Zbrinjavanje dišnoga puta uz direktnu laringoskopiju u djeteta s Goldenharovim sindromom

Goldenhar syndrome, also known as oculoauriculovertebral dysplasia, is a rare congenital condition characterized by facial, cranial, vertebral, ocular, auricular and cardiac abnormalities. This syndrome is associated with hemifacial microsomia due to inadequate growth of the mandible and vertebral anomaly of the cervical part of the spine. For anesthesiologists, airway management is of great interest because of facial and oral abnormalities such as mandibular hypoplasia and limitation of neck movement. Considering different conditions of Goldenhar syndrome, every patient should be preoperatively evaluated in order to make the plan for the anticipated difficult airway management. We report a case of a 2.5-year-old boy undergoing palatoplasty, who required general anesthesia and orotracheal intubation. Our decision to intubate with direct laryngoscopy and with slight external pressure on the larynx proved successful.Goldenharov sindrom je kongenitalni sindrom s općom manifestacijom hemifacijalne mikrosomije zbog nedostatnog sazrijevanja mandibule i anomalijama vratne kralježnice. Svaki anesteziolog treba znati da se u djece s Goldenharovim sindromom predviđa otežano zbrinjavanje dišnoga puta, otežana ventilacija i intubacija. Sindromi se u djece prezentiraju u različitom opsegu. Stoga svako dijete kod kojega je dijagnosticirana malformacija pogotovo dišnoga puta treba detaljno pregledati i odlučiti na koji način pristupiti zbrinjavanju dišnoga puta. U ovom prikazu slučaja dvoipogodišnjeg dječaka zbog zahvata plastike mekoga nepca trebali smo intubirati orotrahealnim putem. Dječak je intubiran direktnom laringoskopijom uz lagani vanjski pritisak na larinks

AIRWAY MANAGEMENT IN A CHILD WITH EDWARD’S SYNDROME

Prikazujemo zbrinjavanje dišnog puta u djevojčice s mozaičnim tipom Edwardsovog sindroma za planirani zahvat laparotomije u općoj anesteziji. Manifestacije Edwardsovog sindroma među ostalima su kraniofacijalne malformacije te je moguća otežana ventilacija i intubacija. U našem slučaju djevojčica je, ovisno o potrebi zahvata, imala postavljeno supraglotično pomagalo tijekom anestezije za dijagnostičku pretragu magnetskom rezonancijom (MR), intubirana je fi berbronhoskopski za elektivni zahvat laparoskopije, a u jedinici intenzivne medicine direktnom laringoskopijom. Ventilacija i intubacija protekle su bez komplikacija. Poslijeoperacijski oporavak komplicirao se hipotonijom, pneumonijom te potrebom za reintubacijom i mehaničkom ventilacijom.We report on airway management in a girl with mosaic type of Edward’s syndrome for elective surgery, laparotomy in general anesthesia. In Edward’s syndrome, among other manifestations, craniofacial anomalies are expressed and there is a possibility of diffi cult ventilation and intubation. In this case, we secured the airway with supraglottic airway device during diagnostics (anesthesia for magnetic resonance imaging), we performed fi beroptic intubation for elective laparoscopy, and in the intensive care unit, she was intubated with direct laryngoscopy. Ventilation and intubation were accomplished without problems. Postoperative recovery was complicated with hypotonia, pneumonia and the need of reintubation and mechanical ventilation

Airway Management with Direct Laryngoscopy in a Child with Goldenhar Syndrome

Goldenhar syndrome, also known as oculoauriculovertebral dysplasia, is a rare congenital condition characterized by facial, cranial, vertebral, ocular, auricular and cardiac abnormalities. This syndrome is associated with hemifacial microsomia due to inadequate growth of the mandible and vertebral anomaly of the cervical part of the spine. For anesthesiologists, airway management is of great interest because of facial and oral abnormalities such as mandibular hypoplasia and limitation of neck movement. Considering different conditions of Goldenhar syndrome, every patient should be preoperatively evaluated in order to make the plan for the anticipated difficult airway management. We report a case of a 2.5-year-old boy undergoing palatoplasty, who required general anesthesia and orotracheal intubation. Our decision to intubate with direct laryngoscopy and with slight external pressure on the larynx proved successful

High PEEP with recruitment maneuvers versus Low PEEP During General Anesthesia for Surgery -a Bayesian individual patient data meta-analysis of three randomized clinical trials

Background: The influence of high positive end-expiratory pressure (PEEP) with recruitment maneuvers on the occurrence of postoperative pulmonary complications after surgery is still not definitively established. Bayesian analysis can help to gain further insights from the available data and provide a probabilistic framework that is easier to interpret. Our objective was to estimate the posterior probability that the use of high PEEP with recruitment maneuvers is associated with reduced postoperative pulmonary complications in patients with intermediate-to-high risk under neutral, pessimistic, and optimistic expectations regarding the treatment effect. Methods: Multilevel Bayesian logistic regression analysis on individual patient data from three randomized clinical trials carried out on surgical patients at Intermediate-to-High Risk for postoperative pulmonary complications. The main outcome was the occurrence of postoperative pulmonary complications in the early postoperative period. We studied the effect of high PEEP with recruitment maneuvers versus Low PEEP Ventilation. Priors were chosen to reflect neutral, pessimistic, and optimistic expectations of the treatment effect. Results: Using a neutral, pessimistic, or optimistic prior, the posterior mean odds ratio (OR) for High PEEP with recruitment maneuvers compared to Low PEEP was 0.85 (95% Credible Interval [CrI] 0.71 to 1.02), 0.87 (0.72 to 1.04), and 0.86 (0.71 to 1.02), respectively. Regardless of prior beliefs, the posterior probability of experiencing a beneficial effect exceeded 90%. Subgroup analysis indicated a more pronounced effect in patients who underwent laparoscopy (OR: 0.67 [0.50 to 0.87]) and those at high risk for PPCs (OR: 0.80 [0.53 to 1.13]). Sensitivity analysis, considering severe postoperative pulmonary complications only or applying a different heterogeneity prior, yielded consistent results. Conclusion: High PEEP with recruitment maneuvers demonstrated a moderate reduction in the probability of PPC occurrence, with a high posterior probability of benefit observed consistently across various prior beliefs, particularly among patients who underwent laparoscopy

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications