In-office Laryngeal Procedures: a Modern Perspective for Vocal Fold Interventions

Introduction: The purpose of this article is to discuss in-office laryngeal procedures as an alternative to surgical intervention under general anesthesia. In-office procedures have become more common due to technological advancements. As a result, these approaches are less invasive and more patient-friendly, with increased pain tolerance and reduced procedure time and cost. Methods: We conducted a thematic analysis of published reports regarding the best known and performed in-office laryngeal interventions. Three questions guided our analysis: What laryngological procedures can be performed in the office setting? What are the advantages of in-office laryngology procedures compared to operating room surgical procedures? Why aren't more in-office procedures performed in some Latin American countries? Discussion: Despite being performed more frequently, there is still controversy whether in-office procedures should be performed as often due to the risk of complications. Furthermore, procedures that are done in the office setting are more popular in some countries than in others, even though their benefit has been well demonstrated. This article describes various in-office procedures, including biopsy, vocal fold injections, and laser surgery. We also discuss what factors might contribute to having office-procedures being performed more frequently in some countries than others. Conclusion: Awake interventions offer numerous benefits, including shorter procedure time, reduced costs, and lower patient morbidity. These advantages have significantly transformed the treatment of laryngeal diseases in modern laryngology practice in a global manner.

Introducción: El propósito de este artículo es discutir los procedimientos laríngeos en el consultorio como una alternativa a la intervención quirúrgica bajo anestesia general. Los procedimientos en consultorio se han vuelto más comunes debido a los avances tecnológicos. Como resultado, estos enfoques son menos invasivos y más amigables para el paciente, con mayor tolerancia al dolor y reducción del tiempo y costo del procedimiento. Métodos: Realizamos un análisis temático de los informes publicados sobre las intervenciones laríngeas más conocidas y realizadas. Tres preguntas guiaron nuestro análisis: ¿Qué procedimientos laringológicos se pueden realizar en el consultorio y cuales sin los más frecuentes?, ¿cuáles son las ventajas de los procedimientos laringológicos fuera del quirófano frente a los que se realizan bajo anestesia general?, ¿por qué no se realizan más procedimientos laringológicos en el consultorio en la mayoría de los países en Latinoamérica? Discusión: A pesar de que se realizan con mayor frecuencia, aún existe controversia sobre si los procedimientos en consultorio deben realizarse con tanta frecuencia debido al riesgo de complicaciones. Además, los procedimientos que se realizan en el consultorio son más populares en algunos países que en otros, aunque sus beneficios han sido bien demostrados. Este artículo describe varios procedimientos en el consultorio, incluida la biopsia, las inyecciones de cuerdas vocales y la cirugía con láser. También se discutieron los factores que podrían contribuir a que los procedimientos en el consultorio se realicen con más frecuencia en algunos países que en otros. Conclusión: Las intervenciones con pacientes despiertos ofrecen numerosos beneficios, incluido un tiempo de procedimiento más corto, costos reducidos y una menor morbilidad para el paciente. Estas ventajas han transformado significativamente el tratamiento de las enfermedades laríngeas en la práctica de la laringología moderna a nivel mundial.

Awake craniotomy for eloquent pial arteriovenous fistula: anesthetic and surgical consideration of a rare case

Abstract Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function.

Diagnosis and prevalence of probable awake and sleep bruxism in adolescents: an exploratory analysis

Abstract The aims of this study were to perform an exploratory analysis of probable awake (AB) and sleep bruxism (SB) prevalence using of different diagnosis criteria based on the International Consensus; evaluate the associations between self-report and clinical signs/symptoms in adolescents. Participated in this cross-sectional study 403 adolescents aged 12- to 19-years-old enrolled in public and private schools from Belo Horizonte, Brazil. Parents/caregivers answered a questionnaire about sociodemographic status and adolescents' health status. Adolescents answered a questionnaire evaluating AB (e.g., grinding and clenching) and SB (e.g., grinding, bracing, and thrusting) activities and frequent headaches. A clinical examination was performed on adolescents to evaluate bruxism clinical signs/symptoms (pain upon palpation on masseter and temporal, linea alba, indentation on the tongue and attrition wear severity). Descriptive statistics and Pearson's Qui-square test were performed (P≤0.05). Adolescents mean age was 14.3±1.5 years, and 58.1% were female. Self-report of SB was identified in 31% of participants and self-report of AB in 51.6%. Almost all adolescents (99%) presented at least one tooth with attrition wear (98.5% on enamel and 0.5% on dentin), with a mean number of 12.4±5.7 teeth. Depending on the diagnosis criteria, the prevalence of probable SB and AB varied from 0- 99% and 0.2- 99%, respectively. A high inconsistency was found for the prevalence of probable AB and SB in adolescents, which were influenced by the different clinical sings/symptoms used as diagnosis criteria. Frequent headaches and pain upon palpation on masseter and temporal muscle were associated to self-report of AB and SB among adolescents.

Resumo Os objetivos deste estudo foram realizar uma análise exploratória da prevalência de provável bruxismo em vigília (BV)e do sono (BS) utilizando diferentes critérios de diagnóstico baseados no Consenso Internacional; avaliar a associação entre o autorrelato e os sinais/sintomas clínicos em adolescentes. Participaram deste estudo transversal 403 adolescentes de 12 a 19 anos de idade matriculados em escolas públicas e privadas de Belo Horizonte, Brasil. Os pais/responsáveis responderam um questionário sobre dados sociodemográficos e estado de saúde dos adolescentes. Os adolescentes relataram atividades do BV (ranger e apertar) e BS (ranger, bracing e thrusting) e dores de cabeça frequentes. Um exame clínico foi realizado nos adolescentes para avaliar os sinais/sintomas clínicos do bruxismo (dor à palpação nos músculos masseter e temporal, marcas de endentação na língua e linha alba, desgaste dentário por atrição). Análises descritiva e teste Qui-quadrado de Pearson foram realizados (P≤0,05). A média de idade dos adolescentes foi de 14,3±1,5 anos e 58,1% eram do sexo feminino. O autorrelato de BS foi identificado em 31% dos participantes e o autorrelato do BV em 51,6%. Quase a totalidade dos adolescentes (99%) apresentaram pelo menos um dente com desgaste dentário (98,5% em esmalte; 0,5% em dentina), com média de 12,4±5,7 dentes acometidos. Dependendo do critério de diagnóstico, a prevalência do provável BS e BV variou de 0- 99% e 0,2- 99%, respectivamente. Uma grande inconsistência foi identificada na prevalência de provável BV e BS em adolescentes, que foram influenciadas pelos diferentes sinais/sintomas usados como critério de diagnóstico. Dores de cabeça frequentes e dor à palpação no masseter e temporal foram associados ao autorrelato de bruxismo em crianças e adolescentes.

Application of a sleep electroencephalogram in the diagnosis of epilepsy in children / 中国基层医药

Objective:To investigate the significance of sleep electroencephalogram (EEG) monitoring in the diagnosis and differential diagnosis of childhood epilepsy.Methods:The clinical data of 56 children with epilepsy diagnosed in The Maternal and Child Health Hospital of Huainan from February 2020 to February 2022 were retrospectively analyzed. The relationship between the positive rate of epileptiform discharge under sleep EEG monitoring and its location and sleep phase was analyzed.Results:Of the 56 children, 36 (64%) children had normal results of routine awake EEG monitoring, and 20 (36%) children had abnormal results. Among the 56 children, 9 (16%) children had normal sleep and 47 (84%) had abnormal sleep. The difference in EEG monitoring results between the awake and asleep states was statistically significant ( χ2 = 27.08, P < 0.001). Among abnormal EEG in 47 patients, paroxysmal abnormality (epileptiform discharge) was found in 44 patients and non-specific abnormality was found in 3 patients. Among the 44 children with epileptic discharges, 5 (11%) had epileptic discharges during wakefulness, 11 (25%) children had epileptic discharges during a sleepless period, and 28 (64%) had epileptic discharges during a slight sleep period. EEG epileptiform discharges occurred in the central temporal region in 9 (21%) patients, temporal region in 8 (18%) patients, parieto-occipital region in 1 (2%) patient, frontal region in 5 (11%) patients, and the frontotemporal region in 6 (14%) patients. Generalized discharges were found in 14 (32%) patients, and generalized hypsarrhythmia was found in 1 (2%) patient. Conclusion:Children with clinically highly suspected epilepsy should be reexamined by sleep EEG if the routine awake EEG, monitoring results are normal, to reduce the rates of misdiagnosis and missed diagnosis in children with epilepsy.

Comparison of Ultrasound / Anatomical landmark guided technique for superior laryngeal nerve block along with Topical Anesthesia for awake nasal intubation in various Oral& faciomaxillary & Dental surgeries

ABSTRACT:Background: Endotracheal intubation is gold standard of general anesthesia. various oral,Maxillofacial, Dental surgeries are carried out in high-risk patients having chances ofdifficult intubation. If we give sedation or general anesthesia, we can be trapped in criticalairway accidents.Aims & objectives: To access & compare efficacy of anatomical landmark guided/Ultrasound guided superior laryngeal nerve block associated with topical Anesthesia &transtracheal block for awake blind nasal intubation.Method:Group A: Anatomical landmark guided superior laryngeal nerve block given(n=30)Group B: ultrasound guided superior laryngeal nerve block(n=30)In both groups topical Anesthesia & transtracheal block for awake blind nasal intubation wasgiven.Results: upper airway block provide clinical ease to facilitate blind nasal awake intubation.ultrasound guided block has less adverse reactions.Conclusion: Both methods provide good quality of Endotracheal intubation, but ultrasoundguided block is more efficient & scientific method to block superior laryngeal nerve forawake nasal intubation.

Abordaje perioperatorio en cirugía neurológica con el paciente despierto / Perioperative approach in neurological surgery with the patient awake

Resumen: La craneotomía con el paciente despierto se refiere a aquellos procedimientos en los que el paciente conserva su estado de consciencia durante toda la cirugía o en parte de ésta con el objetivo de explorar la integridad de sus funciones cerebrales superiores en tiempo real. Estas técnicas neuroanestésicas son útiles para ayudar al neurocirujano a preservar la integridad del tejido cerebral, o bien, no causar mayor daño del que la propia enfermedad ha causado.

Abstract: Awake craniotomy refers to those procedures in which the patient remains conscious for all or part the time, with the aim of explore in real time the integrity of their higher brain functions. This kind of neuroanesthetic techniques are useful in assisting the neurosurgeon to preserve the integrity of the brain or not to damage more than what the disease has caused.

Conciencia transoperatoria en personas operadas mediante craneotomía despierto / Intraoperative awareness in awake craniotomy patients

La craneotomía con paciente despierto (CPD) demanda un manejo multidisciplinario particular debido al componente de conciencia transoperatoria que aporta beneficios en la resección tumoral y preservación neurológica, pero también implica el manejo de los riesgos asociados a la necesidad de cooperación del paciente durante el procedimiento. En este trabajo se describen los beneficios y las complicaciones en pacientes operados bajo la modalidad de CPD. Además, se abordan los retos documentados tanto para el equipo profesional a cargo, como para los pacientes, los cuales tienen un rol activo durante la cirugía. En ese sentido, se exponen los criterios para la selección, preparación psicológica y neuropsicológica tanto previo como durante la cirugía. A su vez, se proponen las consideraciones para lograr un procedimiento exitoso y evitar las posibles secuelas psicológicas a largo plazo, como insumos para la protocolización de este tipo de procedimientos con base en nuestra experiencia.

Awake craniotomy (AC) requires a multidisciplinary management due to trans operative awareness, which benefits the tumor resection and neurologic preservation, but it also implies risks for the patient cooperation during the procedure. This article describes the benefits and complications in patients operated under AC. Besides, it approaches the documented challenges for both the professional team and patients, who have an active role during surgery. In this regard, the criteria for selection and psychological and neuropsychological preparation before and during surgery are set out. It suggests considerations to achieve a successful procedure and to avoid possible long- term psychological sequelae, as a resource for the protocol of this type of procedures based on our experience.

Bruxismo do sono e em vigília em adolescentes: prevalência, fatores associados e análise de caminhos / Sleep and awake bruxism in adolescents: prevalence, associated factors and pathways to occurrence

O Bruxismo é um comportamento, com atividade muscular mastigatória, que pode apresentar-se como bruxismo do sono (BS) e bruxismo em vigília (BV). Possui etiologia multifatorial, sendo pouco explorado entre adolescente. Essa tese é composta por dois artigos que avaliam a prevalência, fatores associados e análise de caminhos. O objetivo do artigo 1 (n=403) foi reconhecer os caminhos que influenciam a ocorrência de provável bruxismo do sono (PBS) e provável bruxismo em vigília (PBV) em adolescentes. O artigo 2 (n=342) objetivou avaliar a associação entre PBV e hábitos de morder, satisfação de vida, caracteristicas do sono e perfil cronotipo em adolescentes, por meio de um estudo caso-controle. Com aprovação do comitê de ética institucional, participaram do estudo adolescentes de 12 a 19 anos de idade, regularmente matriculados em escolas públicas e privadas de Belo Horizonte. Os pais/cuidadores responderam a um questionário sobre características do sono de seus filhos. Os adolescentes responderam aos seguintes instrumentos: questionário sobre hábitos de morder, características do sono e relato de bruxismo; a escala "The Circadian Energy Scale" (CIRENS), para mensurar o perfil cronotipo; e o dominio self da versão brasileira da Escala Multidimensional de Satisfação de Vida para Adolescentes (EMSVA). O PBS e PBV foram mensurados considerando o auto relato positivo, somado à presença de desgaste dentário por atrição aferido em exame clinico feito pela pesquisadora previamente calibrada. A análise descritiva foi incluida nos artigos 1 e 2. O artigo 1 usou a análise de caminhos, tecnica que descreve as dependências direcionadas entre um conjunto de variáveis. No artigo 2 foi feita regressão logistica condicional (OR) (p<0,05). Como resultados no artigo 1, verificou-se que 22,3% dos adolescentes apresentaram PBS e 51,1% PBV. As duas manifestações de bruxismo apresentaram associação entre si, com uma correlação moderada e positiva (ß= 0,390). Qualidade do sono e renda familiar tiveram um efeito direto sobre PBS (ß= - 0,138; ß=0,123; respectivamente) e em PBV (ß= - 0,155; ß=0,116; respectivamente), de modo que aqueles com maior renda e com má qualidade do sono tenderam a apresentar provável bruxismo tanto BS, quanto BV. Cronotipo teve efeito direto sobre o PBS, de modo que adolescentes com cronotipo matutino tenderam a ter o comportamento (ß= -0,102). Adolescentes que relataram babar no travesseiro enquanto dormiam (ß= 0,184) e/ou que tinham sono agitado (ß= 0,104) tenderam a apresentar PBS. Já no artgido 2 verificou-se que má qualidade do sono (OR=1,731, IC95% 1,054-2,842, p=0,030), hábito de morder objetos muitas vezes (OR=3,303, IC95% 1,631-6,690, p=0,001), hábito de morder ou apertar os lábios algumas vezes (OR=2,134, IC95% 1,230-3,702, p=0,007) e hábito de morder ou apertar os lábios muitas vezes nas duas semanas anteriores à avaliação (OR=2,355, IC95% 1,203- 4,608, p=0,012) foram associados à ocorrencia de PBV. Concluiu-se com o artigo 1 que o perfil cronotipo, renda familiar e caracteristicas do sono influenciaram no caminho percorrido pelo PBS, enquanto renda e qualidade do sono influenciam o PBV. Enquato atraves do artigo 2, concluiu- se que adolescentes com má qualidade do sono e que apresentam habitos de morder tiveram mais chance de apresentar PBV.

Bruxism is a behavior, with masticatory muscle activity, which can present itself as sleep bruxism (SB) and awake bruxism (AB). It has a multifactorial etiology, and is little explored among adolescents. This thesis is composed of two articles assessing prevalence, associated factors, and path analysis. The objective of article 1 (n=403) was to recognize the pathways influencing the occurrence of probable sleep bruxism (PSB) and probable awake bruxism (PAB) in adolescents. Paper 2 (n=342) aimed to evaluate the association between PSB and biting habits, life satisfaction, sleep characteristics and chronotype profile in adolescents by means of a case-control study. After approval by the institutional ethics committee, adolescents aged 12 to 19 years, regularly enrolled in public and private schools in Belo Horizonte, Brazil, participated in the study. Parents/caregivers answered a questionnaire about their children's sleep characteristics. The adolescents answered the following instruments: a questionnaire about biting habits, sleep characteristics and bruxism report; the Circadian Energy Scale (CIRENS), to measure the chronotype profile; and the self domain of the Brazilian version of the Multidimensional Life Satisfaction Scale for Adolescents (MLSSA). The PSB and PAB were measured considering the positive self-report, added to the presence of attrition dental wear measured in a clinical examination performed by a previously calibrated researcher. Descriptive analysis was included in articles 1 and 2. Article 1 used path analysis, a technique that describes the directed dependencies among a set of variables. In article 2, conditional logistic regression (OR) was performed (p<0.05). As results in article 1, it was found that 22.3% of the adolescents presented PSB and 51.1% PAB. The two manifestations of bruxism showed an association with each other, with a moderate and positive correlation (ß= 0.390). Sleep quality and family income had a direct effect on PSB (ß= - 0.138; ß=0.123; respectively) and on PAB (ß= -0.155; ß=0.116; respectively), so that those with higher income and poor sleep quality tended to show likely bruxism in both SB and AB. Chronotype had a direct effect on PSB, such that adolescents with morning chronotype tended to have the behavior (ß= -0.102). Adolescents who reported drooling on the pillow while sleeping (ß= 0.184) and/or who had restless sleep (ß= 0.104) tended to present PSB. In artgid 2, on the other hand, it was found that poor sleep quality (OR=1.731, 95%CI 1.054-2.842, p=0.030), habit of biting objects often (OR=3.303, 95%CI 1.631-6.690, p=0.001), habit of biting or tightening lips sometimes (OR=2, 134, 95%CI 1.230-3.702, p=0.007) and biting or lip-squeezing often in the two weeks prior to evaluation (OR=2.355, 95%CI 1.203- 4.608, p=0.012) were associated with the occurrence of PAB. It was concluded with article 1 that the chronotype profile, family income and sleep characteristics influence the path taken by PSB, while income and quality of sleep influence PAB. In article 2, it was concluded that adolescents with poor sleep quality and those with biting habits were more likely to present PAB.

Clinical study of awake prone positioning treatment in patients with common coronavirus disease 2019 caused by Omicron variant / 中华危重病急救医学

Objective:To evaluate the clinical effect of awake prone positioning (APP) for common coronavirus disease 2019 (COVID-19) caused by Omicron variant.Methods:Retrospectively analyze the clinical data of patients with COVID-19 caused by Omicron variant admitted by medical team of Tianjin Third Central Hospital during the period of supporting Tianjin COVID-19 designated hospital from January 8 to February 20, 2022. Patients who met the diagnostic criteria for common COVID-19 and had risk factors for developing severe disease or had pulse oxygen saturation (SpO 2) ≤0.93 after exercise without supplementary oxygen were enrolled. Patients were divided into APP group and control group according to whether they completed the daily 12-hours APP in the first three days after enrollment. Demographic characteristics, clinical symptoms, COVID-19 vaccination status, laboratory examination, disease progression (progression to severe), time to nucleic acid negative conversion, length of hospital stay, and adverse reactions and tolerability [visual analog scale (VAS) score (the higher the score, the worse the tolerability] during APP were evaluated in two groups. Interleukin-6 (IL-6), C-reactive protein (CRP), SpO 2/inhaled oxygen concentration (FiO 2) ratio and ROX index (ROXI) were compared between two groups at enrollment, 3rd and 7th day after enrollment. Results:There were no significant differences in demographic characteristics, clinical symptoms, vaccination rates of COVID-19 and laboratory tests between the two groups. There were no statistically significant differences in IL-6, CRP, SpO 2/FiO 2 ratio and ROXI between two groups at the time of enrollment. Compared with the group at the time of enrollment, SpO 2/FiO 2 ratio and ROXI in APP group increased significantly at the 3rd day after enrollment [SpO 2/FiO 2 ratio: 461.90 (457.10, 466.70) vs. 446.67 (437.14, 457.10), ROXI: 25.40 (23.33, 25.93) vs. 22.57 (21.86, 24.40), all P < 0.05], and the levels of IL-6 and CRP in control group were significantly increased [IL-6 (ng/L): 18.30 (6.50, 37.75) vs. 7.40 (5.10, 11.15), CRP (mg/L): 11.46 (2.11, 17.96) vs. 4.11 (1.72, 9.05), all P < 0.05]. At the 3rd day of enrollment, the levels of IL-6 and CRP in APP group were significantly lower than those in control group [IL-6 (ng/L): 7.35 (4.35, 12.80) vs. 18.30 (6.50, 37.75), CRP (mg/L): 4.52 (1.98, 9.66) vs. 11.46 (2.11, 17.96), all P < 0.05], while SpO 2/FiO 2 ratio and ROXI were significantly higher than those in control group [SpO 2/FiO 2 ratio: 461.90 (457.10, 466.70) vs. 446.67 (441.90, 459.52), ROXI: 25.40 (23.33, 25.93) vs. 23.31 (22.10, 24.66), all P < 0.05]. At the 7th day of enrollment,there were no significant differences in IL-6, CRP, SpO 2/FiO 2 ratio and ROXI between two groups. There were no severe cases in both groups. The time of nucleic acid negative conversion and length of hospital stay in APP group were significantly shorter than those in control group [10.0 (8.0, 12.0) days vs. 11.0 (9.0, 13.0) days, 12.0 (10.0, 14.0) days vs. 14.0 (12.0, 16.0) days, respectively, all P < 0.05]. The main adverse reaction during APP was back pain, and the incidence in APP group was slightly lower than that in control group, but the difference was not statistically significant [17.9% (17/95) vs. 26.5% (27/102), P = 0.149]. VAS score in control group was significantly higher than that in APP group [score: 2.5 (2.0, 4.0) vs. 2.0 (1.0, 3.0), P = 0.004]. Conclusions:In common COVID-19 patients caused by Omicron variant with high risk factors for progression to severe disease or decreased oxygen reserve capacity, early APP can shorten the time of nucleic acid negative conversion and the length of hospital stay, but its effect on preventing disease progression cannot be determined.

Abordaje de la vía aérea en el paciente neuroquirúrgico / Airway approach in the neurosurgical patient

Resumen: El abordaje de la vía aérea en el paciente neuroquirúrgico presenta grandes retos debido al escenario tan complejo al cual nos enfrentamos; debemos considerar las características propias del paciente, las comorbilidades presentes y la patología neurológica por la que va a ser intervenido. Conocer la patología neurológica y las implicaciones o repercusiones que ésta puede llegar a tener en el manejo de la vía aérea ayudarán a la toma de decisiones y conocer los retos y escenarios que se pudieran presentar durante el evento anestésico-quirúrgico.

Abstract: The approach to the airway in the neurosurgical patient presents great challenges due to the complex scenario we face; we must consider the patient's own characteristics, the co-morbidities present and the neurological pathology for which it is going to be intervened. Knowing the neurological pathology and the implications or repercussions that this may have over the management of the airway will help decision making and manage the challenges and scenarios that could arise during the anesthetic surgical event.

Craneotomía en el paciente despierto / Awake craniotomy

Introducción: La craneotomía con el paciente despierto es útil para lograr resecciones cerebrales amplias de lesiones de áreas elocuentes. Objetivo: Presentar un caso al que se le realizó la técnica dormido- despierto. Método: Se realizó la inducción de la anestesia con propofol/fentanilo/rocuronio y se colocó una mascarilla laríngea. Después del bloqueo de escalpe se mantuvo la infusión de propofol/fentanilo y lidocaína hasta que se realizó la craneotomía. Se disminuyó la velocidad de infusión y se mantuvo de esta manera hasta finalizada la intervención. Resultados: Se logró el despertar del paciente a los 13 minutos de reducida la infusión. Se mantuvo buena estabilidad hemodinámica, sin depresión respiratoria ni otras complicaciones. El paciente se mantuvo colaborador, respondió preguntas y movilizó sus extremidades. No presentó complicaciones posoperatorias. Discusión: Dentro de las técnicas anestésicas utilizadas en el mundo la dormido- despierto-dormido es la más popular; sin embargo, constituye una alternativa no dormir nuevamente al paciente ni reinstrumentar la vía respiratoria. Los medicamentos más empleados son el propofol/remifentanilo, aunque la comparación con otros opioides no arrojan diferencias significativas; aunque sí supone un beneficio adicional la dexmedetomidina. Conclusiones: La craneotomía con el paciente despierto es posible de realizar en el entorno hospitalario siempre que exista un equipo multidisciplinario que consensue las mejores acciones médicas para el paciente(AU)

Introduction: Awake craniotomy is useful to achieve wide brain resections of lesions in eloquent areas. Objective: To present the case of a patient who was operated on with the asleep-awake-asleep technique. Method: Anesthesia was induced with propofol-fentanyl-rocuronium and a laryngeal mask was placed. After scalp block, the propofol-fentanyl and lidocaine infusion was maintained until craniotomy was performed. The infusion rate was decreased and remained this way until the end of the intervention. Results: The patient was awakened thirteen minutes after the infusion was reduced. Good hemodynamic stability was maintained, without respiratory depression or other complications. The patient remained collaborative, answered questions, and mobilized his limbs. He had no postoperative complications. Discussion: Among the anesthetic techniques used in the world, asleep-awake-asleep is the most popular. However, it is an alternative not to put the patient back to sleep or re-instrument the airway. The most commonly used drugs are propofol-remifentanil, although the comparison with other opioids does not show significant differences, except for dexmedetomidine, which does represent an additional benefit. Conclusions: Awake craniotomy is possible to be performed in the hospital setting as long as there is a multidisciplinary team that agrees on the best medical actions for the patient(AU)

Angina de Ludwig en la paciente embarazada. Reporte de un caso / Ludwig's angina in the pregnant patient. A case report

Resumen: Introducción: La angina de Ludwig es una patología odontogénica de origen infeccioso que involucra los espacios submaxilar, sublingual y submentoniano y que compromete de forma notable la vía aérea. El mantenimiento de las vías respiratorias debe ser prioridad en el tratamiento de esta patología, ya que la asfixia por obstrucción es la primera causa de muerte en un primer momento. Caso clínico: Paciente de 22 años de edad con embarazo de 35.5 SDG con amenaza de parto pretérmino más angina de Ludwig, a la cual se le realizó cesárea Kerr y drenaje de absceso profundo de cuello bajo anestesia regional y anestesia general balanceada con intubación con paciente despierta. Discusión: La angina de Ludwig debido a la distorsión anatómica condiciona vía aérea difícil y esto se exacerba aunado al embarazo a causa de los cambios anatómicos que ocurren, lo que nos obliga a la intubación endotraqueal con la paciente despierta de primera intención para asegurar la vía aérea.

Abstract: Introduction: Ludwig's angina is an odontogenic pathology of infectious origin that involves the submaxillary, sublingual and submental spaces and that significantly com-promises the airway. The maintenance of the respiratory tract must be a priority in the treatment of this pathology since asphyxia by obstruction is the first cause of death at first. Case report: A 22-year-old patient with a 35.5 SDG pregnancy plus preterm labor threat plus Ludwig's angina, who underwent cesarean Kerr and deep neck abscess drainage under regional anesthesia plus balanced general anesthesia with intubation with awake patient. Discussion: Ludwig's angina due to anatomical distortion conditions difficult air-way and this together with pregnancy exacerbates it due to the anatomical changes that exist in it, it forces us to endotracheal intubation with the awake patient of first intention to ensure the pathway aerial.

Challenges in the performance of awake craniotomies in the Philippine General Hospital: A case series

@#Awake craniotomy is a neurosurgical technique that involves an awake neurological testing during the resection of an intracranial lesion in eloquent cerebral cortical areas representing motor, language, and speech. This technique is highlighted by an intra-operative cortical mapping that requires active participation by the patient and poses unique challenges to the anesthesiologist. The surgical and anesthetic techniques have evolved significantly over time, as the neurosurgeon and the anesthesiologist learn new steps in making this technique safe to achieve reasonable patient satisfaction. A thorough understanding of this surgical technique's rationale will guide the anesthesiologist in planning the anesthetic management depending on the surgery and neurologic testing. Constant communication between the neurosurgeon, anesthesiologist, and the patient will define this surgical technique's success. It is already a well-established procedure; however, factors that contribute to failures in awake craniotomy procedures have not been well characterized in the literature. Failure is defined as the inability to conduct awake neurologic testing during the awake craniotomy procedure because of various factors which will be described. This paper aims to review the challenges in the performance of three (3) cases of awake craniotomies performed in the Philippine General Hospital. The challenges described in these three (3) cases reveal that this can be experienced by the neurosurgeon, neuroanesthesiologist, and most especially the patient in an acute critical condition. Identification of the procedures' failure and the steps taken to manage such situations with the patient's safety in mind are discussed.

Manejo de vía aérea en pandemia. Caso clínico / Difficult airway during pandemia: Case report

We present a 38 years female patient with known difficult airway associated with an important anatomic deformation due to a tumoral removal back in 2014 (maxilectomy). This patient was scheduled for a new tumoral resection at the base of the skull, which was considered a potential regrowth of her maxilar sinus cancer, and because of that, the surgery admitted no delays. A multi-disciplinary approach is convenied and an AFOI with topical airway anesthesia and dexmedetomidine sedation is planned to secure the airway during surgery. The main Objective was to optimize the protective measures against SARS CoV2 transmission while securing spontaneous ventilation and patient collaboration during the procedure. To achieve this it was necessary a complex and multi-disciplinary teamwork between de intervening personal. Eventually the airway approach was successful and the surgery was carried out uneventfully. The patient was extubate and taken to the post anesthesia care unit with no recall nor sequel of the procedure.

Presentamos un caso de una paciente de 38 años con predictores de vía aérea dificultosa anticipada, asociada a importante alteración anatómica secundaria a maxilectomía, por patología tumoral, en el año 2014. Actualmente, se sometió a resección tumoral de base de cráneo, considerada una patología no diferible (tiempo sensible) en el contexto de pandemia por COVID-19. Decidimos aplicar un plan de manejo multidisciplinario e intubación orotraqueal vigil mediante fibrobroncoscopia asociada a sedación superficial con dexmedetomidina y anestesia tópica. El objetivo principal fue maximizar las medidas de seguridad, manteniendo la ventilación espontánea y colaboración de la paciente durante el procedimiento. Finalmente, resultó exitoso, siendo la paciente extubada en el quirófano pasando luego a la Unidad de Recuperación Postanestésica, sin manifestar recuerdos ni secuelas del procedimiento realizado para concluir su postoperatorio en sala común.

Experiencia emocional percibida por pacientes sometidos a craneotomía con despertar intraoperatorio / Emotional experience perceived by patients undergoing craniotomy with intraoperative awakening / Experiência emocional percebida por pacientes submetidos à craniotomia com despertar intraoperatório

Resumen: Introducción: la craneotomía vigil para el tratamiento de tumores cerebrales en áreas elocuentes es una técnica que se realiza en forma cada vez más frecuente. Sin embargo, muy poca literatura se ha publicado en referencia a cómo percibe el paciente esta experiencia que podría parecer estresante. El objetivo de este trabajo es describir la experiencia emocional de los pacientes sometidos a despertar intraoperatorio para el tratamiento de los gliomas. Materiales y Métodos: Se realizó una revisión retrospectiva de 16 pacientes operados entre enero de 2015 y octubre de 2017, a los cuales se les efectuó una craneotomía con despertar intraoperatorio. Se identificaron 6 pacientes que cumplieron con los criterios de inclusión. Posteriormente a la cirugía se realizó, en una primera instancia, encuestas estandarizadas en donde se evaluó: datos sociodemográficos, nivel de ansiedad durante el despertar intraoperatorio, miedo a la anestesia y nivel de información de la enfermedad. En una segunda instancia, se le realizó una entrevista subjetiva por parte de un Licenciado en Psicología. Resultados: De los datos sociodemográficos obtuvimos que el 67% son hombres, y que la media de edad era de 30,66 años. En cuanto a la ansiedad observamos que el 60% de los pacientes tenían un nivel de ansiedad bajo, el 40% un nivel de ansiedad medio, y destacamos que ningún paciente tuvo un nivel de ansiedad alto. Con respecto al miedo a la anestesia y acto quirúrgico el 67% no tuvo miedo, mientras que el 37% restante afirman tenerlo, y los motivos más frecuentes para ello fueron: a morir, y a quedar con secuelas. En cuanto al nivel de información que fue proporcionada por el médico, en un 17% fue excelente, 33% muy completa, el 33% indicaron que la información fue suficiente y el 17% restante indica que la misma fue escasa. Conclusión: Destacamos que la cirugía con despertar intraoperatorio es bien tolerada. De las lecciones prácticas aprendidas enfatizamos la importancia de la entrevista preoperatoria en donde se explican con detalle el objetivo del procedimiento y cuáles son los pasos a seguir, para de esta manera maximizar la cooperación.

Abstract: Introduction: awake craniotomy for brain tumors surgery is a technique that is performed for tumors located on eloquent areas. However, a few articles has been published in reference to how the patient perceives this experience. Our objective is to describe the emotional experience of patients undergoing intraoperative awakening for the treatment of gliomas. Materials and Methods: Retrospective review of 16 patients operated between January 2015 and October 2017, who underwent awake craniotomy. Six patients who met the inclusion criteria were identified. After the surgery, standardized surveys were carried out, in the first instance, where the following were evaluated: sociodemographic data, level of anxiety during intraoperative awakening, fear of anesthesia and level of information about the disease. In a second instance, a subjective interview was conducted by a Psychologist. Results: There were 4 mans and 2 womens with average age was 30.66 years. Regarding anxiety, we observed that 60% of patients had a low anxiety level, 40% had a medium level of anxiety, and we emphasized that no patient had a high level of anxiety. Regarding the fear of anesthesia and surgery, 67% were not afraid, while the remaining 37% claim to have fear of death or sequelae. Regarding the level of information that was provided by the doctor, 17% was excellent, 33% very complete, 33% indicated that the information was sufficient and the remaining 17% indicated that it was scarce. Conclusion: We emphasize that surgery with intraoperative awakening is well tolerated. From the practical lessons learned we emphasize the importance of the preoperative interview where the objective of the procedure is explained in detail and which are the steps to follow, in order to maximize cooperation.

Resumo: Introdução: A craniotomia de vigília para o tratamento de tumores cerebrais em áreas eloqüentes é uma técnica cada vez mais realizada. No entanto, muito pouca literatura foi publicada em referência a como o paciente percebe essa experiência que pode parecer estressante. O objetivo deste trabalho é descrever a experiência emocional de pacientes submetidos ao despertar intraoperatório para o tratamento de gliomas. Materiais e Métodos: Revisão retrospectiva de 16 pacientes operados entre janeiro de 2015 e outubro de 2017, submetidos à craniotomia com despertar intraoperatório. Foram identificados seis pacientes que preencheram os critérios de inclusão. Após a cirurgia, em primeira instância, foram realizados inquéritos padronizados, nos quais foram avaliados: dados sociodemográficos, nível de ansiedade durante o despertar intraoperatório, medo da anestesia e nível de informação sobre a doença. Em um segundo momento, uma entrevista subjetiva foi conduzida por um Bacharel em Psicologia. Resultados: A partir dos dados sociodemográficos, obtivemos que 67% são homens e a idade média foi de 30,66 anos. Em relação à ansiedade, observamos que 60% dos pacientes apresentavam baixo nível de ansiedade, 40% apresentavam nível médio de ansiedade e enfatizamos que nenhum paciente apresentava alto nível de ansiedade. Com relação ao medo da anestesia e da cirurgia, 67% não temeram, enquanto os 37% restantes afirmaram tê-lo, e os motivos mais frequentes foram: morrer e ficar com seqüelas. Em relação ao nível de informação que foi fornecido pelo médico, 17% foi excelente, 33% muito completo, 33% indicaram que a informação era suficiente e os 17% restantes indicaram que esta era escassa. Conclusão: Enfatizamos que a cirurgia com despertar intraoperatório é bem tolerada. A partir das lições práticas aprendidas, enfatizamos a importância da entrevista pré-operatória, onde o objetivo do procedimento é explicado em detalhes e quais são os passos a seguir, a fim de maximizar a cooperação.

Airway Management In Extensive Facial Burns- A Case Report

Anesthetic management of burns of the head, neck, face and upper airway needs special precautions as establishing the airway provides challenges to the anesthesiologist. A 27 year old female presented with acute second degree thermal burns of the head, neck, face, shoulders and was posted for emergency escharotomy and dressing. Her scalp hair was singed, nasal mucosa was burnt and her whole face and neck were burnt with huge blisters and raw areas over the chest, shoulders and both upper limbs. Intravenous line was established through the right femoral vein and she was resuscitated with ringer lactate. Holding the face mask was impossible in view of her facial burns. Awake oro tracheal intubation was done by fiber optic onchoscopy guidance and airway was established successfully. Anesthesia was maintained by titrated doses of opioids, non-depolarising muscle relaxants and inhalational agents. She recovered well and was extubated awake. Hence awake fiber optic onchoscope guided intubation can be done to establish the airway in extensive head, neck, face and upper airway burns.

Application of wide awake local anesthesia no tourniquet in wrist arthroscopy / 中华创伤骨科杂志

Objective To explore the effectiveness of wide awake local anesthesia no tourniquet (WALANT) in arthroscopy for diagnosis and treatment of wrist injuries and conditions.Methods Between January 2012 and January 2016,WALANT approach was used in wrist arthroscopy for 22 patients with wrist injury or condition at Department of Hand Surgery,Beijing Jishuitan Hospital.They were 10 males and 12 females,aged from 19 to 56 years(average,34 years).Arthroscopic exploration was conducted in 7 cases,arthroscopic synovectomy in 6,dorsal wrist ganglionectomy in 3,triangular fibrocartilage complex (TFCC) debridement in 5 and TFCC repair in one.All the patients were anesthetized using portal site local anesthesia (PSLA) technique.Additional local infiltration around ulnar-sided wrist incisions was performed in 2 TFCC repairs.Bupivacaine was used for both techniques.The effects were evaluated using a ten-point visual analogue scale (VAS).Results Desired objectives were achieved in all patients.No operative complication was observed.Mild pain was noted in all the patients when local anesthetic was injected to the portal sites,with an average VAS score of 2.5 points (from 1 to 3 points).In the following arthroscopic procedures,most of the patients did not report any discomfort.Only one patient undergoing TFCC repair reported mild pain (VAS score of 3 points) during ulnar-carpal suture procedure.Conclusion The new WALANT technique is safe,time-saving,economical and capable of pain control during arthroscopy for numerous wrist injuries and conditions.

Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review / 대한마취과학회지

Awake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as ‘supraglottic airway guided’ FBI (SAGFBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu Auragain™ SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an ‘awake test insertion’ of the SAD, an ‘awake look’ at the periglottic region, and an ‘awake test ventilation.’ In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.

Reliability and validity of Chinese version of sensory-motor function scale during awake craniotomy / 中华行为医学与脑科学杂志

Objective To translate English version of sensory-motor profile awake ( SMP-a) into Chinese version (the Chinese Version of SMP-a),and analyze the reliability and validity of the scale before and after craniotomy under awakening anesthesia. Methods Eighty-one patients whose tumors were located near or already in sensory-motor functional area were included in this study. Before and after awake cranioto-my,the Chinese version of SMP-a was used to accurately assess the sensory-motor function of each patient. Finally, the reliability and validity of the scale were analyzed by SPSS statistical software. Results Cronbach's α coefficient in the Chinese version of SMP-a was 0. 971,and Cronbach's α coefficient in the four subscales of face,hand,leg and sensation was 0. 965,0. 989,0. 981 and 0. 970,respectively. The test-retest reliability of the Chinese version of sensorimotor assessment scale was 0. 910,0. 904,0. 884,0. 898 and 0. 695 (total,face,hands,legs and sensory score respectively). The raters' consistency reliability was above 0. 949,0. 960,0. 934,0. 887 and 0. 660,respectively. The Pearson correlation coefficients of sensorimotor function score with SF-36 physiological function factors and KPS score were 0. 868 and 0. 790,respectively. Conclusion Before or after operation,the Chinese version of SMP-a has preferable reliability,internal con-sistency reliability and structural validity. It is feasible in awakening anesthesia craniotomy,and the degree of damage can be determined by repeated measurement of the sensorimotor sites that may be impaired by the patient.

Videotoracoscopía con anestesia peridural en paciente despierto / Epidural anesthesia for videoassisted thoracic surgery in awake patient

Video-assisted thoracic surgery (VATS) is traditionally performed under general anesthesia and endotracheal intubation with a double lumen tube. In recent years, a growing trend towards these procedures being performed under loco regional anesthesia, particularly under epidural block with or without sedation in patients in spontaneous ventilation has appeared. It can be used to perform procedures that include pneumothorax management, wedge resection, lobectomy and surgical reduction of lung volume. The most attractive reason is to eliminate the side effects related to general anesthesia looking for a lower perioperative risks and shorter hospital stays, especially in elderly patients and those with compromised respiratory function. The thoracic epidural anesthesia has been effective allowing an adequate surgical approach, guaranteeing an idoneus level of analgesia, an optimal oxygenation, and facilitating an early postoperative recovery. We present a case of a patient undergoing to lung biopsy performed by VATS patient under epidural block and Ramsay scale sedation level III in spontaneous ventilation, who was discharged 48 hours after the surgical procedure.

La cirugía torácica asistida por vídeo se realiza tradicionalmente bajo anestesia general e intubación endotraqueal con tubo de doble luz. En los últimos años ha existido una corriente creciente hacia la realización de estos procedimientos en pacientes bajo anestesia locorregional, particularmente con bloqueo epidural con o sin sedación y en ventilación espontánea, para procedimientos que incluyen manejo de neumotórax, resección en cuña, lobectomía y cirugía de reducción de volumen pulmonar. La razón más atractiva es evitar los efectos secundarios relacionados con la anestesia general en búsqueda de menor riesgo perioperatorio y menor estancia hospitalaria, especialmente en pacientes mayores y en aquellos con función respiratoria comprometida. La anestesia epidural torácico (AET) ha sido efectiva para permitir un adecuado abordaje quirúrgico, garantizando un idóneo nivel de anestesia, una correcta oxigenación y facilitando la recuperación posoperatoria precoz]. Se presenta el caso clínico de una biopsia pulmonar realizada mediante toracoscopia en un paciente bajo AET con sedación escala Ramsay III y en ventilación espontánea, quien fue dado de alta a las 48 horas posterior a la cirugía.