Use of a urinary catheter as a guidewire to facilitate safe nasotracheal intubation following iatrogenic retropharyngeal perforation

Nasotracheal intubation facilitates adequate access for surgical procedures in the oral cavity, is not limited by mouth opening and can be better tolerated by patients in intensive care. Complications of nasotracheal intubation can include epistaxis, turbinate injury and sinusitis. Retropharyngeal submucosal perforation by the tracheal tube has also been infrequently reported. Here, we report a case of difficult nasotracheal intubation resulting in retropharyngeal submucosal perforation in a patient with a history of obstructive sleep apnoea listed for uvulopalatopharyngoplasty. To facilitate successful tracheal re-intubation, we used a soft urinary catheter via the other nostril. In this report, we discuss the reasons why this complication may have occurred, how submucosal perforation could be avoided, and reflect on our management of this rare complication. Difficult nasotracheal intubation can present unique challenges, and airway management plans should be made accordingly.

Association between Preoperative hs-crp/Albumin Ratio and Postoperative sirs in Elderly Patients: A Retrospective Observational Cohort Study

OBJECTIVES

Systemic inflammatory response syndrome (SIRS) is one of the severe postoperative complications in elderly patients and seriously affects their prognosis and survival rate. Heretofore, there have been no reliable and accurate methods to predict postoperative SIRS in elderly patients. The aim of this study was to determine whether increased preoperative hs-CRP/albumin ratio (CAR) was associated with postoperative SIRS in elderly population.

METHODS

The data of patients aged ≥ 65 years who underwent general anesthesia in two centers of Third Affiliated Hospital of Sun Yat-sen University between January 2015 and September 2020 were retrieved and analyzed. Based on the perioperative dataset, we used the targeted maximum likelihood estimation (TMLE) to estimate the association between preoperative CAR and postoperative SIRS in elderly population. Patients' CAR was calculated and divided into two groups (< 0.278 and ≥ 0.278) according to its normal range in our hospital. Adjusted odd ratios (aORs) and 95% confidence intervals (CIs) were calculated respectively. Further sensitivity analyses were conducted to evaluate the robustness of the results.

RESULTS

A total of 16141 elderly patients were accessed and 7009 of them were enrolled in the final analysis, and 1674 (23.9%) patients developed SIRS within 3 days after surgery. Compared with non-SIRS patients, patients with SIRS had a significantly longer postoperative hospitalization, higher cost and higher risk of in-hospital mortality. Compared with patients with preoperative CAR < 0.278, we found that CAR ≥ 0.278 had a significantly higher risk for the development of postoperative SIRS after multivariable adjustment [aOR = 1.27; 95% CI (1.21, 1.33)]. The interaction effect of preoperative CAR ≥ 0.278 and SIRS was stronger among patients with the following characteristics: aged ≥ 75 years, male, comorbid with diabetes mellitus and admitted to ICU after surgery, duration of surgery < 120 minutes, underwent cerebral surgery or skin, spine and joint surgery (all P < 0.001). The above results remained robust in the sensitivity analysis.

CONCLUSIONS

Preoperative CAR ≥ 0.278 was significantly associated with increased risk of postoperative SIRS in elderly patients. Special attention should be paid to elderly patients with a preoperative CAR ≥ 0.278 so as to reduce the incidence of postoperative SIRS.

[Anesthetic management of adult patients under orthotopic liver transplantation]

OBJECTIVE

To study the perioperative changes of and anesthetic management for patient under orthotopic liver transplantation (OLT).

METHODS

General anesthesia or general anesthesia combined with epidural block anesthesia was conducted. During the anhepatic phase, extracorporeal veno-venous bypass (EVVB) was used. Hemodynamics, respiratory function, blood gas, blood biochemistry, coagulation function, body temperature, blood glucose, urinary output and bleeding output were monitored during the operation. According to the characteristics of pre-anhepatic phase, anhepatic phase and neohepatic phases, corresponding anesthetic management measures were supplied.

RESULTS

(1) Forty-four patients tolerated the operation. One patient died of massive blood loss intraoperatively. 2 000 approximately 4 000 ml of blood was transfused to 29 patients, 4 000 approximately 6 000 ml to 7 patients and more than 6 000 ml to 8 patients. (2) During the anhepatic phase hemodynamics in 44 patients remained stable. However, in the fifteen minutes' primary stages of anhepatic phase and in neohepatic phase, transient circulatory instability occurred. Blood volume expansion was applied immediately and succeeded to correct the instability. (3) No patient, except one with massive blood loss showed obvious acid-base disturbance occurred during OLT. (4)The main electrolytic change during perioperative phase was hypocalcemia. (5) During the operation a marked change in body temperature took place. (6) Disturbance of coagulation function to a certain degree occurred. (7) The blood glucose level was higher than normal during OLT, and gradually decreased during the neohepatic phase.

CONCLUSIONS

Attention should be paid to the anesthetic management and monitoring during different phases of OLT. Appropriate treatment helps to keep the blood gas, blood biochemistry and coagulation function remain normal and stable. Use of EVVB during anhepatic phase can be helpful to keep hemodynamics stable and prevent obvious acidosis and hyperkalemia. Supplementation of coagulation factors, and proper use of hemostatic drugs and protamine to neutralize heparin were needed. Anti-rejection drugs were necessary during OLT.