ChatGPT's learning and reasoning capacity in anesthesiology

Introduction: Over the past few months, ChatGPT has raised a lot of interest given its ability to perform complex tasks through natural language and conversation. However, its use in clinical decision-making is limited and its application in the field of anesthesiology is unknown. Objective: To assess ChatGPT's basic and clinical reasoning and its learning ability in a performance test on general and specific anesthesia topics. Methods: A three-phase assessment was conducted. Basic knowledge of anesthesia was assessed in the first phase, followed by a review of difficult airway management and, finally, measurement of decision-making ability in ten clinical cases. The second and the third phases were conducted before and after feeding ChatGPT with the 2022 guidelines of the American Society of Anesthesiologists on difficult airway management. Results: On average, ChatGPT succeded 65% of the time in the first phase and 48% of the time in the second phase. Agreement in clinical cases was 20%, with 90% relevance and 10% error rate. After learning, ChatGPT improved in the second phase, and was correct 59% of the time, with agreement in clinical cases also increasing to 40%. Conclusions: ChatGPT showed acceptable accuracy in the basic knowledge test, high relevance in the management of specific difficult airway clinical cases, and the ability to improve after learning.

Introducción: En los últimos meses, ChatGPT ha suscitado un gran interés debido a su capacidad para realizar tareas complejas a través del lenguaje natural y la conversación. Sin embargo, su uso en la toma de decisiones clínicas es limitado y su aplicación en el campo de anestesiología es desconocido. Objetivo: Evaluar el razonamiento básico, clínico y la capacidad de aprendizaje de ChatGPT en una prueba de rendimiento sobre temas generales y específicos de anestesiología. Métodos: Se llevó a cabo una evaluación dividida en tres fases. Se valoraron conocimientos básicos de anestesiología en la primera fase, seguida de una revisión del manejo de vía aérea difícil y, finalmente, se midió la toma de decisiones en diez casos clínicos. La segunda y tercera fases se realizaron antes y después de alimentar a ChatGPT con las guías de la Sociedad Americana de Anestesiólogos del manejo de la vía aérea difícil del 2022. Resultados: ChatGPT obtuvo una tasa de acierto promedio del 65 % en la primera fase y del 48 % en la segunda fase. En los casos clínicos, obtuvo una concordancia del 20 %, una relevancia del 90 % y una tasa de error del 10 %. Posterior al aprendizaje, ChatGPT mejoró su tasa de acierto al 59 % en la segunda fase y aumentó la concordancia al 40 % en los casos clínicos. Conclusiones: ChatGPT demostró una precisión aceptable en la prueba de conocimientos básicos, una alta relevancia en el manejo de los casos clínicos específicos de vía aérea difícil y la capacidad de mejoría secundaria a un aprendizaje.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Abstract Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in adults

Abstract Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available.

Traqueotomía percutánea guiada por ultrasonografía en tiempo real. Revisión de la literatura / Literature Review. Real-time ultrasonography-guided percutaneous tracheotomy

La traqueotomía percutánea por dilatación es un procedimiento que se realiza en las unidades de paciente crítico, implica la disección roma de los tejidos pretraqueales, seguida de la dilatación de la tráquea sobre la guía y la inserción de la cánula traqueal mediante la técnica de Seldinger. En las últimas décadas, la evidencia sugiere que, en manos de médicos capacitados, es al menos tan segura como la traqueotomía quirúrgica, con similar incidencia de complicaciones. La selección adecuada de pacientes y el uso de herramientas de seguridad complementarias, como broncoscopio o ultrasonido, disminuyen las tasas de falla y complicaciones. Siendo contraindicaciones absolutas para traqueotomía percutánea por dilatación una anatomía anormal, tumor maligno en el sitio de traqueostomía, coagulopatías o vía aérea difícil. La guía mediante broncoscopia permite la evaluación de la profundidad del tubo endotraqueal, confirma la posición de la aguja en el eje de la tráquea y la adecuada inserción del cable guía y dilatador. Entre sus desventajas destacan que, el sitio de punción está sujeto a sesgo y no puede guiar con precisión la aguja en la penetración de la tráquea. La traqueotomía percutánea guiada por ultrasonido es una alternativa validada en unidades, donde no se cuente con broncoscopia. Es un método rápido, seguro, que permite la identificación de estructuras anatómicas, vasculatura cervical, permite identificar el sitio de la punción y guía la inserción de la aguja en la tráquea. Esta técnica presenta altas tasas de éxito al primer intento, reduciendo significativamente el número de punciones.

Percutaneous dilation tracheostomy is a procedure performed in critical patient units. It involves blunt dissection of the pretracheal tissues followed by dilation of the trachea over the guidewire and insertion of the tracheal cannula using the Seldinger technique. In recent decades, evidence suggests that in the hands of trained physicians it is at least as safe as surgical tracheostomy, with a similar incidence of complications. The proper selection of patients and the use of complementary safety tools such as bronchoscope or ultrasound reduce failure rates and complications. Being absolute contraindications for PDT abnormal anatomy, malignant tumor at the tracheostomy site, coagulopathies, or difficult to treat airway. Bronchoscopy guidance allows evaluation of the depth of the endotracheal tube, confirms the position of the needle in the axis of the trachea and the proper insertion of the guide wire and dilator. Among its disadvantages are that the puncture site is subject to slant and cannot accurately guide the needle into the trachea. In addition, it requires Critical Patient Units with bronchoscope and trained personnel. Ultrasound-guided percutaneous tracheotomy is a validated alternative in units where bronchoscopy is not available. It is a fast, safe method that allows the identification of anatomical structures, cervical vasculature, identifies the puncture site and guides the insertion of the needle into the trachea. With high first-attempt success rates, significantly reducing the number of punctures.

Colecistectomía Laparoscópica difícil: tratamiento quirúrgico / The surgical management of difficult LaparoscopicCholecystectomy

Objetivo: Caracterizar el tratamiento laparoscópico de pacientes con colecistitis difícil en el Servicio de Cirugía I del Hospital Universitario de Caracas durante el quinquenio2017-2021. Métodos: Estudio retrospectivo, observacional, descriptivo y de corte transversal. Muestra de tipo no probabilístico por conveniencia, seleccionada de la base de datos del Departamento de Historias Médicas del Hospital Universitario de Caracas. El análisis estadístico se realizó con el programa SPSS en su versión 26. Resultados: se recolectaron61 Historias Clínicas con características de colecistectomías laparoscópicas difíciles, el grupo etario más numeroso con67,19%, fue entre 30-59 años; sexo predominante: el femenino con 85,2%; el 42,62% de los pacientes presentaron a su ingreso: litiasis vesicular simple, el cólico vesicular persistente fue la complicación más frecuente con 31,23%. El 65,57% se ubicó en Grado I según Nassar como hallazgo intraoperatorio más frecuente, y según Parkland el 75,40% en grado I, sin individuos afectados con Grado V. Todos los casos fueron tratados quirúrgicamente (colecistectomía laparoscópica total).Conclusión: el total de los pacientes sometidos a tratamiento quirúrgico con hallazgos de colecistectomía laparoscópica difícil, se completó mediante colecistectomía laparoscópica total(AU)

Objective: To characterize the surgical treatment of difficult cholecystectomy in the Chair of Clinical and Surgical therapeutics "A" / Surgery Service I of the University Hospital of Caracas during the five-year period 2017 -2021.Methods: A retrospective, observational, descriptive and cross-sectional study will be carried out. The sample will be of anon-probabilistic type for convenience, selecting from the listof patients in the database of the Department of Medical Records of the Hospital Universitario de Caracas. The statistical analyzes will be carried out with the SPSS program in its version 26. Results: 61 difficult laparoscopic cholecystectomies were observed, the most frequent age group with 67.19%, was between 30-59 years, the female sex with 85.2% was the predominantone. 42.62% of the admission diagnoses were simple gallstones, followed by persistent gallbladder colic as the most frequent complication with 31.23%. 65.57% represent Grade I accordingto Nassar as the most frequent intraoperative finding and according to Parkland 75.40% represented by grade I, leaving Grade V without affected individuals. 100% of the sample were surgically treated by total laparoscopic cholecystectomy. Conclusion: the total number of patients undergoing surgical treatment with difficult laparoscopic cholecystectomy findingswas completed by total laparoscopic cholecystectomy(AU)

Factors Predicting Difficulty in Insertion of Real?Time?Three?Dimensional Transesophageal Echocardiography Probe in Adult Patients Undergoing Cardiac Surgery

Background:Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion. Methods: A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick抯 maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients� predictive factors such as demographic characteristics and factors related to difficult intubation. Results: Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P?value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P?value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001). Conclusion: Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Difficult Ventilation in a Patient with a Giant Aortic Aneurysm: A Challenge for the Anesthesiologist

Patients with Marfan syndrome present anatomic variations that may increase the risk of a difficult airway. Moreover, they can present large aortic aneurysms, which may cause extrinsic airway compression. Therefore, difficult ventilation during general anesthesia poses a challenge in that the anesthesiologist has to promptly make a crucial differential diagnosis. Multidisciplinary preoperative assessment and planning of the airway and ventilation management are of utmost importance in such uncommon and highly complex clinical cases. Fiberoptic bronchoscopy is probably a really useful tool in order to assess the severity and extent of the airway compression, both preoperatively and intraoperatively. We present a clinical case where difficult ventilation occurred immediately after the induction of general anesthesia.

Escobar syndrome, difficult airway management in pediatrics: A case report / Síndrome de Escobar, manejo de vía aérea difícil pediátrica: a propósito de un caso

Abstract Escobar syndrome is a rare, autosomal recessive disease of unknown incidence. It is characterized by multiple skeletal, genitourinary and orofacial abnormalities. The multiple malformations (mainly orofacial) and restricted mobility of these patients pose a challenge to the anesthesia team, especially as regards airway management. We describe the clinical case of a pediatric patient diagnosed with Escobar syndrome who underwent two consecutive anesthesia interventions, with evidence of progressive airway anomalies that characterize this syndrome. The case required adaptation, according to the clinical stage of the disease, of the current algorithms used to approach an anticipated difficult airway in pediatrics, and the incorporation of new devices, not described so far in patients with this pathology, as part of the planning and execution phases.

Resumen El síndrome de Escobar es una enfermedad rara, autosómica recesiva, de incidencia desconocida. Se caracteriza por múltiples anomalías esqueléticas, genitourinarias y orofaciales. Las múltiples malformaciones (principalmente orofaciales) y la restricción de la movilidad de estos pacientes determinan un desafío para el equipo anestésico, especialmente en el manejo de la vía aérea. Se describe el caso clínico de una paciente pediátrica con diagnóstico de síndrome de Escobar que fue sometida a dos anestesias consecutivas, en el que se evidencia una progresión de las anomalías de la vía aérea propias del síndrome, por lo que se requiere adecuar, según el estadío clínico de la enfermedad, los algoritmos actuales de abordaje de vía aérea difícil pediátrica anticipada y la incorporación de nuevos dispositivos en la planificación y ejecución para su manejo que no han sido descritos en pacientes con esta patología.

Efficacy and safety of balloon dilation technique during ureteroscopic lithotripsy with "difficult ureter" / 中华泌尿外科杂志

Objective:To summarize the preliminary clinical experience of utilizing ureteral balloon dilation catheter in the treatment of "difficult ureter" during ureteroscopic lithotripsy, and to discuss the efficacy and safety of the technique.Methods:Clinical data of 28 patients (30 sides) with upper urinary tract calculi admitted to Beijing Tsinghua Changgung Hospital Affiliated to Tsinghua University from April 2021 to July 2022 were retrospectively analyzed. There were 23 males (82.1%) and 5 females (17.9%), with age of (51.5±13.6) years. Among the 30 sides, 20 (66.7%) on the left and 10(33.3%) were on the right. Calculi were either located in the renal pelvis or calyxes in 7 sides (23.3%), upper ureter in 17 sides (56.7%), and lower ureter in 6 sides (20.0%). The maximum diameter of the stones was (9.4±4.2)mm, and 23 sides (76.7%) were combined with hydronephrosis before surgery. When "difficult ureter" was encountered during the procedure, that is, it was difficult to insert ureteroscope or ureteral access sheath (UAS) due to small ureteral lumen, balloon catheter was used for dilation in the first stage, in which the balloon diameter was 4 mm on 22 sides and 5mm on 8 sides. The instrument was retrogradely inserted through the working channel of F8 semi-rigid ureteroscope, and the small site of the ureteral lumen was dilated under direct endoscopic view. After a single dilation, the balloon catheter was withdrawn, and the effect of dilation was evaluated by semi-rigid ureteroscopy to determine whether to proceed with the following procedures. The intraoperative data were recorded, including surgical method, stage of "difficult ureter" occurred, site of the small part of the ureter, related data of utilizing ureteral dilatation balloon catheter, grade of ureteral injury after dilatation (according to the 0-4 grading classification of endoscopic ureteral injuries), total operation time, balloon catheter-related adverse events, stone-free rate, and time of removing ureteral stents.Results:Among the 30 sides, 29 (96.7%) had difficulty in the stage of ureteroscope insertion, and 1(3.3%) had difficulty in the stage of UAS insertion. A total of 37 small sites of ureter were involved, including 18 in the intramural segment, 10 in the lower part, 2 in the middle part, and 7 in the upper part. Each site was dilated once with a median time of 3 (0.5, 5.0) minutes and a median maximum balloon pressure of 1 215.9(1 215.9, 1 443.9)kPa[12.0(12.0, 14.3)atm]. There were 28 sites of grade Ⅰ injury, 8 sites of grade Ⅱinjury, and 1 site of grade Ⅲinjury. The total duration of unilateral procedure was (73.4±30.3) min. Ureteroscope or UAS insertion was successful in 28 sides(93.3%) after balloon dilation, and failed in 2 sides(6.7%), both of which were in the stage of inserting ureteroscope and ureteral stent was indwelled for the second-stage procedures. On the first day after surgery, the hemoglobin level was (134.1±12.9)g/L, which was significantly different from the preoperative parameters ( P<0.01), and serum creatinine level was (86.7±23.2)μmol/L, which showed no significant difference from the preoperative one ( P=0.263). The primary stone-free rate was 92.9% (26/28), and the total postoperative complication rate was 13.3% (4/30), including 3 of grade Ⅰ (lateral lower abdominal pain requiring additional analgesic drugs) and 1 of grade Ⅱ (postoperative hematuria requiring intravenous hemostatic drugs). Follow-up was conducted for 3 months. All of the 28 successful sides had their ureteral stents removed before the last follow-up, and the time of removal was (36.9±11.5) days. No hydronephrosis was found in the ipsilateral kidney by ultrasound 3 months after operation. Conclusions:Balloon dilation technique showed good efficacy and safety in the treatment of "difficult ureter" during ureteroscopic lithotripsy.

Clinical characteristics of choledocholithiasis combined with periampullary diverticulum and influencing factor analysis for difficult cannulation of endoscopic retrograde cholangiopan-creatography: a report of 1 920 cases / 中华消化外科杂志

Objective:To investigate the clinical characteristics of choledocholithiasis com-bined with periampullary diverticulum and influencing factor for difficult cannulation of endoscopic retrograde cholangiopancreatography (ERCP).Methods:The retrospective case-control study was conducted. The clinical data of 1 920 patients who underwent ERCP for choledocholithiasis in 15 medical centers, including the First Hospital of Lanzhou University, et al, from July 2015 to December 2017 were collected. There were 915 males and 1 005 females, aged (63±16)years. Of 1 920 patients, there were 228 cases with periampullary diverticulum and 1 692 cases without periampullary diverticulum. Observation indicators: (1) clinical characteristics of patients with choledocholithiasis; (2) intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis; (3) influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Logistic regression model was used for univariate and multivariate analyses. Results:(1) Clinical characteristics of patients with choledocholithiasis. Age, body mass index, cases with complications as chronic obstructive pulmonary disease, diameter of common bile duct, cases with diameter of common bile duct as <8 mm, 8?12 mm, >12 mm, diameter of stone, cases with number of stones as single and multiple were (69±12)years, (23.3±3.0)kg/m 2, 16, (14±4)mm, 11, 95, 122, (12±4)mm, 89, 139 in patients with choledocholithiasis combined with periampullary diverticulum, versus (62±16)years, (23.8±2.8)kg/m 2, 67, (12±4)mm, 159, 892, 641, (10±4)mm, 817, 875 in patients with choledocholithiasis not combined with periampullary diver-ticulum, showing significant differences in the above indicators between the two groups ( t=?7.55, 2.45, χ2=4.54, t=?4.92, Z=4.66, t=?7.31, χ2=6.90, P<0.05). (2) Intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis. The balloon expansion diameter, cases with intraoperative bleeding, cases with hemorrhage management of submucosal injection, hemostatic clip, spray hemostasis, electrocoagulation hemostasis and other treatment, cases with endoscopic plastic stent placement, cases with endoscopic nasal bile duct drainage, cases with mechanical lithotripsy, cases with stone complete clearing, cases with difficult cannulation, cases with delayed intubation, cases undergoing >5 times of cannulation attempts, cannulation time, X-ray exposure time, operation time were 10.0(range, 8.5?12.0)mm, 56, 6, 5, 43, 1, 1, 52, 177, 67, 201, 74, 38, 74, (7.4±3.1)minutes, (6±3)minutes, (46±19)minutes in patients with choledocholithiasis combined with periampullary diverticulum, versus 9.0(range, 8.0?11.0)mm, 243, 35, 14, 109, 73, 12, 230, 1 457, 167, 1 565, 395, 171, 395, (6.6±2.9)minutes, (6±5)minutes, (41±17)minutes in patients with choledocholithiasis not combined with periampullary diverticulum, showing significant differences in the above indicators between the two groups ( Z=6.31, χ2=15.90, 26.02, 13.61, 11.40, 71.51, 5.12, 9.04, 8.92, 9.04, t=?3.89, 2.67, ?3.61, P<0.05). (3) Influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Results of multivariate analysis showed total bilirubin >30 umol/L, number of stones >1, combined with periampullary diverticulum were indepen-dent risk factors for difficult cannulation in patients with periampullary diverticulum who underwent ERCP for choledocholithiasis ( odds ratio=1.31, 1.48, 1.44, 95% confidence interval as 1.06?1.61, 1.20?1.84, 1.06?1.95, P<0.05). Results of further analysis showed that, of 1 920 patients undergoing ERCP for choledocholithiasis, the incidence of postoperative pancreatitis was 17.271%(81/469) and 8.132%(118/1 451) in the 469 cases with difficult cannulation and 1 451 cases without difficult cannula-tion, respectively, showing a significant difference between them ( χ2=31.86, P<0.05). In the 1 692 patients with choledocholithiasis not combined with periampullary diverticulum, the incidence of postopera-tive pancreatitis was 17.722%(70/395) and 8.250%(107/1 297) in 395 cases with difficult cannula-tion and 1 297 cases without difficult cannulation, respectively, showing a significant difference between them ( χ2=29.00, P<0.05). In the 228 patients with choledocholithiasis combined with peri-ampullary diverticulum, the incidence of postoperative pancreatitis was 14.865%(11/74) and 7.143%(11/154) in 74 cases with difficult cannulation and 154 cases without difficult cannulation, respectively, showing no significant difference between them ( χ2=3.42, P>0.05). Conclusions:Compared with patients with choledocholithiasis not combined with periampullary divertioulum, periampullary divertioulum often occurs in choledocholithiasis patients of elderly and low body mass index. The proportion of chronic obstructive pulmonary disease is high in choledocholithiasis patients with periampullary diverticulum, and the diameter of stone is large, the number of stone is more in these patients. Combined with periampullary diverticulum will increase the difficult of cannulation and the ratio of patient with mechanical lithotripsy, and reduce the ratio of patient with stone complete clearing without increasing postoperative complications of choledocholithiasis patients undergoing ERCP. Total bilirubin >30 μmol/L, number of stones >1, combined with periampullary diverticulum are independent risk factors for difficult cannulation in patients of periampullary diverticulum who underwent ERCP for choledocholithiasis.

Applications of different flow rates of humidified high flow nasal cannula oxygen therapy on ICU patients with difficult weaning / 中国实用护理杂志

Objective:To explore the effects of different initial flow rates of humidified high flow nasal cannula oxygen therapy on weaning outcomes and comfort level among ICU patients with difficult weaning.Methods:A total of 99 ICU patients with difficult weaning received at Guangzhou Red Cross Hospital ICU from June 2019 to June 2021 were enrolled in the present study, they were assigned to 40 L/min group, 50 L/min group and 60 L/min group according to the random number table method, with 33 cases in each group. The weaning outcomes among three groups were compared, the degree of dryness of oral/nasal cavity, throat pain as well as vital signs and blood gas indexes were also compared before extubation and 30 min after the first humidified high flow nasal cannula (HHFNC) oxygen therapy.Results:There was no significant difference in length of stay in ICU and hospital, re-intubation within 7 days, the mortality within 28 days in ICU and the hospital among three groups ( P>0.05). The weaning success rate were 78.8% (24/33) and 77.4% (23/31) in 50 L/min group and 60 L/min, higher than in the 40 L/min group 53.1% (17/32), the difference was statistically significant ( χ2=4.78, 4.09, both P<0.05). After oxygen therapy, the scores of dryness of oral/nasal cavity and throat pain in the 40 L/min group, 50 L/min group and 60 L/min group were (3.16 ± 0.77), (2.94 ± 0.80) and (3.27 ± 0.92), (3.09 ± 0.77), and (4.10 ± 1.01), (3.97 ± 1.40), the differences were statistically significant ( F=5.21, 9.26, both P<0.05), and the differences between 50 L/min group and 40 L/min group and 60 L/min group were statistically significant ( t values were 2.62-3.99, all P<0.05). However, there was no significant difference in vital signs and blood gas indexes among the three groups before extubation and after oxygen therapy ( P>0.05). Conclusions:Humidified high flow nasal cannula oxygen therapy for the ICU patients with difficult weaning, oxygen flow with 50L/min can not only effectively promote weaning success rate but also improve patients′ respiratory comfort level.

Factors Associated with Difficulties Faced by Ward Nurses When Providing Support to Families of Patients with Advanced Cancer in Surrogate Decision-making

This study aimed to describe the types of support that ward nurses provide to families of patients with advanced cancer in surrogate decision-making and the factors associated with the difficulties these nurses experienced . An anonymous self-administered questionnaire survey was conducted among 285 nurses practicing in the cancer wards of four facilities. In total, 230 (80.7%) nurses provided support in surrogate decision-making, such as attending discussions. Additionally, 41 (17.8%) of the respondents often experienced difficulties performing this task. Results of a binary logistic regression analysis showed that the factors associated with the nurses’ recognition of difficulties were frequency of surrogate decision-making support requirements (OR=2.41, P=0.009) and incomprehension of the relationships between patients and their families (OR=2.41, P=0.009). To promote nurses’ support in surrogate decision-making, we suggest routinely collecting information on the relationships between patients and their families.

Discussion on the relationship between yuan-source points of yang meridians and diseases of fu- organs / 中国针灸

Huangdi Neijing (Yellow Emperor 's Canon of Medicine) establishes the theory that yuan-source points are indicated in zangfu diseases. However, compared with the yuan-source points of yin meridians for the treatment of zang-organ diseases, there is less attention to the indication of yuan-source points of yang meridians for fu-organ diseases, and this statement is even questioned. Collating the early literature and associating with the researches of medical experts, it is found that Nanjing (Classic of Difficult Questions) should be the theoretic origin that yuan-source points of yang meridians are indicated in fu-organ diseases. Regarding the reasons why this theory has not received clinical attention, the three aspects are involved, i.e. the theoretic completion of "he-sea points of three-foot-yang meridians for the diseases of six fu-organs", the limitation of the theory itself, and the lack of literature materials. It is proposed that the exploration on this theory should be deepened in views of the essence of yuan-source points relevant with the characteristic of the wrist-ankle pulse palpation region, acupoint combination, modern technology, etc.

A quantitative study of airway ultrasound in predicting difficult laryngoscopy: A prospective study / 中华创伤杂志(英文版)

PURPOSE@#As common clinical screening tests cannot effectively predict a difficult airway, and unanticipated difficult laryngoscopy remains a challenge for physicians. We herein used ultrasound to develop some point-of-care predictors for difficult laryngoscopy.@*METHODS@#This prospective observational study included 502 patients who underwent laryngoscopy and a detailed sonographic assessment. Patients under 18 years old, or with maxillofacial deformities or fractures, limited mouth opening, limited neck movement or history of neck surgery were excluded from the study. Laryngoscopic views of all patients were scored and grouping using the modified Cormack-Lehane (CL) scoring system. The measurements acquired comprised tongue width, the longitudinal cross-sectional area of the tongue, tongue volume, the mandible-hyoid bone distance, the hyoid bone-glottis distance, the mandible-hyoid bone-glottis angle, the skin-thyrohyoid membrane distance, the glottis-superior edge of the thyroid cartilage distance (DGTC), the skin-hyoid bone distance, and the epiglottis midway-skin distance. ANOVA and Chi-square were used to compare differences between groups. Logistic regression was used to identify risk factors for difficult laryngoscopy and it was visualized by receiver operating characteristic curves and nomogram. R version 3.6.3 and SPSS version 26.0 were used for statistical analyses.@*RESULTS@#Difficult laryngoscopy was indicated in 49 patients (CL grade Ⅲ - Ⅳ) and easy laryngoscopy in 453 patients (CL grade Ⅰ - Ⅱ). The ultrasound-measured mandible-hyoid bone-glottis angle and DGTC significantly differed between the 2 groups (p < 0.001). Difficult laryngoscopy was predicted by an area under the curve (AUC) of 0.930 with a threshold mandible-hyoid bone-glottis angle of 125.5° and by an AUC of 0.722 with a threshold DGTC of 1.22 cm. The longitudinal cross-sectional area of the tongue, tongue width, tongue volume, the mandible-hyoid distance, and the hyoid-glottis distance did not significantly differ between the groups.@*CONCLUSION@#Difficult laryngoscopy may be anticipated in patients in whom the mandible-hyoid bone-glottis angle is smaller than 125.5° or DGTC is larger than 1.22 cm.

Obstructive sleep apnea in surgical patients and its relationship with difficult intubation: two years of experience from a single center

Abstract Background and objectives: In this study, we aimed to determine the risk of obstructive sleep apnea (OSA) in patients undergoing elective surgery and its relationship with difficult intubation (DI). Methods: This prospective, descriptive, cross-sectional study was conducted between December 2018 and February 2020 in the anesthesiology and reanimation service of a training and research hospital. The study included patients who were ASA I-II, 18 years of age, and older who underwent elective surgery under general anesthesia. A form regarding the baseline characteristics of the participants as well as STOP-Bang score, Mallampati, and Cormack-Lehane classification was used to collect the data. Results: The study included 307 patients. It was determined that 64.2% of patients had a high risk of OSA. The presence of DI (determined by repeated attempts at intubation) was 28.6% in the high-risk OSA group, while there was no DI in the low-risk OSA group. A statistically significant difference was found between the groups in terms of OSA risk according to the presence of DI according to repeated attempts, Cormack-Lehane classification, and Mallampati classification (p < 0.001). Conclusion: Due to the high rate of DI in patients with a high risk of OSA, the security of the airway in these patients is endangered. Early clinical recognition of OSA can help in designing a safer care plan.

Airway management in mucopolysaccharidosis: a retrospective case series review

Abstract Airway management can be difficult in surgeries of patients with mucopolysaccharidosis. We performed a retrospective review of 31 surgeries performed between 2015 and 2019. The mean age of the patients was 127.6 months. MPS-IV and MPS-VI were the most frequent subtypes. Orthopedic surgeries were the most common surgery type. Difficult intubation was seen in 10 procedures. All patients with difficult intubation were aged over 36 months. Video laryngoscopy was the most common intubation method. Seventeen patients were followed up in the intensive care unit. Although video laryngoscopy seems to be a safe method in these patients, one should always be prepared for alternative methods.

Score preoperatorio para la predicción de colecistectomía difícil / Realization of a preoperative score for the prediction of difficult cholecystectomy

Introducción: La colecistectomía es una de las intervenciones quirúrgicas más frecuentes en la práctica médica diaria, la misma no está exenta de complicaciones, especialmente en algunos pacientes con mayor predisposición. Objetivo: Diseñar un score de puntuación preoperatoria para la predicción de la colecistectomía difícil en el área de emergencia y consulta del servicio de Cirugía General del Hospital General del Este "Dr. Domingo Luciani" Caracas - Venezzuela. Métodos: Estudio descriptivo, de diseño longitudinal. Realizado en el período agosto 2018 - agosto 2019. Contó con una muestra de 99 pacientes a los cuales se les aplicó un score predictivo preoperatorio donde se precisaron datos sobre el examen físico, antecedentes personales y quirúrgicos, enfermedades asociadas, exámenes de laboratorio y hallazgos en ultrasonido abdominal, previa firma del consentimiento informado se procedió a evaluar y hacer revisión de los paraclínicos de cada paciente, para luego ser reportado en el score. Resultados: Se registró una edad promedio muestral de 48,25 años ± 1,58, con una mediana de 47 años, el sexo femenino fue el más frecuente (60,61% = 60 casos), de aquellos pacientes clasificados con colecistectomía difícil según el score predictivo experimental predominaron aquellos con presencia de vesícula palpable y antecedentes de colecistitis, el hallazgo de laboratorio más importante fue la leucocitosis (≥ 15x106). Conclusión: El uso del score predictivo planteado permite predecir el riesgo de complicación en una colecistectomía difícil usando como base, las características clínicas y paraclínicas del paciente al momento de su evaluación preoperatoria(AU)

Introduction: Cholecystectomy is one of the most frequent surgical interventions in daily medical practice, it is not without complications, especially in some patients with greater predisposition.. Objective: Design a preoperative score for the prediction of difficult cholecystectomy in the emergency and medical consultation area of the General Surgery service of the Eastern General Hospital "Dr. Domingo Luciani". Methods: A descriptive study, longitudinal design. Performed in the period August 2018-August 2019. It had a sample of 99 patients who were given a preoperative predictive score requiring data on the physical examination, personal and surgical history, associated diseases, laboratory test and findings in abdominal ultrasound, upon signature of the informed consent was proceeded to evaluate and make revision of the paraclinical of each patient, and then be reported in the score. Results: An average sample age of 48.25 years ± 1.58, with a median age of 47 years, the female sex was the most common (60.61%=60 cases), in those patients classified with difficult cholecystectomy, according to the experimental predictive score, predominated those with the presence of palpable vesicle and history of cholecystitis, the most important laboratory finding was leukocytosis (≥ 15x106). Conclusion: The use of the predicted score allows to precise the risk of complication in a difficult cholecystectomy using the clinical and paraclinical characteristics of the patient at the time of their preoperative evaluation(AU)

Estratégias e dificuldades encontradas na comunicação de notícias difíceis em um hospital universitário / Strategies and difficulties found in communicating difficult news in a university hospital / Estrategias y dificultades encontradas para comunicar noticias difíciles en un hospital universitario

O trabalho teve como objetivo apresentar estratégias e dificuldades que influenciam o processo de Comunicação de Notícias Difíceis por médicos em um hospital universitário. Trata-se de um estudo descritivo-exploratório, de orientação qualitativa, sobre as estratégias e dificuldades encontradas por residentes (R1, R2 ou R3) e staffs, dos quatro programas da área médica: Ginecologia e Obstetrícia (GO), Pediatria, Cirurgia Geral (CG) e Clínica Médica (CM). A partir de uma entrevista semiestruturada para a análise dos dados foi utilizado o método do Discurso do Sujeito Coletivo (DSC), que mostrou como é importante utilizar protocolos para subsidiar a melhor abordagem com o paciente. Além da formação profissional, para realizar a comunicação de notícias difíceis, foi citado o protocolo SPIKES, seus pontos estratégicos e como ele pode auxiliar o profissional a realizar a melhor conduta. No que tange às dificuldades, a falta de preparo foi um dos destaques, bem como a ausência de um local adequado para a comunicação e os aspectos emocionais envolvidos, tanto por parte dos pacientes quanto dos profissionais de saúde. (AU)

The aim of this study was to present the strategies and difficulties that influence the process of communicating difficult news by doctors in a university hospital. This is a descriptive-exploratory study with a qualitative orientation on the strategies and difficulties encountered by residents (R1, R2 or R3) and staff from the four medical programs: Obstetrics and Gynecology (O&G), Pediatrics, General Surgery (GS) and Internal Medicine (IM). Based on a semi-structured interview, the Collective Subject Discourse (CSD) method was used for data analysis, which showed the importance of using protocols to support the best approach to the patient. In addition to professional training for communicating difficult news, the SPIKES protocol and its strategic points were mentioned, as well as how it can help professionals to conduct themselves effectively. The lack of preparation was one of the main difficulties reported, as well as the absence of an appropriate location for communication and the emotional aspects involved for both patients and health professionals. (AU)

El objetivo de este trabajo fue presentar estrategias y dificultades que influyen en el proceso de Comunicación de Noticias Difíciles por parte de médicos en un hospital universitario. Se trata de un estudio descriptivo-exploratorio, con orientación cualitativa, sobre las estrategias y dificultades encontradas por los residentes (R1, R2 o R3) y personal, de los cuatro programas del área médica: Ginecología y Obstetricia (GO), Pediatría, General Cirugía (CG) y Medicina Interna (CM). A partir de una entrevista semiestructurada para el análisis de los datos, se utilizó el método del Discurso del Sujeto Colectivo (CSD), que mostró cuán importante es el uso de protocolos para apoyar el mejor abordaje del paciente. Además de la formación profesional, para comunicar noticias difíciles, se mencionó el protocolo SPIKES, sus puntos estratégicos y cómo puede ayudar a los profesionales a llevar a cabo la mejor conducta. En cuanto a las dificultades, la falta de preparación fue uno de los destaques, así como la ausencia de un lugar adecuado para la comunicación y los aspectos emocionales involucrados, tanto por parte de los pacientes como de los profe-sionales de la salud. (AU)

Abordaje Quirúrgico de Quiste Epidermoide del Piso de la Cavidad Oral, con Vía Aérea Difícil e Intubación Vigil

Los quistes epidermoides son patologías benignas que se originan cuando células germinativas quedan atrapadas dentro de los arcos branquiales durante su cierre. Su prevalencia es baja, siendo aún menos prevalente su par, el quiste dermoide. Se presenta el caso clínico de una paciente de 17 años, de sexo femenino que debuta con aumento de volumen en piso de la cavidad, bilateral (de larga data), con obstrucción parcial de vía aérea, dificultad a la fonación y deglución. La tomografía computarizada entrega una imagen hipodensa, autolimitada, en los espacios submandibular y sublingual. Como hipótesis diagnóstica se sugiere un quiste dermoide o epidermoide. La paciente es intervenida y la muestra entregada a anatomopatología. El diagnóstico definitivo corrobora la hipótesis presuntiva de quiste epidermoide.

Epidermoid cysts are benign pathologies that originate when germinative cells become trapped within the branchial arches during their closure. Its prevalence is low, and its peer, the dermoid cyst, is even less prevalent. The clinical case is presented of a 17-year-old female patient who presents a bilateral increase in the oral cavity (long- standing), with partial obstruction of the airway, difficulty in phonation and swallowing. The computed tomography provides a hypodense, self-limited image in the submandibular and sublingual spaces. A dermoid or epidermoid cyst is suggested as a diagnostic hypothesis. The patient undergoes surgery, and the sample is delivered to pathology. The definitive diagnosis corroborates the presumptive hypothesis of an epidermoid cyst.