Anesthetic induction and endotracheal intubation in the sitting position due to the fixed forearm caught by a meat grinder

Abstract A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning.

Role of melatonin in attenuation of hemodynamic response to intubation and anesthetic requirements: a randomized, controlled, double-blind study

Abstract Background Melatonin has been studied to have anxiolytic, sedative, and analgesic effects. However, there is limited data on the effect of melatonin in the attenuation of hemodynamic response to intubation. We aimed to study whether preanesthetic oral melatonin attenuates hemodynamic responses to intubation and anesthetic requirements. Methods Sixty-four patients scheduled for laparoscopic cholecystectomy were randomized into melatonin or placebo group (n = 32 each). Melatonin group received two tablets (3 mg each) of melatonin, and the placebo group received two tablets of vitamin D3 120 min before induction. Hemodynamic parameters were recorded during induction and postintubation for 15 minutes. Total induction dose of propofol, total intraoperative fentanyl consumption, and adverse effects of melatonin were also noted. Results Postintubation rise in heart rate (HR) was less in the melatonin group compared to the placebo group (10.59% vs. 37.08% at 1 min, respectively) (p< 0.0001). Maximum percentage increase in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) was lesser in melatonin group than placebo group (SBP 9.25% vs. 37.73%, DBP 10.58% vs. 35.51%, MBP 9.99% vs. 36.45% at 1 min postintubation. respectively) (p< 0.0001). Induction dose of propofol (1.42 mg.kg-1 vs. 2.01 mg.kg-1) and the number of patients requiring additional fentanyl intraoperatively (3 vs. 11) were also significantly reduced in the melatonin group. Conclusion Premedication with 6 mg of oral melatonin resulted in significant attenuation of postintubation rise in HR, SBP, DBP, and MBP. It also reduced the induction dose of propofol, total intraoperative fentanyl consumption without any adverse effects.

Predictive performance of thyromental height for difficult laryngoscopies in adults: a systematic review and meta-analysis

Abstract Background Thyromental height (TMH) was first reported as a great single test for prediction of difficult laryngoscopies, although further studies have shown variable estimates of its accuracy. We thus performed this meta-analysis to summarize the predictive values of TMH mainly for prediction of difficult laryngoscopies. Methods A search in PubMed, EMBASE, LILACS, and Scielo was conducted in June 2020. We included prospective cohorts fully reported with patients ≥ 16 years old, providing data on predictive values of TMH for prediction of either difficult laryngoscopies or difficult intubations. Diagnostic properties and association between TMH and Cormack and Lehanes's classification by direct laryngoscopy were evaluated. A random-effects meta-analysis using hierarchical models was performed. Results Eight studies evaluating 2844 patients were included. All included studies had high risk of bias and low concern regarding applicability. There was significant heterogeneity among the studies. The pooled diagnostic odds ratio (DOR) and positive (LR+) and negative (LR-) likelihood ratios were as follows: DOR, 57.94 (95% CI: 18.19-184.55); LR+, 11.32 (95% CI: 4.28-29.92); and LR-, 0.23 (95% CI: 0.15-0.35). Summary sensitivity and specificity for studies with common threshold were 82.6 (95% CI: 74-88.8%) and 93.5 (95% CI: 79-98.2%), respectively. The estimated AUC was 81.1%. Conclusion TMH arises as a good predictor of difficult laryngoscopies in adult patients from diverse populations presenting better predictive values than most previously reported bedside tests. However, the high risk of bias throughout the studies may have skewed the results of the individual research as well as the summary points of the present meta-analysis.

Awake airway endoscopy in mucopolysaccharidosis: a case report

Abstract Mucopolysaccharidosis (MPS) are a group of rare genetic inherited diseases with a progressive course due to the accumulation of glycosaminoglycans resulting in anatomic abnormalities and organ dysfunction, including the respiratory, cardiovascular, skeletal, and neurological systems that can increase the risk of anesthesia complications. Clinical manifestations are variable, multisystemic, and include severe morphological changes. The anesthetic management of these patients is complex, particularly airway management, which can be planned to include a fiberoptic airway investigation prior to surgery. We present two cases of patients with MPS type VI and VII who underwent fiberoptic airway mapping under conscious sedation, with no complications. Since MPS is a rare but challenging disease concerning the airway management, we propose a safe and effective anesthetic technique that could be used for fiberoptic bronchoscopy and allow fiberoptic-assisted tracheal intubation at the time of surgery.

The evolution of approach in the resuscitation of neonates born with meconium-stained amniotic fluid: a tale of two countries, China and U.S.A., in the past 60 years / 中国当代儿科杂志

Neonates born through meconium-stained amniotic fluid (MSAF) may develop complications including meconium aspiration syndrome, persistent pulmonary hypertension of newborn and death. The approach to the resuscitation of these neonates has significantly evolved for the past few decades. Initially, under direct visualization technique, neonates with MSAF were commonly suctioned below the vocal cords soon after delivery. Since 2015, Neonatal Resuscitation Program (NRP®) of the American Academy of Pediatrics has recommended against "routine" endotracheal suctioning of non-vigorous neonates with MSAF but favored immediate resuscitation with positive pressure ventilation via face-mask bagging. However, the China neonatal resuscitation 2021 guidelines continue to recommend routine endotracheal suctioning of non-vigorous neonates born with MSAF at birth. This review article discusses the differences and the rationales in the approach in the resuscitation of neonates with MSAF between Chinese and American NRP® guidelines over the past 60 years.

Is Mallampati classification a good screening test? A prospective cohort evaluating the predictive values of Mallampati test at different thresholds

Abstract Background There is currently some discussion over the actual usefulness of performing preoperative upper airway assessment to predict difficult airways. In this field, modified Mallampati test (MMT) is a widespread tool used for prediction of difficult airways showing only a feeble predictive performance as a diagnostic test. We therefore aimed at evaluating if MMT test would perform better when used as a screening test rather than diagnostic. Methods An accuracy prospective study was conducted with 570 patients undergoing general anesthesia for surgical procedures. We collected preoperatively data on sex, age, weight, height, body mass index (BMI), ASA physical status, and MMT. The main outcome was difficult laryngoscopy defined as Cormack and Lahane classes 3 or 4. Bivariate analyses were performed to build three different predictive models with their ROC curves. Results Difficult laryngoscopy was reported in 36 patients (6.32%). Sex, ASA physical status, and MMT were associated with difficult laryngoscopy, while body mass index (BMI) was not. The MMT cut-off with the highest odds ratio was the class II, which also presented significantly higher sensitivity (94.44%). The balanced accuracy was 67.11% (95% CI: 62.78-71.44%) for the cut-off of class II and 71.68% (95% CI: 63.83-79.54) for the class III. Conclusion MMT seems to be more clinically useful when the class II is employed as the threshold for possible difficult laryngoscopies. At this cut-off, MMT shows the considerable highest sensitivity plus the highest odds ratio, prioritizing thus the anticipation of difficult laryngoscopies.

Predictive model for difficult laryngoscopy using machine learning: retrospective cohort study

Abstract Background Both predictions and predictors of difficult laryngoscopy are controversial. Machine learning is an excellent alternative method for predicting difficult laryngoscopy. This study aimed to develop and validate practical predictive models for difficult laryngoscopy through machine learning. Methods Variables for the prediction of difficult laryngoscopy included age, Mallampati grade, body mass index, sternomental distance, and neck circumference. Difficult laryngoscopy was defined as grade 3 and 4 by the Cormack-Lehane classification. Pre-anesthesia and anesthesia data of 616 patients who had undergone anesthesia at a single center were included. The dataset was divided into a base training set (n = 492) and a base test set (n = 124), with equal distribution of difficult laryngoscopy. Training data sets were trained with six algorithms (multilayer perceptron, logistic regression, supportive vector machine, random forest, extreme gradient boosting, and light gradient boosting machine), and cross-validated. The model with the highest area under the receiver operating characteristic curve (AUROC) was chosen as the final model, which was validated with the test set. Results The results of cross-validation were best using the light gradient boosting machine algorithm with Mallampati score x age and sternomental distance as predictive model parameters. The predicted AUROC for the difficult laryngoscopy class was 0.71 (95% confidence interval, 0.59-0.83; p= 0.014), and the recall (sensitivity) was 0.85. Conclusion Predicting difficult laryngoscopy is possible with three parameters. Severe damage resulting from failure to predict difficult laryngoscopy with high recall is small with the reported model. The model's performance can be further enhanced by additional data training.

Manejo de vía aérea difícil en intubación de emergencia, revisión sistemática y metaanálisis / Difficult airway management in emergency intubation, systematic review and meta-analysis

Introducción: la vía aérea difícil es aquella situación clínica en la cual un anestesiólogo entrenado convencionalmente experimenta dificultad en la aplicación de ventilación con mascarilla facial, en la intubación endotraqueal o ambas, es de vital importancia su identificación, puesto que su manejo adecuado marcará la diferencia en el desenlace de los pacientes que requieren intubación, en especial los recibidos en urgencias. Objetivo: revisar de manera sistemática el estado actual del conocimiento y evidencia clínica relacionada al manejo de la vía aérea difícil en in- tubación de emergencia. Material y métodos: se realizó una revisión sistemática en PubMed, Cochrane, EBSCO y OVID; se emplearon los términos manejo de vía aérea difícil e intubación de emergencia. Resul- tados: la búsqueda arrojó 356 resultados, se excluyeron los estudios de revisión sistemática, metaanálisis, artículos basados en opiniones, infor- mes de casos, cartas al editor; 128 artículos fueron analizados; además, se buscó analizar artículos de distinta área de la investigación médica; se seleccionaron 21 artículos para ser analizados en esta revisión sistemática. Conclusiones: inesperadamente los artículos revisados concluyen, en su gran mayoría, que independientemente del protocolo de intubación, el aspecto que juega un rol determinante en el manejo de la vía aérea difícil es la experiencia y preparación previa del médico anestesiólogo (AU)

Introduction: difficult airway is that clinical situation in which a conventionally trained anesthesiologist experiences difficulty in ventilation with a face mask, in endotracheal intubation or both. In this review article we will focus on emergency intubation. Objective: to systematically review the current state of knowledge and clinical evidence related to the management of difficult airways in emergency intubation. Material and methods: a systematic review was carried out in PubMed, Cochrane data base, EBSCO and OVID; the terms: difficult airway management and emergency intubation; only clinical trials and scientific research reports were analyzed. Results: the search yielded 356 results, of which systematic review studies, meta-analysis, opinion-based articles, case reports, letters to the editor were excluded; which gave us 128 articles, after they were analyzed; it was also sought to analyze articles from different areas of medical research; 21 articles were selected to be analyzed in this systematic review. Conclusions: unexpectedly, the majority of the reviewed articles conclude that regardless of the intubation protocol or the tools used, the aspect that plays a decisive role in the management of the difficult airway is the experience and previous preparation of the anesthesiologist (AU))

Aplicaciones diagnósticas y terapéuticas del videolaringoscopio C-MAC® en cirugía de vía aérea pediátrica / Diagnostic and therapeutic applications of the C-MAC® videolaryngoscope in pediatric airway surgery

Resumen La patología quirúrgica de la vía aérea pediátrica suele ser desafiante. Una visualización adecuada de las estructuras faríngeas y laríngeas es absolutamente necesaria para su correcto diagnóstico y tratamiento. Distintos instrumentos, como laringoscopios de intubación, laringoscopios de suspensión y broncoscopios flexibles o rígidos, permiten acceder a la vía aérea. Muchas veces se requiere el uso de una combinación de ellos para abordar con éxito estos problemas. En esta revisión, discutimos el uso de videolaringoscopios en el manejo de condiciones como estenosis subglótica, lesiones de vía aérea y cuerpos extraños. Aunque los anestesiólogos los utilizan frecuentemente para intubaciones difíciles debido a su cámara incorporada que facilita la visión de las estructuras laríngeas, existen escasos informes sobre su uso por cirujanos de vía aérea. Las ventajas sobre la laringoscopía convencional incluyen una mejor visualización, la capacidad de supervisar el procedimiento a través de una pantalla, una mejor ergonomía, que es portátil y que permite una rápida inserción de diferentes instrumentos. Consideramos que es particularmente útil en la dilatación de estenosis subglóticas. Presentamos un método fácil, barato y reproducible para realizarla.

Abstract Surgical pediatric airway diseases are often challenging, and an adequate visualization of pharyngeal and laryngeal structures is absolutely necessary for their correct diagnosis and treatment. Different instruments such as intubation laryngoscopes, suspension laryngoscopes and flexible and rigid bronchoscopes allow for access to the airway, and using a combination of them, is usually required to successfully address these problems. In this review, we discuss the use of videolaryngoscopes in the management of conditions such as subglottic stenosis, airway lesions and foreign bodies. Although commonly used by anesthesiologists for difficult intubations because of their built-in cameras that facilitate the view of laryngeal structures, there are scarce reports on its use by airway surgeons. Advantages over standard laryngoscopy include improved visualization and the ability to supervise the procedure through a screen. We also consider that it allows for improved ergonomics, portability and fast insertion of different instruments. We have found it to be particularly useful in subglottic stenosis dilation and an easy, cheap and reproducible method is also presented.

Simulación de intubación pediátrica con videolaringoscopio de bajo costo en contexto de pandemia por COVID-19 / Simulation of pediatric intubation using a low-cost videolaryngoscope in the setting of the COVID-19 pandemic

En pacientes con infección por SARS-CoV-2 la intubación endotraqueal es un procedimiento con riesgo elevado de contagio. La videolaringoscopia complementa la protección del profesional, pero los videolaringoscopios comerciales son caros y no siempre están disponibles en las terapias intensivas pediátricas argentinas. El objetivo fue describir la práctica de intubación en un modelo de cabeza de simulación de lactante con un videolaringoscopio artesanal de bajo costo.Quince pediatras sin experiencia previa con el dispositivo participaron de una práctica de intubación en una cabeza de simulación con un videolaringoscopio artesanal. El tiempo promedio del primer intento fue de 116,4 segundos (intervalo de confianza del 95 % [IC95 %]: 84,8-148,0) y, el del siguiente fue de 44,2 segundos (IC95 %: 27,7­60,6). El tiempo disminuyó de forma significativa en el segundo intento (p : 0,0001). El dispositivo permitió la intubación exitosa en todos los intentos acortando la duración del procedimiento en la segunda práctica

In patients with SARS-CoV-2 infection, endotracheal intubation is a procedure with a high risk for transmission. A videolaryngoscopy is a supplementary level of health care provider protection, but commercial videolaryngoscopes are expensive and not always available in pediatric intensive care units in Argentina. Our objective was to describe intubation practice using an infant head mannequin with a low-cost, handcrafted videolaryngoscope.Fifteen pediatricians with no prior experience using the device participated in an intubation practice in a head mannequin with a handcrafted videolaryngoscope. The average time for the first attempt was 116.4 seconds (95 % confidence interval [CI]: 84.8-148.0) and, for the second one, 44.2 seconds (95 % CI: 27.7-60.6). Time decreased significantly for the second attempt (p: 0.0001).A successful intubation was achieved with the device in all attempts, and the procedure duration decreased with the second practice

Renal replacement therapy by the popliteal vein in a critical patient with COVID-19 in the prone position / Terapia renal substitutiva pela veia poplítea em paciente crítico com COVID-19 na posição de pronação

Abstract This patient was a 73-year-old man who initially came to our service with acute respiratory failure secondary to COVID-19. Soon after hospitalization, he was submitted to orotracheal intubation and placed in the prone position to improve hypoxia, due to severe acute respiratory syndrome (SARS). On the third day of hospitalization, he developed acute oliguric kidney injury and volume overload. The nephrology service was activated to obtain deep venous access for renal replacement therapy (RRT). The patient could not be placed in the supine position due to significant hypoxemia. A 50-cm Permcath (MAHURKARTM, Covidien, Massachusetts, USA) was inserted through the left popliteal vein. This case report describes a possible challenging scenario that the interventional nephrologist may encounter when dealing with patients with COVID-19 with respiratory impairment in the prone position.

Resumo O paciente era um homem de 73 anos de idade que inicialmente veio ao nosso serviço com insuficiência respiratória aguda secundária à COVID-19. Logo após a internação, ele foi submetido à intubação orotraqueal e pronado para melhorar a hipóxia devido à síndrome respiratória aguda grave (SARS - do inglês "severe acute respiratory syndrome"). No terceiro dia de internação, o mesmo desenvolveu lesão renal aguda oligúrica e sobrecarga de volume. O serviço de nefrologia foi acionado para realizar acesso venoso profundo para terapia renal substitutiva (TRS). O paciente não pôde ser colocado na posição de decúbito dorsal devido a uma hipoxemia significativa. Um Permcath de 50 cm (MAHURKARTM, Covidien, Massachusetts, EUA) foi inserido através da veia poplítea esquerda. Este relato de caso descreve um possível cenário desafiador com o qual o nefrologista intervencionista pode se deparar ao lidar com pacientes com COVID-19 com problemas respiratórios e colocados em pronação.

Consenso para el manejo de la analgesia, sedación y delirium en adultos con síndrome de distrés respiratorio agudo por COVID-19 / Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome

RESUMEN Objetivo: Proponer estrategias agile para este abordaje integral de la analgesia, sedación, delirium, implementación de movilidad temprana e inclusión familiar del paciente con síndrome de dificultad respiratoria aguda por COVID-19, considerando el alto riesgo de infección que existe entre los trabajadores de salud, el tratamiento humanitario que debemos brindar al paciente y su familia, en un contexto de falta estrategias terapéuticas específicas contra el virus globalmente disponibles a la fecha y una potencial falta de recursos sanitarios. Metodos: Se llevó a cabo una revision no sistemática de la evidencia científica en las principales bases de datos bibliográficos, sumada a la experiencia y juicio clínico nacional e internacional. Finalmente, se realizó un consenso de recomendaciones entre los integrantes del Comité de Analgesia, Sedación y Delirium de la Sociedad Argentina de Terapia Intensiva. Resultados: Se acordaron recomendaciones y se desarrollaron herramientas para asegurar un abordaje integral de analgesia, sedación, delirium, implementación de movilidad temprana e inclusión familiar del paciente adulto con síndrome de dificultad respiratoria aguda por COVID-19. Discusión: Ante el nuevo orden generado en las terapias intensivas por la progresión de la pandemia de COVID-19, proponemos no dejar atrás las buenas prácticas habituales, sino adaptarlas al contexto particular generado. Nuestro consenso está respaldado en la evidencia científica, la experiencia nacional e internacional, y será una herramienta de consulta atractiva en las terapias intensivas.

ABSTRACT Objective: To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources. Methods: A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva. Results: Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19. Discussion: Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.

Comparación de máscaras laríngeas (I-gel Fastrach) para realización de intubación endotraqueal guiada con broncofibroscopio flexible / Comparison of I-gel Fastrach laryngeal masks in conducting flexible bronchofiberscope-guided

GOALS: Determine the success rate of guided intubation with a flexible bronchofibroscope (BFC) through supraglottic devices: I-gel or Fastrach, establish the degree of fibroscopic visualization and determine the insertion time of the laryngeal mask airway (LMA) and endotracheal intubation. METHODS: Experimental, prospective, comparative and randomized study of 60 ASA I-II-III patients, older than 18 years, undergoing elective surgeries that required general anesthesia and endotracheal intubation. After anesthetic induction, the assigned LMA was placed and intubation with BFC was performed through it. Both the success of laryngeal mask insertion and intubation were recorded, as well as the time (in seconds) equired for these procedures. The vision of the laryngeal structures was classified according to the Brimacombe Scale. RESULTS: The groups analyzed presented similar general characteristics. Insertion time of he LMA was significantly lower with I-gel than Fastrach (median 12 s vs 16 s. Respectively, p = 0.001). Also, in the intubation time BFC guided through the laryngeal mask, differences in favor of I-gel were found, with a median of 72 s. vs 89 s. (p = 0.001). Regarding the degree of glottic visualization with BFC, no statistically significant differences were found between both groups.CONCLUSIONS: Although both devices had the highest success rate (both in their placement and in intubation through them), with I-gel the intubation was performed quicker.

OBJETIVOS: Determinar la tasa de éxito de intubación guiada con broncofibroscopio flexible (BFC) a través de los dispositivos supraglóticos: I-gel o Fastrach, establecer el grado de visualización fibroscópica y determinar el tiempo de inserción de la máscara laríngea y de intubación endotraqueal. MATERIALES Y MÉTODOS: Estudio experimental, prospectivo, comparativo y aleatorizado de 60 pacientes ASA I- II ­III, mayores de 18 años, sometidos a cirugías electivas que requerían anestesia general e intubación endotraqueal. Luego de la inducción anestésica, se procedió a colocar la máscara laríngea asignada y se realizó la intubación con BFC a través de la misma. Tanto el éxito de inserción de máscara laríngea como de intubación fueron registrados, así como el tiempo (en segundos) requerido para dichos procedimientos. La visión de las estructuras laríngeas fue clasificada de acuerdo a Escala de Brimacombe. RESULTADOS: Los grupos analizados presentaron características generales similares. El tiempo de inserción de la ML fue significativamente menor con I-gel que con Fastrach (medianas: 12 s. vs 16 s. respectivamente, p = 0,001). También en el tiempo de intubación guiada con BFC a través de la máscara laríngea, se encontraron diferencias en favor de I-gel, con una mediana de 72 s. vs 89 s. (p = 0,001). Respecto al grado de visualización glótica con BFC, no se encontraron diferencias estadísticamente significativas entre ambos grupos. CONCLUSIONES: Aunque ambos dispositivos tuvieron la máxima tasa de éxito (tanto en su colocación como en la intubación a través de ellos), con I-gel se realizó la intubación de manera más rápida.

Caracterización de estenosis traqueal por intubación prolongada en pacientes adultos / Characterization of tracheal stenosis by prolonged Intubation in adult patients

La estenosis traqueal es la disminución del calibre de la luz laríngea y traqueal como resultado de la maduración de tejido cicatrizal por lesión isquémica que el balón del tubo endotraqueal produce sobre las mucosas de la pared laringo traqueal cuando es insuflada por encima de la presión capilar (20-30 mm Hg) por un periodo incluso corto. La Asociación Americana de Cuidados Respiratorios recomienda que se utilice intubación para aquellos pacientes que ameriten ventilación mecánica por 7-10 días o menos y traqueostomía para aquellos pacientes que necesitan ventilación por más tiempo. Objetivo: Caracterizar la estenosis traqueal por intubación prolongada. Metodología: Se realizó un estudio descriptivo, retrospectivo que incluyó pacientes adultos con diagnóstico de estenosis traqueal por intubación mayor de 7 días en el Hospital General San Juan de Dios durante enero 2016 a diciembre 2019. Se evaluaron los datos epidemiológicos, clínicos, diagnóstico y terapéuticos en los registros clínicos de los servicios de cirugía torácica, otorrinolaringología y neumología. Resultados: Se evaluaron 52 pacientes adultos con intubación traqueal prolongada que desarrollaron estenosis traqueal. La mayoría son hombres jóvenes con mediana de intubación de dos semanas, la indicación de intubación más frecuente fue por trauma craneoencefálico severo. La forma de diagnóstico más frecuente fue clínico seguido por radiografía y tomografía teniendo en su mayoría estenosis tipo I y II. La mayoría de los pacientes con estenosis traqueal son tratados de manera quirúrgica, comúnmente con traqueostomía, dos semanas después del primer día de intubación. La única variable asociada al tipo de tratamiento fue que se le realizara al paciente una traqueotomía, la cual fue la forma de tratamiento quirúrgico de la mayoría de los pacientes para la corrección de la estrechez traqueal (p=0.01). Conclusiones: el tiempo de intubación endotraqueal es determinante para el desarrollo de la estenosis traqueal. En este estudio se documentaron 52 pacientes que recibieron intubación traqueal prolongada y desarrollaron estenosis traqueal tras una mediana de intubación de dos semanas, lo cual deberá hacernos reflexionar sobre las prácticas y guías para implementar la realización de traqueostomías tempranas en pacientes ventilados después de 7 días (AU)

Tracheal stenosis is the decrease in the caliber of the laryngeal and tracheal lumen as a result of the maturation of scar tissue due to ischemic injury that the balloon of the endotracheal tube produces on the mucosa of the laryngo-tracheal wall when it is insufflated above capillary pressure (20-30 mm Hg) for an even short period. The American Association for Respiratory Care recommends that intubation be used for those patients who require mechanical ventilation for 7-10 days or less and tracheostomy for those patients who require ventilation for longer. Objective: To characterize tracheal stenosis due to prolonged intubation. Methodology: A descriptive, retrospective study was carried out that included adult patients with a diagnosis of tracheal stenosis due to intubation greater than 7 days at the San Juan de Dios General Hospital from january 2016 to december 2019. Epidemiological, clinical, diagnostic and therapeutic data were evaluated in the clinical records of the thoracic surgery, otorhinolaryngology and pulmonology services. Results: 52 adult patients with prolonged tracheal intubation who developed tracheal stenosis were evaluated. Most are young men with a median intubation of two weeks, the most frequent indication for intubation was for severe head trauma. The most frequent form of diagnosis was clinical followed by radiography and tomography, mostly type I and II stenosis. Most patients with tracheal stenosis are treated surgically, commonly with a tracheostomy, two weeks after the first day of intubation. The only variable associated with the type of treatment was that the patient underwent a tracheostomy, which was the form of surgical treatment for most patients to correct the tracheal narrowing (p = 0.01). Conclusions: endotracheal intubation time is decisive for the development of tracheal stenosis. In this study, 52 patients who received prolonged tracheal intubation and developed tracheal stenosis after a median intubation of two weeks were documented, which should make us reflect on the practices and guidelines for implementing early tracheostomies in patients ventilated after 7 days

Effectiveness of simplified predictive intubation difficulty score and thyromental height in head and neck surgeries: an observational study / Eficácia do escore simplificado preditivo de dificuldade de intubação e da altura tiromentoniana em cirurgias de cabeça e pescoço: estudo observacional

Abstract Background and objectives: In this study, we aimed to investigate the predictive value of different airway assessment tools, including parts of the Simplified Predictive Intubation Difficulty Score (SPIDS), the SPIDS itself and the Thyromental Height Test (TMHT), in intubations defined as difficult by the Intubation Difficulty Score (IDS) in a group of patients who have head and neck pathologies. Methods: One hundred fifty-three patients who underwent head and neck surgeries were included in the study. The Modified Mallampati Test (MMT) result, Thyromental Distance (TMD), Ratio of the Height/Thyromental Distance (RHTMD), TMHT, maximum range of head and neck motion and mouth opening were measured. The SPIDSs were calculated, and the IDSs were determined. Results: A total of 25.4% of the patients had difficult intubations. SPIDS scores >10 had 86.27% sensitivity, 71.57% specificity and 91.2% Negative Predictive Value (NPV). The results of the Receiver Operating Curve (ROC) analysis for the airway screening tests and SPIDS revealed that the SPIDS had the highest area under the curve; however, it was statistically similar to other tests, except for the MMT. Conclusions: The current study demonstrates the practical use of the SPIDS in predicting intubation difficulty in patients with head and neck pathologies. The performance of the SPIDS in predicting airway difficulty was found to be as efficient as those of the other tests evaluated in this study. The SPIDS may be considered a comprehensive, detailed tool for predicting airway difficulty.

Resumo Justificativa e objetivos: Neste estudo, avaliamos o valor preditivo de diferentes ferramentas de avaliação das vias aéreas, incluindo componentes do Escore Simplificado Preditivo de Intubação Difícil (ESPID), o próprio ESPID e a Medida da Altura Tireomentoniana (MATM), em intubações definidas como difícies pelo Escore de Dificuldade de Intubação (EDI) em um grupo de pacientes com patologia de cabeça e pescoço. Método: Incluímos no estudo 153 pacientes submetidos a cirurgia de cabeça e pescoço. Coletamos os resultados do Teste de Mallampati Modificado (TMM), Distância Tireomentoniana (DTM), Razão Altura/Distância Tireomentoniana (RADTM), MATM, amplitude máxima de movimentação da cabeça e pescoço e da abertura da boca. Os ESPIDs foram calculados e os EDIs, determinados. Resultados: Observamos intubação difícil em 25,4% dos pacientes. Os escores de ESPID > 10 tiveram sensibilidade de 86,27%, especificidade de 71,57% e valor preditivo negativo de 91,2% (VPN). O resultado da análise da curva de operação do receptor (curva ROC) para os testes de avaliação das vias aéreas e ESPID mostrou que o ESPID tinha a maior área sob a curva; no entanto, foi estatisticamente semelhante a outros testes, exceto para o TMM. Conclusões: O presente estudo demonstra o uso prático do ESPID na previsão da dificuldade de intubação em pacientes com patologia de cabeça e pescoço. O desempenho do ESPID na predição de via aérea difícil mostrou-se tão eficiente quanto os demais testes avaliados neste estudo. O ESPID pode ser considerado ferramenta abrangente e detalhada para prever via aérea difícil.