Marwan S. Rizk

Advancing the Tracheal Tube over a Flexible Fiberoptic Bronchoscope by a Sleeve Mounted on the Insertion Cord

The advancement of an endotracheal tube (ETT) over a flexible fiberoptic bronchoscope (FOB) is often impeded at the glottis. This is attributed to the creation of a cleft by the difference in the outer diameter of the fiberscope and the internal diameter of the tube. We designed a conical-shaped polyvinyl chloride sleeve to fit the insertion cord. This report compares the ease of advancement of the tube over a sleeved versus a nonsleeved bronchoscope. General anesthesia was induced, and one anesthesiologist introduced the FOB (a 3.8-mm Olympus LF2). Patients were randomly assigned to undergo tracheal intubation with the regular bronchoscope (25 patients) or the sleeved bronchoscope (25 patients). The FOB was advanced to approximately 1 cm above the carina. A blinded operator advanced the tube over the bronchoscope. The ETT was successfully advanced over the nonsleeved bronchoscope into the trachea on the first attempt in 64% of the patients, whereas tracheal intubation succeeded from the first attempt in 96% of patients when the sleeved FOB was used (P < 0.05). Advancement of the ETT over the fiberscope can be facilitated by using a conically shaped sleeve mounted on the insertion cord.

Facilitation of Passing the Endotracheal Tube over the Flexible Fiberoptic Bronchoscope Using a Cook® Airway Exchange Catheter

EPIDURAL blood patch (EBP) is now recommended as the treatment of choice for managing postdural puncture headache (PDPH). Choi noted an initial success rate of 91% and a long-term success rate of 61% in managing PDPH with EBP. In a prospective study of 504 patients undergoing EBP for PDPH, however, Safa-Tisseront et al. observed less initial success in managing PDPH with EBP and reported complete relief of symptoms in 75% of patients, incomplete relief in 18%, and failure in 7%. The currently recommended volume of autologous blood for EBP is 10–20 ml; however, repeated EBPs for refractory PDPH have used larger volumes of autologous blood. We report a case of permanent spastic paraparesis with cauda equina syndrome after EBP with 30 ml of autologous blood for the successful management of PDPH.

Spontaneous intracranial hypotension syndrome treated with fludrocortisone.

Spontaneous intracranial hypotension is a rare syndrome characterized by orthostatic headache not associated with trauma or dural puncture. In most cases, it is caused by a spontaneous spinal cerebrospinal fluid leakage as demonstrated by neuroradiological studies. The standard of care consists of conservative treatment including bed rest, hydration, and administration of caffeine or glucocorticoids. When such conservative therapy fails, an epidural blood patch is recommended. In this report, we describe the treatment of 2 patients with spontaneous intracranial hypotension who failed conservative treatment and went on to have complete and sustained resolution of their symptoms after the administration of oral fludrocortisone.

A peripheral nerve stimulator for nerve location controlled by the scrubbed anaesthetist

This newly designed peripheral nerve stimulator allows the scrubbed anaesthetist performing a nerve block to adjust the electrical current output needed for localisation of the target nerve without the need for an assistant.

Voice outcome measures after flexible endoscopic injection laryngoplasty

Objective To report voice outcome measures after injection laryngoplasty using the transnasal or transoral flexible endoscopic technique. Methods A retrospective review of all patients who underwent flexible endoscopic injection laryngoplasty between June 2010 and August 2016 was carried out. Only those patients who had pre- and post-injection voice outcome measures recorded were included. Voice outcome measures recorded included perceptual voice evaluation using GRBAS, Voice Handicap Index-10 (VHI-10), maximum phonation time (MPT) and closed quotient (CQ) before and after treatment. Results Forty-six patients were identified, of which 32 had pre- and post-injection voice outcome measures recorded. There were 19 males and 13 females. The mean age was 56.97 years (range 20–86 years) and the most common indication was unilateral vocal fold paralysis. Thirteen patients had a transnasal flexible endoscopic injection), while 19 patients were injected transorally. Following injection laryngoplasty, there was significant improvement in the mean grade of dysphonia (2.81 vs. 1.22, P < 0.01, roughness (2.44 vs. 1.34, P < 0.01), breathiness (2.72 vs. 1.13, P < 0.01), asthenia (2.78 vs. 1.06, P < 0.01), and strain (2.44 vs. 1.19, P < 0.01), MPT (3.85 s vs. 9.85 s, P < 0.01) and mean CQ (0.19 vs. 0.46, P < 0.01). There was also a decrease in the mean VHI-10 score (33.31 vs. 7.94, P < 0.01). Conclusion s: Patients achieved significant improvement in both subjective and objective voice measures after flexible endoscopic injection laryngoplasty via the nasal or transoral route. Voice outcomes were comparable to those reported for other approaches. This technique provides an alternative approach for the management of patients with vocal fold paralysis or glottal insufficiency.

Improving Pain Management in Maxillofacial Cosmetic Surgical Procedures

Pain still ranks among the highest patient as well as surgeon concerns for unwanted surgical outcomes. Thus, pain management plays a major role in patient satisfaction and improving our patients’ safety. This chapter will review the pathogenesis of pain. Strategies for pain control will be addressed. Additionally, various pain disorders which can affect our patients’ postoperative course will be discussed.

Relaxantes musculares não despolarizantes melhoram a visibilidade em laringoscopia direta sem efeito sobre a ventilação via máscara facial

BACKGROUND Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. METHODS In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. RESULTS Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p=0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. CONCLUSION The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

A new device for easier handling of the transoesophageal echocardiography probe

In their paper reporting the changes in blood concentration of sevoflurane during anaesthesia, Lu et al. draw some surprising conclusions, which must be not taken lightly (Lu et al. Anaesthesia 2003; 58: 951–6). In their paper they summarise four main findings. First, they report that it took about 40 min for the sevoflurane concentration in arterial blood and jugular bulb blood to become the same. As they point out, this contrasts markedly with the time that is derived from known values for brain blood flow, solubility, and mass, which is about 10 min. They propose a blood–brain barrier as the only explanation for this remarkable discrepancy, which has not been suggested previously for volatile anaesthetic agents. I suggest an alternative: since the arterial concentration of sevoflurane was increasing over these 40 min, brain uptake would continue over this time, and equilibrium would be delayed. The plan of their study unfortunately did not maintain a stable arterial concentration, so assessment of cerebral uptake is confounded. They note that the difference between arterial and mixed venous sevoflurane concentration increased from zero (before sevoflurane was given) and then became stable. They state that the uptake of sevoflurane can be estimated from either this difference, or the difference between the inspired and end-tidal sevoflurane concentration, although they clearly state in the preceding sentence that there is a difference between these quantities because of the alveolar washin. This will affect the gas concentration difference, but not the arteriovenous difference. However in this regard it is not clear that the method they used to administer the anaesthetic would allow an accurate measure of inspired concentration. They used a circle system, with some recirculation of exhaled gases since the minute ventilation of at least some of their subjects would have been more than the fresh gas flow they used, which was 5 l.min. In these circumstances, the inspired gas may not be fully mixed, and the maximum concentration measured during inspiration by the analyser they used may not have been the same as the mean inspired concentration. Homogeneity is most marked at the start of the procedure. It would be important to know if there were fluctuations in inspired concentration at this time. In addition, we are told that the temperature of the subjects decreased passively, but not how much change occurred in the period of study. Arterial carbon dioxide was maintained stable, but in the context of deepening anaesthesia and probable decreasing temperature, carbon dioxide production would probably have decreased. How much was ventilation reduced, over the period of the study, to maintain the arterial carbon dioxide constant? Changes in ventilation would necessarily affect the rate of delivery of anaesthetic agent to the patients. They noted that the difference between arterial and end-expired concentration was considerable. It is unfortunate that they did not consider it appropriate to compare the partial pressures, which would have been very similar. Any difference between these values would be attributable, in simple terms, to ‘alveolar’ deadspace (to summarise several complex processes in a single concept). Do they not consider that the large concentration (not partial pressure) difference they report reflects the blood: gas partition of sevoflurane? They use this finding to suggest a different measure of brain anaesthetic levels. Rather than use the end-tidal sevoflurane concentration as a measure of brain concentration (which is the usual approximation, assuming arterial blood and brain have reached equilibrium) they suggest that brain concentration might be best considered to be midway between arterial and jugular venous concentrations. This contradicts accepted kinetic concepts of anaesthetic uptake in organs. Would they not agree that the difference between arterial input and venous effluent concentrations represents the process of brain uptake, and that the blood leaving the brain is likely to be in equilibrium with the brain tissues? If this is so, then the ‘future index’ of ‘anaesthetic depth’ they propose should be avoided. It is a changing value, derived from invasive measurements, with no theoretical basis for validity.