9 research outputs found
Airtraq® is the preferred device for difficultintubation by residents?
Background: The Airtraq® optical laryngoscope is an intubation device designed to provide
a view of the glottis without alignment of the oro-pharyngeal and laryngeal axes. Recent literature shows that, given its two significant features: time effectiveness and short learning curve,
Airtraq® is the most favorable option when it comes to difficult intubation.
Objectives: The goal was to analyze Airtraq® effectiveness when used by inexperienced
physicians in anticipated difficult intubation in adult patients.
Materials and methods: We conducted a prospective evaluation in ten medical residents
using the Airtraq® device for the first time. All of them were experienced in using Macintosh.
Each resident conducted laryngoscopy and intubation with the Airtraq® device after short didactic
guidance. Eighteen patients were included, over a period of seven months. The patients showed
four difficult intubation predictors: history of difficult intubation, thyromental distance less than
60 mm, mouth opening less than 35 mm and Mallampati class 3 or 4. All of them were clinically
examined for difficult airway by an ENT specialist.
Results: Before induction of anaesthesia all residents received a short demonstration on the
use of the Airtraq®. Every participant was supervised by an Airtraq® handling specialist for each
intubation maneuver. In sixteen patients, Airtraq® insertion, glottis visualization and subsequent
intubation were easy and rapid, without arterial oxygen desaturation. In two patients the trachea
was intubated from the second and third attempt. There were two tracheal intubation failures,
associated with extended tracheal intubation and an Airtraq® specialist had to continue with intubation. The Airtraq® reduced the duration of intubation attempts in all cases, reduced the number
of optimization maneuvers required, and reduced the potential for dental trauma. However, the
two intubation failures emphasize the fact that Airtraq® laryngoscopy requires a clinical training
process, especially in the event of anticipated difficult airway management situations.
Conclusion: The residents participating the study, found the Airtraq® easier to use in all
scenarios compared to the Macintosh laryngoscope. The Airtraq® may be the preferred device,
required by inexperienced physicians in cases of difficult airwa
Prediction value of oxygenation index as predictor for postoperative pulmonary complications in urologic surgery
Introduction: It is believed that pressure/flow (P/F) ratio (arterial oxygen to inspired oxygen fraction)
Does not give the best expression of oxygenation status in mechanically ventilated patients. Therefore,
a new oxygenation index (OI) where the mean airway pressure (MAP) is incorporated (PaO2/FiOxMAP)
Is showed as superior to P/F in expression of the lung oxygenation status. In this article we wanted to
assess the prediction value of OI calculated during urological surgeries as a predictive marker for
Developing postoperative pulmonary complications (PPC).
Material and methods: We evaluated all elective urologic patients operated in general endotracheal
anesthesia, aged 18 to 65 years, without any known history of respiratory disease for the period from
January till December 2017. We calculated the P/F ratio and the OI at three time points: after induction
in general endotracheal anesthesia in the beginning of mechanical ventilation, 1 hour after induction in
Anesthesia, and at the end of the surgery before weaning the mechanical ventilation. The primary
Outcomes were PPC defined by European Society of Anesthesia. The second outcomes were: length of
Hospital stay, admission to intensive care unit (ICU) and mortality.
Results: A total of 240 patients who met the inclusion criteria were included in this evaluation and
finally analyzed. PPC was diagnosed in 25% of patients and respectively 75% were without
Complications. The postoperative hospital stay was longer in PPC group no matter they were operated
laparoscopically or with classic open surgery (PPC laparoscopy 4.9 ± 2.2 vs. non PPC laparoscopy 3.3 ±
1.7, PPC laparotomy 6.8 ± 5.2 vs. non PPC 5.6 ± 2.1 laparotomy). Ten patients were admitted to ICU, 8
from PPC group and 2 from non PPC group. In PPC group patients were admitted to ICU for mean 3.7 ±
2.4 days, and in non PPC group patients were hospitalized in ICU only for 2 days. All evaluated patients
were discharged from the hospital and no mortality was observed in the 30 postoperative days.
In the univariate and multivariate logistic regression analysis neither OI nor P/F were significantly
associated with PPC.
Conclusion: This study does not offer a conclusive answer to the prediction value of OI for PPC. It
would be fruitful to pursue further research about predictive variables for pulmonary complications.
Keywords: oxygenation index, pressure/flow ratio, mean airway pressure, postoperative pulmonary
complications
Survey of Current Difficult Airway Management Practice
BACKGROUND: Even for the most experienced anesthesiologists “can’t ventilate can’t intubate†scenario in difficult airway management is challenging, and although rare it is life-threatening.
AIM: The aim of this survey was to analyse the current practice of difficult airway management at our University teaching hospital.
MATERIAL AND METHODS: A ten-question-survey was conducted in the Tertiary University Teaching Hospital “Mother Theresaâ€, Clinic for Anesthesia, Reanimation and Intensive Care. The survey included demographic data, experience in training anaesthesia, practice in management of anticipated and non-anticipated difficult airway scenario, preferable equipment and knowledge of guidelines and protocols. Responses were noted, evaluated and analysed with the SPSS statistical program.
RESULTS: The overall response rate was very good; 94.5% answered the survey. During the assessment of the level of comfort with diverse airway equipment, there was diversity of answers due the experience of anaesthesia training, although the most frequent technique among all responders for anticipated difficult intubation was video laryngoscopy (48%). As for non-anticipated difficult intubation when conventional techniques failed to secure the airway most of the responders answered that they used supra-gothic airway device – laryngeal mask (38%) as a rescue measure.
CONCLUSION: Airway assessment, adequate training, experience, and availability of essential equipment are the pillars of successful airway management
Evaluation of Anesthesia Profile in Pediatric Patients after Inguinal Hernia Repair with Caudal Block or Local Wound Infiltration
AIM: The aim of this study is to evaluate anesthesia and recovery profile in pediatric patients after inguinal hernia repair with caudal block or local wound infiltration.MATERIAL AND METHODS: In this prospective interventional clinical study, the anesthesia and recovery profile was assessed in sixty pediatric patients undergoing inguinal hernia repair. Enrolled children were randomly assigned to either Group Caudal or Group Local infiltration. For caudal blocks, Caudal Group received 1 ml/kg of 0.25% bupivacaine; Local Infiltration Group received 0.2 ml/kg 0.25% bupivacaine. Investigator who was blinded to group allocation provided postoperative care and assessments. Postoperative pain was assessed. Motor functions and sedation were assessed as well.RESULTS: The two groups did not differ in terms of patient characteristic data and surgical profiles and there weren’t any hemodynamic changes between groups. Regarding the difference between groups for analgesic requirement there were two major points - on one hand it was statistically significant p < 0.05 whereas on the other hand time to first analgesic administration was not statistically significant p = 0.40. There were significant differences in the incidence of adverse effects in caudal and local group including: vomiting, delirium and urinary retention.CONCLUSIONS: Between children undergoing inguinal hernia repair, local wound infiltration insures safety and satisfactory analgesia for surgery. Compared to caudal block it is not overwhelming. Caudal block provides longer analgesia, however complications are rather common
Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy
Background: Due to its numerous benefits laparoscopic surgery become very popular
among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can
be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving
visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in
arterial blood gasses.
Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0
before induction – basal, T1 after one hour of CO2 insufflation, and T2
at the end of the surgery.
Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ±
8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in
retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002).
Conclusion: The findings that we have presented can suggest that both approaches are safe
although hypercarbia is observed in retroperitoneal group.
Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy,
urologic laparoscopy.
Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia,
Reanimation and Intensive Care, Skopje, Republic of North Macedoni
Hypoxia during one lung ventilation in thoracic surgery
Background. The technique of one lung
ventilation (OLV) is used with the purpose
of achieving isolation of the diseased
lung being operated upon, using a doublelumen
endobronchial tube. Thoracic surgical
procedures which are performed in the
lateral decubitus position, nowadays could
not be imagined without OLV. In spite of
advantages regarding surgical exposure,
OLV is associated with serious respiratory
impairment. Hypoxemia is considered to
be the most important challenge during
OLV. The goal of this study was to establish
the magnitude of intrapulmonary shunt, as
well as the immensity of hypoxia during
general anesthesia with OLV.
Materials and Methods. In this prospective
interventional clinical study thirty patients
were enrolled who underwent elective
thoracic surgery with a prolonged period
of OLV. The patients received balanced
general anesthesia with fentanyl/propofol/
rocuronium. A double-lumen endobronchial
tube was inserted in all patients, and
mechanical ventilation with 50% oxygen in
air was used during the entire study. Arterial
blood gases were recorded in a lateral
decubitus position with two-lung ventilation,
at the beginning of OLV (OLV 0)
and at 10 and 30 min. (OLV 10, OLV 30,
respectively) after initiating OLV in all
patients. Standard monitoring procedures
were used. Arterial oxygenation (PaO2),
arterial oxygen saturation (SaO2) and venous
admixture percentage - intrapulmonary
shunt (Qs/Qt %) were measured, as
well as mean arterial pressure and heart
rate during the same time intervals. For
the purpose of this study, the quantitative
value of Qs/Qt% was mathematically calculated
using the blood gas analyser AVL
Compact 3. A p value <0.05 was taken to
be statistically significant.
Results. When OLV was instituted, arterial
oxygenation decreased, whereas Qs/Qt%
increased, about 10 min. after commencement,
with improvement of oxygenation
approximately half an hour afterwards. A
statistically relevant difference (p<0.05)
occurred in PaO2, SaO2 and Qs/Qt at the
different time points.
Conclusion. Hypoxia during OLV, with an
increase in Qs/Qt, usually occurs after 10
min. of its initiation. After 30 min, the values
of the Qs/Qt ratio regularly return to
normal levels
Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study
Summary
Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally.
Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies
have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of
the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income
countries globally, and identified factors associated with mortality.
Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to
hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis,
exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a
minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical
status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary
intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause,
in-hospital mortality for all conditions combined and each condition individually, stratified by country income status.
We did a complete case analysis.
Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital
diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal
malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome
countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male.
Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3).
Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income
countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups).
Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome
countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries;
p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients
combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11],
p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20
[1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention
(ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety
checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed
(ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of
parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65
[0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality.
Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome,
middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will
be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger
than 5 years by 2030
Carboxyhemoglobin changes in relation to inspired oxygen fraction during general anesthesia
Measurement of carboxyhemoglobin could be a new method for evaluation of the severity of inflammatory airway disease, acute organ dysfunction, or stress by surgery and anesthesia. To use this measurement during mechanical ventilation, it is important to clarify the effects of factors that interfere with carboxy- hemoglobin levels. The aim of our study was to investigate the preoperative changes of carboxyhemoglobin to inspired oxygen fraction during general anesthesia and mechanical ventilation. Our second aim was to evaluate the effect of preoxygenation on the level of carboxyhemo- globin. Methods: The study included 30 patients scheduled for urologic surgery under general endotracheal anesthesia, aged 18-60 years, divided into two groups. The study group comprised patients who were smoking cigarettes or tobacco pipe, while the control group included non-smokers. In both groups carboxyhemoglobin levels were determined preoperatively, after preoxygenation, and one hour after induction in anesthesia. Results: carboxyhemoglobin levels were decreased after preoxygenation in both groups. One hour after induction in anesthesia under mechanical ventilation with inhaled fraction of a mixture of O2 (50%) and air (50%) the average values of carboxyhemoglobin between the two groups were different. The average values of carboxyhemoglobin between the two groups in all three time points were statistically significantly different (p=0.00). Conclusion: Changes in carboxyhemoglobin concentrations in arterial blood occur during general anesthesia and mechanical ventilation, although these amplitudes are small when compared to carbon monoxide intoxication. It is likely that organ perfusion and functions are affected by these monoxide gas mediators during surgery
Major abdominal surgery for Jehovah’s Witnesses: Challenge while practicing bloodless medicine in a middle income country
We present a 59-year-old female Jehovah’s Witness patient transferred from another facility to our tertiary center as an emergency case owing to anemia due to gastrointestinal bleeding. A computed tomography scan and gastroscopy confirmed an invasion of the duodenum by a malignant process. The patient underwent a Whipple procedure and a right hemicolectomy refusing blood transfusion. On the 17th postoperative day, the patient was discharged following a successful surgery. This article’s objectives are to first highlight the moral and ethical quandary and then share our surgical experiences with this particular patient population. In conclusion, Jehovah’s Witnesses’ management of major abdominal surgery poses considerable clinical, moral, and legal difficulties. Despite them, doctors must put the patients’ needs first while also honoring their religious convictions. However, urgent situations continue to arise, forcing medical professionals to weigh their religious convictions against the need to save a patient’s life