaction rate (RR 1.88, 95% CI 1.05-3.34, p = 0.03), and lower overall complications (RR 0.29, 95% CI 0.19-0.45, p < 0.00001). The overall quality of evidence was moderate.

CONCLUSIONS

Based on current published evidence, airway nerve blocks provide better airway anesthesia quality for ATI with a shorter intubation time, better intubation conditions including higher no reaction to placement of the flexible scope and tracheal tube, lower cough or gag reflex during intubation, higher excellent patient satisfaction, and lower overall complications.

Analgaesic efficacy of single-injection serratus anterior plane block for breast surgery: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials

There is conflicting evidence regarding the analgaesic efficacy of single-shot serratus anterior plane block (SAP) for breast surgery. This meta-analysis aimed to evaluate the analgaesic efficacy of SAP compared with non-block care (NBC) and other regional blocks, i.e. paravertebral block (PVB) and modified pectoral nerve block (PECS block) for breast surgery. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomized controlled trials reporting the use of the SAP block in adult breast surgery. The primary outcome was postoperative oral morphine equivalent (OME) consumption for up to 24 hours. Random-effects models were used to pool results and mean difference (MD), and odds ratio (OR) was calculated for continuous and dichotomous outcomes, respectively. GRADE guidelines were used to evaluate the strength of evidence, and trial sequential analysis (TSA) was performed to provide certainty to the conclusion. Twenty-four trials enrolling 1789 patients were included. Moderate strength evidence suggested that SAP provided a significant reduction in 24-hour OME compared with NBC [MD - 24.9 mg (95% CI - 41.54, -8.25; P < 0.001, I² = 99.68%)]. TSA ruled out the possibility of false-positive results. Subgroup analysis for the SAP demonstrated that the superficial plane approach was more effective in reducing opioid consumption than the deep approach. The odds of developing PONV were significantly lower in SAP compared to NBC. Compared with PVB and PECS, SAP block was not statistically different for 24-hour OME and time to first rescue analgaesia. Single-shot SAP reduced opioid consumption, prolonged analgaesia duration, lowered pain scores, and decreased the incidence of PONV compared to NBC. There was no statistically significant difference in the studied endpoints between SAP, PVB, and PECS blocks.

Infrared flashing light through the cricothyroid membrane as guidance to awake intubation with a flexible bronchoscope: A randomised cross-over study

BACKGROUND

In case of distorted airway anatomy, awake intubation with a flexible bronchoscope can be extremely difficult or even impossible. To facilitate this demanding procedure, an infrared flashing light source can be placed on the patient's neck superficial to the cricothyroid membrane. The light travels through the skin and tissue to the trachea, from where it can be registered by the advancing bronchoscope in the pharynx and seen as flashing white light on the monitor. We hypothesised that the application of this technique would allow more proximal and easier identification of the correct pathway to the trachea in patients with severe airway pathology.

METHODS

As part of awake intubation, patients underwent insertion of a flexible video bronchoscope via the mouth into the trachea. The procedure was performed twice, in random order in each patient, with and without the aid of the transcutaneous flashing infrared light. All insertions were video recorded to determine at which anatomical landmark within the airway the correct pathway was identified. The videos are accessible via this link: https://airwaymanagement.dk/infrared_comparative. The predefined landmarks were in successive order: oral cavity, oro-pharynx, tip of epiglottis, arytenoid cartilages, false cords, vocal cords and trachea, as well as the spaces between them.

RESULTS

Twenty-two patients had a total of 44 awake insertions with the flexible bronchoscope. The median anatomical level, at which correct identification of the trachea was obtained on the monitor, was, past the epiglottis, with the conventional technique, and at the level of the oropharynx, when using the infrared flashing light (p = .005). The time until the flashing light or the vocal cords were seen was 21 (22) S, mean (SD), and 48 (62) S, during the insertion with and without infrared flashing light activated, respectively (p = .005). Endoscopists rated it easier (p = .001) to recognise the entrance to the trachea in the infrared-group.

CONCLUSION

During awake intubation of patients with airway pathology, the application of trans-cricothyroid infrared flashing light to guide the insertion of a flexible bronchoscope significantly facilitated the recognition of the pathway into the trachea and the correct advancement of the flexible endoscope.

REGISTRATION OF CLINICAL TRIAL

NCT03930550.

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review

Introduction

Extracorporeal membrane oxygenation (ECMO) is widely used during refractory cardiac or respiratory failure, and some case reports described ECMO utilization in critical airway interventional therapy.

Methods

Eligible reports about patients receiving airway interventional therapy under ECMO were retrieved from Web of Science, Embase, Medline, and Cochrane databases up to 1 August 2022.

Results

Forty-eight publications including 107 patients who underwent ECMO for critical airway problems met the inclusion criteria. The critical airway problem that was reported the most was tumor-associated airway obstruction (n = 66, 61.7%). The second most reported etiology was postoperative airway collapse or stenosis (n = 19, 17.8%). The main interventional therapies applied were airway stent placement or removal (n = 61, 57.0%), mass removal (n = 22, 20.6%), and endotracheal intubation (n = 12, 11.2%) by bronchoscopy. The median ECMO duration was 39.5 hours. Eleven patients had ECMO-associated complications, including seven cases of airway hemorrhage, one case of arteriovenous fistula, one case of vein rupture and hematoma, one case of foot ischemia, and one case of neuropraxia of the cannulation site. In total, 91.6% of the patients survived and were discharged from the hospital.

Conclusion

ECMO appears to be a viable form of life support for patients undergoing interventional therapy for critical airway problems.

Venoarterial-extra corporeal membrane oxygenation-assisted parathyroidectomy for hypercalcemic crisis due to parathyroid carcinoma complicated by severe circulatory and respiratory failure: a case report

BACKGROUND

Hypercalcemia crisis is a rare but severe form of hypercalcemia complicated by multiple organ failure. Hypercalcemia crisis due to hyperparathyroidism is commonly caused by a parathyroid tumor, which often requires surgical resection. However, there are no clear recommendations on when the surgery should be performed.

CASE PRESENTATION

A 64-year-old female patient developed hyperparathyroidism due to a parathyroid tumor and hypercalcemic crisis, which was complicated by severe circulatory and respiratory failure refractory to medical therapy, and an emergent surgery was planned to resect the parathyroid tumor. To prevent intraoperative circulatory and respiratory collapse, venoarterial-extra corporeal membrane oxygenation (VA-ECMO) was introduced, resulting in a safe operation and anesthetic management.

CONCLUSIONS

In patients with hypercalcemic crisis complicated by severe circulatory and respiratory failure, induction of prophylactic VA-ECMO was useful for safe anesthetic management. Surgical resection should be performed as soon as the diagnosis is made before VA-ECMO is required.

Point-of-Care Ultrasound: A Moving Picture Is Worth a Thousand Tests

The effective utilization of point-of-care ultrasound may decrease the utilization of conventional diagnostic modalities. This review describes the various pathologies that can be effectively and rapidly identified with point-of-care cardiac, lung, abdominal, vascular airway, and ocular ultrasonography.

Fulminant Myocarditis and Cardiogenic Shock Following COVID-19 Infection Versus COVID-19 Vaccination: A Systematic Literature Review

BACKGROUND

Myocarditis, diagnosed by symptoms and troponin elevation, has been well-described with COVID-19 infection, as well as shortly after COVID-19 vaccination. The literature has characterized the outcomes of myocarditis following COVID-19 infection and vaccination, but clinicopathologic, hemodynamic, and pathologic features following fulminant myocarditis have not been well-characterized. We aimed to compare clinical and pathological features of fulminant myocarditis requiring hemodynamic support with vasopressors/inotropes and mechanical circulatory support (MCS), in these two conditions.

METHODS

We analyzed the literature on fulminant myocarditis and cardiogenic shock associated with COVID-19 and COVID-19 vaccination and systematically reviewed all cases and case series where individual patient data were presented. We searched PubMed, EMBASE, and Google Scholar for "COVID", "COVID-19", and "coronavirus" in combination with "vaccine", "fulminant myocarditis", "acute heart failure", and "cardiogenic shock". The Student's t-test was used for continuous variables and the χ2 statistic was used for categorical variables. For non-normal data distributions, the Wilcoxon Rank Sum Test was used for statistical comparisons.

RESULTS

We identified 73 cases and 27 cases of fulminant myocarditis associated with COVID-19 infection (COVID-19 FM) and COVID-19 vaccination (COVID-19 vaccine FM), respectively. Fever, shortness of breath, and chest pain were common presentations, but shortness of breath and pulmonary infiltrates were more often present in COVID-19 FM. Tachycardia, hypotension, leukocytosis, and lactic acidosis were seen in both cohorts, but patients with COVID-19 FM were more tachycardic and hypotensive. Histologically, lymphocytic myocarditis dominated both subsets, with some cases of eosinophilic myocarditis in both cohorts. Cellular necrosis was seen in 44.0% and 47.8% of COVID-19 FM and COVID-19 vaccine FM, respectively. Vasopressors and inotropes were used in 69.9% of COVID-19 FM and in 63.0% of the COVID-19 vaccine FM. Cardiac arrest was observed more in COVID-19 FM (p = 0.008). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for cardiogenic shock was also used more commonly in the COVID-19 fulminant myocarditis group (p = 0.0293). Reported mortality was similar (27.7%) and 27.8%, respectively) but was likely worse for COVID-19 FM as the outcome was still unknown in 11% of cases.

CONCLUSIONS

In the first series to retrospectively assess fulminant myocarditis associated with COVID-19 infection versus COVID-19 vaccination, we found that both conditions had a similarly high mortality rate, while COVID-19 FM had a more malignant course with more symptoms on presentation, more profound hemodynamic decompensation (higher heart rate, lower blood pressure), more cardiac arrests, and higher temporary MCS requirements including VA-ECMO. In terms of pathology, there was no difference in most biopsies/autopsies that demonstrated lymphocytic infiltrates and some eosinophilic or mixed infiltrates. There was no predominance of young males in COVID-19 vaccine FM cases, with male patients representing only 40.9% of the cohort.

Application of Intraoperative Electromyography Intelligent Monitoring in Orthopedic Surgery under General Anesthesia

To study the application of intraoperative EMG intelligent monitoring in orthopedic surgery under general anesthesia, a total of 53 patients who underwent orthopedic surgery from February 2021 to February 2022 were selected. The combined monitoring of somatosensory evoked potential (SEP), motor evoked potential (MEP), and electromyography (EMG) was used to analyze the monitoring efficiency. In 38 of the 53 patients, the intraoperative signal was normal, and there was no postoperative neurological dysfunction; one case had abnormal signal, and the abnormality still existed after debugging, but no obvious neurological dysfunction was found after operation; the remaining 14 cases had abnormal signal. There were 13 early warnings in SEP monitoring; 12 early warnings in MEP monitoring; 10 early warnings in EMG monitoring. There were 15 cases of early warning in the joint monitoring of the three, and the sensitivity of the combined monitoring of SEP + MEP + EMG was significantly higher than that of the single monitoring of SEP, MEP, and EMG (p < 0.05). There was no significant difference in specificity, positive predictive value, and negative predictive value between combined monitoring and single monitoring (p > 0.05). The combined monitoring of EMG, MEP, and SEP in orthopedic surgery can significantly improve the safety of surgery, its sensitivity and negative predictive value were significantly higher than the monitoring effects of the two alone.

Neuromodulation using a hybrid technique of combined perineural local anesthetic and nerve stimulation in six challenging clinical scenarios

PURPOSE

Postamputation pain is challenging because of complex mechanisms involving a multitude of pain pathways and psychological factors. This patient population also tends to have extensive comorbidities with or without a background of chronic pain. Electrical neuromodulation such as peripheral nerve stimulation has gained traction in the realm of chronic pain. Recently, the off-label use of hybrid perineural nerve stimulation in combination with locoregional block via the stimulating nerve block catheter has been described in single-center case reports.

CLINICAL FEATURES

Herein, we present a case series of six patients from two different Canadian hospitals using such a hybrid technique in three different clinical scenarios. These scenarios were (1) local anesthetic dose minimization in the presence of multiple nerve block catheters, (2) analgesia augmentation when local anesthetic alone is insufficient, and (3) provision of an analgesic adjunct as part of a multimodal regimen. A stimulating sciatic nerve block catheter was inserted under ultrasound and nerve stimulation guidance for these cases. Patients tended to experience pain on the subsequent postoperative days whereby the off-label use of nerve stimulation successfully reduced their pain score and stabilized or decreased their opioid consumption or minimized the need to increase the local anesthetic dose when doing so could have precipitated local anesthetic toxicity.

CONCLUSION

Our case series supports the feasibility of using a combination of low-frequency perineural stimulation and local anesthetic infusion via a single perineural nerve block catheter to manage challenging postamputation pain.

Comparison of TritubeTM Tube and Evone® ventilator use with traditional narrow-lumen tube use in microlaryngeal surgery cases

Comparison of TritubeTM Tube and Evone® Ventilator Use with Traditional Narrow-Lumen Tube Use in Microlaryngeal Surgery Cases ABSTRACT Introduction: Upper airway surgery involves certain difficulties, such as tumors located in the endotracheal area, narrowing of the tracheal lumen by the tumor, the use of a narrow lumen tube constantly increasing pressure. In the literature, difficult airway management has been successfully performed in patients intubated with Tritube™ and ventilated with Evone® (Ventinova Medical, Eindhoven, The Netherlands), and the benefits of these tools during laryngeal surgery have been reported. Objectives: To evaluate the feasibility and safety of the Tritube™ tube and Evone® ventilator and compare patients intubated using Tritube™ and ventilated with flow-controlled ventilation (FCV) using Evone® (TT–FCV group) to those intubated using a traditional microlaryngeal intubation tube and ventilated with volume-controlled ventilation (MLT-VCV group) in terms of perioperative parameters and outcomes during microlaryngeal surgery (MLS). Materials and Methods: After receiving their informed consent, 18 patients were randomly assigned to two groups. Patients older than 18 years, who were scheduled for elective MLS were included in the study. The patients’ demographic parameters, American Society of Anesthesiology physical status (ASA), Mallampati and Cormack-Lehane scores, duration of ventilation, duration of surgery, hemodynamic parameters, ventilation parameters, and complications were recorded. Results: When the intraoperative respiratory and hemodynamic parameters of the patients were compared between the two groups, the intraoperative cerebral oxygen saturation (SpO₂) (p=0.020), tidal volume (p=0.005), compliance of the respiratory system (p=0.001), and post-extubation SpO₂ (p=0.001) values were statistically significantly higher in the TT-FVC group compared to the MLT-VCV group. Right SpO₂ (p=0.038), left SpO₂ (p=0.047), and time to extubation (p=0.021) were statistically significantly lower in the TT-FVC group compared to the MLT-VCV group. Discussion: Low airway peak pressure and stable hemodynamics were achieved with Tritube™, and no complications were encountered in the perioperative period. At the end of the surgery, the cuff was lowered, high-frequency jet ventilation was applied, and extubation was safe performed (3). Although the literature on TritubeTM and Evone® is still limited, the use of these tools in MLS appears to be advantageous to achieve safe airway management. Keywords: Microlaryngeal surgery, Ventilation, Hemodynamics

Evaluation of Supraglottic Jet Oxygenation and Ventilation in 105 Patients During Bronchoscopy Using the Twinstream® Microprocessor-Controlled Jet Ventilator and the Wei Nasal Jet® Tube

BACKGROUND The Twinstream® ventilator is a microprocessor-controlled electric jet ventilator that allows the simultaneous application of 2 different jet streams, one at low frequency and one at high frequency to result in pulsatile bi-level (p-BLV) mode of ventilation. This study aimed to evaluate supraglottic jet oxygenation and ventilation in 105 patients during bronchoscopy using the Twinstream® microprocessor-controlled jet ventilator and the Wei Nasal Jet® (WNJ) tube. MATERIAL AND METHODS Patients were randomly divided into 2 parallel groups (N=50 per group): group W using the WNJ tube and group M using an endoscopic face mask connected to Twinstream® microprocessor-controlled jet ventilator under monitored anesthesia care. Arterial blood gas was examined and recorded 15 minutes after the initiation of procedure. The demographic and clinical characteristics, procedure duration, doses of anesthetics, and adverse events in the 2 groups were also recorded. RESULTS The arterial partial pressure of carbon dioxide (PaCO₂) (P=0.006) and lactic acid (P=0.001) were significantly lower, while pH (P=0.024) was significantly higher than in the group M. Pearson analysis showed that PaCO₂ was significantly correlated with ventilation tools (P=0.006) and procedure duration (P=0.003). Multiple linear regression analysis showed that ventilation tools and procedure duration were both independent influencing factors (P=0.006, P=0.002). CONCLUSIONS Supraglottic jet oxygenation and ventilation using the WNJ tube can reduce PaCO2 and had advantages in enhancing oxygenation and ventilation function in patients during bronchoscopy intervention therapy under monitored anesthesia care.

Successful Treatment of Complicated Influenza A(H3N2) Virus Infection and Rhabdomyolysis with Compassionate Use of IV Zanamivir

In 2019, EMA licensed intravenous (IV) zanamivir for severe influenza virus infection in children over 6 months as well as adults. Prior to that, it was possible via a compassionate use program. We present successful compassionate use of IV zanamivir in a 14-year-old female with severe influenza A(H3N2) and multi-organ failure, who had failed oral oseltamivir. Her illness was complicated by acute respiratory distress syndrome and rhabdomyolysis requiring extracorporeal membrane oxygenation and hemofiltration. Considering the broad safety margins with neuraminidase inhibitors, an adult dose of 600 mg IV BID was administered in this 60 kg patient. Influenza virus was cleared rapidly and undetectable on day 13. Creatine kinase (CK) values were dropping from 38,000 to 500 within nine days. Given the recent licensure of IV zanamivir, multi-center prospective observational studies in pediatric Intensive Care Unit patients would be beneficial to guide the most appropriate use of IV zanamivir in this vulnerable age group.

Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management.

METHODS AND ANALYSIS

PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases will be searched from inception to August 2022 to identify randomised controlled trials of elderly patients accepting PENG block for hip diseases. The primary outcome will be the pain intensity after pain management. Secondary outcomes will be quadriceps strength, perioperative rescue analgesia information and perioperative complications. Assessment of heterogeneity will be primarily inspected by forest plots. If there is no indication of funnel plot asymmetry, a random-effects meta-analysis will be performed. The Cochrane risk-of-bias tool, Grading of Recommendations Assessment, Development and Evaluation and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42022313895.

The role and pharmacological properties of P2Y12 receptor in cancer and cancer pain

The G protein-coupled P2Y12 receptor (P2Y12R) was cloned in platelets and found to play a key role in maintaining platelet function in hemostasis and thrombosis, and these effects could be mediated by the P2Y12R. However, it has recently been found that P2Y12R-mediated the progression of tumor through interactions between platelets and tumor and stromal cells, as well as through products secreted by platelets. During tumor progression, tumor cells or other cells in the tumor microenvironment (such as immune cells) can secrete large amounts of ATP into the extracellular matrix, and extracellular ATP can be hydrolyzed into ADP. ADP is a P2Y12R activator and plays an important regulatory role in the proliferation and metastasis of tumor cells. P2Y12R is involved in platelet-cancer cell crosstalk and become a potential target for anticancer therapy. Moreover, tumor progression can induce pain, which seriously affects the quality of life of patients. P2Y12R is expressed in microglia and mediates the activities of microglial and participates in the occurrence of cancer pain. Conversely, inhibiting P2Y12R activation and down-regulating its expression has the effect of inhibiting tumor progression and pain. Therefore, P2Y12R can be a common therapeutic target for both. In this article, we explored the potential link between P2Y12R and cancer, discussed the intrinsic link of P2Y12R in cancer pain and the pharmacological properties of P2Y12R antagonists in the treatment of both.

Anesthetic management of patients undergoing cardiac myxoma resection: a single-center retrospective analysis

Background

Myxomas are the most common primary cardiac tumors. Intracardiac myxomas, although benign, could cause serious consequences such as tricuspid or mitral valve obstruction, hemodynamic collapse, and acute heart failure, which pose challenges during anesthetic management. The current study was designed to summarize the anesthetic management of patients undergoing cardiac myxoma resection.

Methods

This study was performed retrospectively from the perioperative period of patients who underwent myxoma resection. Patients were divided into two groups according to whether the myxoma prolapsed into the ventricle (group O) or not (group N) to evaluate the impact of tricuspid or mitral valve with obstruction.

Results

110 patients, aged 17-78 years, undergoing cardiac myxoma resection between January 2019 and December 2021 were collected, and their perioperative characteristics were recorded. In the preoperative evaluation, common clinical symptoms included dyspnea and palpitation, whereas embolic events occurred in 8 patients, including 5 (4.5%) cerebral thromboembolic events, 2 (1.8%) femoral artery, and 1 (0.9%) obstructive coronary artery. According to the echocardiography, left atrial myxoma was detected in 104 (94.5%) patients, the average dimension of myxoma was 4.03 cm ± 1.52 cm in the largest diameter, and 48 patients were divided into group O. During intraoperative anesthetic management, hemodynamic instability occurred in 38 (34.5%) patients after anesthesia induction. More patients in group O had hemodynamic instability (47.9% vs. 24.2%, p = 0.009) than in group N. The mean postoperative length of stay in the hospital was 10.64 ± 3.01 days, and most of the patients made an uneventful postoperative recovery.

Conclusions

Anesthetic management for myxoma resection can be composed by assessing the myxoma, particularly the echocardiography evaluation and preventing cardiovascular instability. Typically, tricuspid or mitral valve with obstruction is a premier ingredient in anesthetic management.

Perioperative management of a parturient with VACTERL association for a caesarean section

A parturient with VACTERL association (vertebral defects, anal atresia, cardiac defects, trachea-oesophageal fistula, renal abnormalities and limb abnormalities) was listed for an elective caesarean section. She had a short neck with reduced cervical extension and flexion. Magnetic resonance imaging of her whole spine was performed which showed failure of cervical spine segmentation and cervical stenosis. Neuraxial blockade could have resulted in unpredictable spread of local anaesthetic due to the low volume of the spinal canal, and could have caused myelopathic changes within the spinal cord due to cerebrospinal fluid pressure changes. A general anaesthetic using a rapid sequence induction was also predicted to be challenging due to her fixed, unstable neck and severe cervical spine stenosis. After a multidisciplinary discussion Including neurosurgeons, we planned for awake tracheal intubation followed by general anaesthesia. However, before the date of her planned delivery, she required an urgent caesarean section due to severe preeclampsia. This was performed under general anaesthesia following uncomplicated awake tracheal intubation.