Vizualizacija dišnog puta: oči vide ono što mozak zna

Airway management is basic for anesthesia practice, and sometimes it can represent a really dramatic scenario for both the patient and the physicians. Laryngoscopy has been the gold standard of airway visualization for more than 60 years, showing its limitations and failure rates with time. New technology has made available an opportunity to move the physician’s eye inside patient airways thanks to video laryngoscopy and video assisted airway management technique. Undoubtedly, we have entered a new era of high resolution airway visualization and different approach in airway instrumentation. Nevertheless, each new technology needs time to be tested and considered reliable, and pitfalls and limitations may come out with careful and long lasting analysis, so it is probably not the right time yet to promote video assisted approach as a new gold standard for airway visualization, despite the fact that it certainly offers some new prospects. In any case, whatever the visualization approach, no patient dies because of missed airway visualization or failed intubation, but due to failed ventilation, which remains without doubt the gold standard of any patient safety goal and airway management technique.Održavanje dišnog puta je osnovna anesteziološka vještina koja ponekad predstavlja u pravom smislu dramatičan scenarij za bolesnika i liječnika. Laringoskopija, sa svim svojim ograničenjima i neuspjesima, predstavlja zlatni standard vizualizacije dišnog puta već više od 60 godina. Nove tehnologije, zahvaljujući videolaringoskopiji i video asistiranim tehnikamaodržavanja dišnog puta, omogućile su pomicanje očiju liječnika unutar dišnog puta bolesnika. Bez sumnje, ušli smo u novu eru visoke rezolucije vizualizacije dišnog puta i različitog pristupa instrumentalizaciji dišnog puta. Međutim, svaka nova tehnologija zahtijeva vrijeme da bi se testirala i smatrala pouzdanom. Zapreke i ograničenja mogu se iznjedriti nakon pažljive i dugotrajne analize, stoga vjerojatno još nije vrijeme da se promovira video asistirani pristup kao novi zlatni standard u vizualizaciji dišnog puta, iako on definitivno predstavlja novu budućnost. U svakom slučaju, koji kod bio pristup vizualizaciji, nijedan bolesnik ne umire zbog propuštene vizualizacije ili neuspjele intubacije, već umire zbog neuspješne ventilacije koja ostaje bez sumnje zlatni standard bilo kojeg cilja za sigurnost bolesnika i tehnike zbrinjavanja dišnog puta

Fiberoptička bronhoskopija prema video laringoskopiji u zbrinjavanju pedijatrijskog dišnog puta

The primary goal of pediatric airway management is to ensure oxygenation and ventilation. Routine airway management in healthy pediatric patients is normally easy in experienced hands. Really difficult pediatric airway is rare and usually is associated with anatomically and physiologically important findings such as congenital abnormalities and syndromes, trauma, infection, swelling and burns. Using predictors of difficult intubation should be mandatory preoperative assessment in pediatric patients. Difficult airway algorithm for pediatric patients has to consist of three parts: oxygenation (A), tracheal intubation (B), and rescue (C). According to this new algorithm, if conventional direct laryngoscopy fails, we have to use alternative glottic visualization device. Do we really need video laryngoscopy? If we look at numbers, we might estimate that conventional laryngoscopy is successful and effective in around 98.5% of cases. Do we need to replace Macintosh laryngoscope with video laryngoscope completely in our routine practice? Should video laryngoscope be available to replace fiberoptic intubation in pediatric airway management? According to the algorithm, fiberoptic-assisted tracheal intubation combined with extraglottic airway devices is the standard of care. Establishment of protocols for equipping and maintaining airway trolleys and regular training in their use must be provided to avoid tissue hypoxia in children with compromised airway.Primarni cilj u upravljanju pedijatrijskim dišnim putem je osigurati oksigenaciju i ventilaciju. Upravljanje dišnim putem kod pedijatrijskih bolesnika je rutina u rukama iskusnog pedijatrijskog anesteziologa. Problematičan dišni put kod pedijatrijskih bolesnika je rijetkost i vezan je za anatomske i fiziološke nalaze kao što su kongenitalne anomalije i sindromi, traume, infekcije, oticanje i opekline. U prijeoperacijskoj pripremi pedijatrijskih bolesnika obvezno je korištenje prediktora za procjenu dišnog puta. Algoritam za teški dišni put kod pedijatrijskih bolesnika sastoji se od tri dijela: oksigenacije (A), intubacije (B) i spašavanja (C). Prema ovom algoritmu, ako se konvencionalnom laringoskopijom ne uspije vizualizirati glotis i realizirati intubacija, potrebno je koristiti alternativne alatke za vizualizaciju glotisa i intubaciju bolesnika. Ako se pogleda statistika, konvencionalna laringoskopija je uspješna i učinkovita u oko 98,5% slučajeva. Trebamo li zamijeniti Macintosh laringoskop video laringoskopom u našem svakodnevnom radu s pedijatrijskim bolesnicima? Je li video laringoskopska (indirektna) intubacija dostojna zamjena za fiberoptičku intubaciju kada je pedijatrijski dišni put u pitanju? Prema algoritmu fiberoptička intubacija u kombinaciji sa supraglotičnim alatkama za zbrinjavanje pedijatrijskog dišnog puta je standard. Uspostava protokola za opremanje, upravljanje i održavanje dišnih putova kod pedijatrijskih bolesnika te redovita obuka u uporabi alatki za zbrinjavanje dišnog puta je neophodna

Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis

Background: Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia. Methods: We searched the Medline, Scopus, and Web of Science databases from their inception to December 2020. The population of interest included adults who required tracheal intubation for elective surgery under general anesthesia without clear anatomical abnormalities suggesting difficult laryngoscopy. A bivariate model has been used to assess the accuracy of each ultrasound index test to predict difficult direct laryngoscopy. Results: Fifteen studies have been considered for quantitative analysis of summary receiver operating characteristic (SROC). The sensitivity for distance from skin to epiglottis (DSE), distance from skin to hyoid bone (DSHB), and distance from skin to vocal cords (DSVC) was 0.82 (0.74-0.87), 0.71 (0.58-0.82), and 0.75 (0.62-0.84), respectively. The specificity for DSE, DSHB, and DSVC was 0.79 (0.70-0.87), 0.71 (0.57-0.82), and 0.72 (0.45-0.89), respectively. The area under the curve (AUC) for DSE, DSHB, DSVC, and ratio between the depth of the pre-epiglottic space and the distance from the epiglottis to the vocal cords (Pre-E/E-VC) was 0.87 (0.84-0.90), 0.77 (0.73-0.81), 0.78 (0.74-0.81), and 0.71 (0.67-0.75), respectively. Patients with difficult direct laryngoscopy have higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with a mean difference of 0.38 cm (95% confidence interval [CI], 0.17-0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01-0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08-0.39 cm; P = .004), respectively. Conclusions: Our study demonstrates that airway ultrasound index tests are significantly different between patients with easy versus difficult direct laryngoscopy, and the DSE is the most studied index test in literature to predict difficult direct laryngoscopy. However, it is not currently possible to reach a definitive conclusion. Further studies are needed with better standardization of ultrasound assessment to limit all possible sources of heterogeneity

Anaesthesiologic protocol for kidney transplantation in two patients with Fabry Disease: a case series

Fabry's Disease is a rare genetic syndrome, with a classic X-linked alpha -galactosidase A deficiency phenotype, responsible for glico-sphyngolypids metabolism impairment with clinical effects in several organs and functions. We describe the anaesthesiologic implications of two patients with Fabry disease who underwent a kidney transplantation from a deceased donor. We recommend careful preoperative evaluation, including cardiac sonography study and spirometry for Fabry disease patients, and according to our experience, we recommend advanced haemodynamic monitoring during surgery. Careful airway examination should be further performed, with particular attention to patient ventilability prediction and available alternative strategies for airway management in case of difficulties. A nephroprotective strategy and a particular care to the associated end-stage organ disease may significantly improve the long-term outcome of patients with Fabry Disease

Anaesthesiological implications of Kimura's disease: a case report

<p>Abstract</p> <p>Introduction</p> <p>Kimura's disease is a chronic inflammatory condition belonging to the angio-lymphatic proliferative group of disorders, usually affecting young men of Asian race, but is rare in Western countries. It is a benign but locally injurious disease, of unknown aetiology, whose classical clinical features are a tumour-like swelling, usually in the head and neck, with or without satellite lymphadenopathy, often accompanied by eosinophilia and elevated serum IgE.</p> <p>Case presentation</p> <p>We report the case of a 33-year-old Caucasian woman with an atypical localization of Kimura's disease, discussing the anaesthesiological implications and reviewing the current literature on Kimura's disease.</p> <p>Conclusions</p> <p>The diagnosis of Kimura's disease can be difficult and misleading, and anaesthesiological precautions could be ignored. Patients with this disease are often evaluated for other disorders: unnecessary diagnostic tests and investigations, or even surgery, may be avoided by just being aware of Kimura's disease.</p

Awake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Awake fiberoptic intubation is one of the recommended strategies for surgical patients with anticipated difficult airway, especially when concurrent difficult ventilation is expected. We performed the first systematic review of randomized controlled trials assessing different protocols for awake fiberoptic intubation in anticipated difficult airway, including studies investigating elective awake fiberoptic intubation for scheduled surgery; randomized controlled trials comparing different methods for performing awake fiberoptic intubation; and adult patients with anticipated difficult airway. We excluded studies in the nonoperating theater settings, randomized controlled trials comparing awake fiberoptic intubation with other techniques, and studies based on simulation. Primary outcomes were success rate and death; secondary outcomes were major adverse events. Thirty-seven randomized controlled trials evaluating 2045 patients and 4 areas were identified: premedication, local anesthesia, sedation, and ancillary techniques to facilitate awake fiberoptic intubation. Quality of evidence was moderate-low and based on small-sampled randomized controlled trials. Overall, 12 of 2045 intubation failures (0.59%) and 7 of 2045 severe adverse events (0.34%) occurred, with no permanent consequences or death. All evaluated methods to achieve local anesthesia performed similarly well. No differences were observed in success rate with different sedatives. Dexmedetomidine resulted in fewer desaturation episodes compared to propofol and opioids with or without midazolam (relative risk, 0.51 [95% CI, 0.28-0.95]; P = .03); occurrence of desaturation was similar with remifentanil versus propofol, while incidence of apnoea was lower with sevoflurane versus propofol (relative risk, 0.43 [95% CI, 0.22-0.81]; P = .01). A high degree of efficacy and safety was observed with minimal differences among different protocols; dexmedetomidine might offer a better safety profile compared to other sedatives

Airway Rescue using the LMA Supreme™ in the prone position: a case report

Surgery in prone positioning may pose considerable challenges to Anesthesiologists because of general accessibility to the patient; this is particularly true if referring to airway management, because the airway could be relatively inaccessible while the patient is lying prone. We report a case of an obese women scheduled for lower limbs surgery in the prone position in which the initial anesthetic choice for spinal anesthesia needed to be switched to general anesthesia during the procedure both for the occurrence of surgical complications and because the patient began to become uncooperative. We successfully managed this problem by inserting a LMA SupremeTM leaving the patient in the same prone position, and maintaining anesthesia in mechanical ventilation, thus allowing surgical procedure to be completed uneventfully. The possible options in similar cases and the specific features of LMA SupremeTM which allowed such a choice are discussed