Medical intensivist directed VV ECMO cannulation for the facilitation of tracheostomy in a patient with severe tracheal stenosis: A case report

Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.

Surgical outcomes of breast conserving surgery performed under local versus general anaesthesia

Background: Surgical resection remains the mainstay for early breast cancer. However, older patients with multiple co-morbidities may be deemed unsafe for general anaesthesia (GA). The Covid-19 pandemic necessitated some such surgery under local anaesthesia (LA) especially those who lacked anti-hormonal bridging therapy option. We present a retrospective study comparing outcomes following breast conserving surgery (BCS) under LA and GA. Method(s): 31 patients under LA (April 2018-March 2022) were compared with 31 age-matched patients under GA during the same period. Main outcomes were length of hospital stay and rates of margin positivity, re-operation, and post-operative complications within 1 month (including wound infections, seromas needing >=3 aspirations). Statistical analysis (with R-4.2.2) used two-tailed test with significant p-value (<0.05). Result(s): Only 5 LA cases were performed in the 2 years prior to first UK Covid-19 lockdown (March 2020), whilst 26 cases were performed in the 2 years after. [Formula presented] Conclusion(s): The number of BCS cases under LA increased five-fold following Covid-19 pandemic. Outcomes under LA were no worse than under GA. BCS under LA can allow BCS in patients unfit for or unwilling to have GA, especially older patients. Dedicated lists for BCS under LA may reduce need for resources such as hospital beds and overnight stays in the current resource and financially constrained health-care system.Copyright © 2023

Walant-Efficient and Safe Technique-Key Treatment in Covid-19 Pandemic

Aim of the study The aim of the study was to confirm the effectiveness and safety of wide awake local anesthesia no tourniquet (WALANT) technique in hand surgery, as well as its necessity and importance during the COVID-19 pandemics. Material and methods A retrospective study was performed between March 2020 and September 2021 to evaluate advantages of WALANT, taking into consideration the rules imposed by the pandemic context. This study included 360 patients, treated for acute and chronic hand diseases. A statistical investigation was performed using SPSS 20.0 version software and applying the ANOVA regression, evaluating demographic, anatomical and surgical variables. Results: 234 males and 126 females, treated for acute hand trauma (metacarpal and phalanx fractures, tendon and nerves lesions) and chronic hand diseases such as carpal tunnel syndrome (CTS) dupuytren's disease (DD), trigger finger (TF), soft tissue and bone tumors. The average patient waiting time from admission in the operating room was 13.95 minutes, while the mean time of onset of local anesthesia was 12.15 minutes. No complications such as distal digital bleeding, hematoma, the necessity of using the antidote, or necrosis occurred, the outcomes were very good and the patient satisfaction high. Conclusions: The WALANT technique can be considered the "gold standard" in hand surgery anesthesia during the COVID-19 pandemic, ensuring a correct and safe surgical treatment in the restrictive conditions imposed by the epidemiological context.

Polyethylenglycol and polysorbate evaluation for COVID vaccines in two patients with multiple drug allergies

Background: Covid 19 is a global epidemic. One of the most important steps in the fight against this epidemic is vaccination. mRNA vaccines are used in vaccination in our country. Among the additives in the vaccine, the substance with the highest allergenic risk is polyethylene glucose (PEG). There are different molecular weights of PEG. Another additive that has a high risk of cross-reaction with PEG as an additive is POLISORBAT 80. Skin tests with drugs containing PEG and POLISORBAT 80 and, if available, tests with vaccines are instructive. Among the drugs containing PEG: Moxifloxacin tablet, ciprofloxacin tablet, Amoxicillin clavulanic acid tablet;Medicines containing polysorbate include: Omalizumab vaccine, Mepolizumab vaccine. The results of the skin test with PEG-containing methylprednisolone (DEPO-MEDROL) and POLYSORBAT-containing triamcinolone (KENACORT-A) in order to be evaluated in terms of vaccine in our 2 patients who had multiple drug sensitivities before were shared. Method(s): Case 1: 33 y, F *There are diagnoses of urticaria and angioedema. Urticaria 30 minutes after taking aspirin, levofloxacin, cefdinir tablet;5 minutes after taking ciprofloxacin tablets, he has anaphylaxis. *Applies before Biontec vaccine. *The patient had a history of anaphylaxis with PEG-containing ciprofloxacin. In the skin tests performed with DEPO-MEDROL and KENACORT-A, 1/100 intradermal test was positive. *The patient for whom Biontec vaccine was not recommended received Synovac vaccine without any problems. Case 2: 52 years, F * He has a diagnosis of urticaria. 5 minutes after general anesthesia and local anesthesia;The patient who had cardiac arrest 3 times was evaluated. The patient, who had Synovac for 2 times without any problems, wanted to have the 3rd dose of Biontec vaccine. *Tested with general -local anesthetic agents. *Ciprofloxacin skin tests are negative;Urticaria plaques developed after 30 minutes of 1/4 tb in oral provocation. In the skin tests performed with DEPO-MEDROL and KENACORT-A, 1/100 intradermal test was positive. *Biontec vaccine is not recommended. Result(s): A safer vaccination is ensured by testing with additives in Covid 19 vaccines. Conclusion(s): Drug additives should also be kept in mind in patients with multiple drug allergies.

In-office Eustachian tube balloon dilation under local anesthesia as a response to operating room restrictions associated with the COVID-19 pandemic.

Objective: To evaluate the feasibility of local anesthesia for Eustachian tube balloon dilation as an in-office procedure for the treatment of Eustachian tube dilatory dysfunction as a response to the restriction measures of the coronavirus disease 2019 pandemic. Method: Patients with Eustachian tube dilatory dysfunction refractory to nasal steroids undergoing Eustachian tube balloon dilation in local anesthesia were enrolled in a prospective observational cohort between May 2020 and April 2022. The patients were assessed by using the Eustachian tube dysfunction questionnaire (ETDQ-7) score and Eustachian tube mucosal inflammation scale. They underwent clinical examination, tympanometry, and pure tone audiometry. Eustachian tube balloon dilation was performed in-office under local anesthesia. The perioperative experience of the patients was recorded using a 1-10 visual analog scale (VAS). Results: Thirty patients (47 Eustachian tubes) underwent the operation successfully. One attempted dilation was aborded because the patient displayed anxiety. Local anesthesia was performed by using topical lidocaine and nasal packing for all patients. Three patients required an infiltration of the nasal septum and/or tubal nasopharyngeal orifice. The mean time of the operation was 5.7 min per Eustachian tube dilation. The mean level of discomfort during the intervention was 4.7 (on a 1-10 VAS scale). All patients returned home immediately after the intervention. The only reported complication was a self-limiting subcutaneous emphysema. Conclusion: Eustachian tube balloon dilation can be performed under local anesthesia and is well tolerated by most patients. In the patients reported in this study, no major complications occurred. In order to free operation room capacities, the intervention can be performed in an in-office setting with satisfactory patient feedback.

The use of ilioinguinal and iliohypogastric nerve block anesthesia in inguinal bladder hernia repair Minimally invasive anesthesia technique in inguinal bladder hernia repair

Aim: There are data showing that the use of minimally invasive anesthesia methods (local anesthesia, nerve blocks) as an alternative to traditional anesthesia methods used in inguinal hernia repair surgery is safe and effective. During the COVID-19 pandemic, which affected the whole world, we aimed to evaluate the use of minimally invasive anesthesia methods in patients with inguinal bladder hernia, as well as their perioperative and postoperative results in our pilot study. Material(s) and Method(s): We evaluated the perioperative and postoperative data of five patients with inguinal bladder hernia, who underwent surgery with local anesthesia and ilioinguinal/iliohypogastric nerve blockade, four of which were performed during the COVID-19 pandemic. Result(s): It is possible to perform inguinal bladder hernia surgery with local anesthesia and ilioinguinal/iliohypogastric nerve block, including in secondary cases. Better hemodynamic stabilization in the intraoperative period reduces the need for narcotic analgesics by providing effective analgesia in the postoperative period, as well as reducing the risk of contamination in airway control. Discussion(s): Performing inguinal bladder hernia surgery using local anesthesia and ilioinguinal/iliohypogastric nerve block provides reliable and effective analgesia during the perioperative and postoperative periods.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Virtual undergraduate dermatology teaching using headmount camera video

Undergraduate clinical dermatology teaching in our hospital was delivered pre-COVID-19 to fourth-year medical students via an objective structured clinical examination-style circuit education session, with preselected live patients displaying important clinical presentation signs. A combination of posters, quizzes and interactive stations (e.g. topical therapy application and cryotherapy demonstration) were also used. Feedback for this consultant-delivered clinical teaching session was always excellent. However, this format did not lend itself easily to virtual teaching when COVID-19 forced immediate changes to undergraduate teaching delivery. A particular, understandable anxiety specifically reported by students was the loss of 'hands-on' clinical teaching with patients. Despite COVID-19 restrictions, a significant number of our face-toface clinics continued and so to harness these clinical teaching opportunities, both live and recorded patient video interactions were arranged. With local university and health-board approval, we obtained written patient consent to record consultations and used secure portals offered by Microsoft Office 365 to display live videos or recorded consultations using a secure NHS Microsoft Teams group, which allowed storage of these teaching videos within its One Drive application. To mimic a 'hands-on' patient interaction, a head-mount (temporal), wireless, 4 K camera was used to mirror the view of the clinician. For skin lesion consultations, ring lamp and dermoscopy magnification examination could also be included (additional still images could also be added retrospectively to any offline video edit). Full-skin examination and general dermatology findings, such as rash pattern and distribution, were highlighted. Some surgical procedures were also recorded, including local anaesthesia infiltration, skin excisions and curettage, as well as cryotherapy administration and topical therapy application. Despite novice use of this teaching technique, video quality was good and feedback excellent, with students appreciating the efforts made to provide interactive clinical teaching during an unprecedented time. Limited existing literature highlighting the use of such teaching models has mainly come from its application in postgraduate surgical specialty intraoperative teaching. We hope the merits of these techniques can be applied to current undergraduate dermatology teaching methodology. We plan to continue to record further clinical consultations to expand our existing teaching video portfolio and are likely to continue to use this as an adjunct resource in our undergraduate teaching delivery. Depending on student feedback, we may consider future professional video recording methods from our university and medical illustration colleagues.

Successful treatment of viral warts with topical and intralesional cidofovir in an immunocompromised paediatric patient

Cidofovir is well described as an effective antiviral agent. It is reported to treat viral warts successfully in immunocompetent and immunocompromised individuals. Unfortunately, its use may be limited by the high cost and pain of treatment. We here report the successful treatment of multiple palmoplantar warts in an 8-year old male undergoing chemotherapy for relapsed acute lymphoblastic leukaemia. His most significant lesion was a 3 x 3 x 1.5 cm tumorous lesion on the central plantar forefoot that interfered with weight bearing. It had been resistant to over-the-counter treatments, cryotherapy, silver nitrate cautery, curettage and cautery, cantharadin and topical 5-fluorouracil. He was developing multiple satellite lesions and they had spread to the toes, the other foot and both hands, totalling more than 30 lesions. The first treatment session was during sedation for intrathecal chemotherapy. One millilitre of cidofovir (diluted to 15 mg mL-1) was instilled to the largest lesion (although solution was seen visibly escaping from the surface). The remainder of the vial was compounded to topical cidofovir 1% in Eucerin, which he applied once daily to remaining lesions. His postprocedure recovery was unremarkable, with no analgesia requirements or other complications. By the time of review 4 weeks later, the verruca that had received one session of intralesional treatment had completely resolved. Some of the smaller warts had shrunk in size. Despite reports of pain associated with intralesional cidofovir injections, our patient was keen for a repeated treatment to more lesions without sedation/anaesthetic. He tolerated the treatment of a number of remaining lesions without the need for topical or local anaesthesia. Treatments continued at 4-weekly intervals (to coincide with his chemotherapy regimen) with good response and no side-effects. After three treatment sessions most lesions had resolved with only some smaller lesions remaining. Unfortunately, his next treatments were suspended as he contracted COVID-19. In summary, we report the successful eradication of significant and widespread viral warts in an immunocompromised paediatric patient. Reports in patients under 10 years of age are scarce. We also confirm excellent tolerance of the procedure. Although the high cost of cidofovir may seem prohibitive, given that one vial could generate around 25 mL solution and 0.2-1 mL is needed per lesion, we would argue that it may be more costeffective than multiple sessions of other less/ineffective modalities. Furthermore, its antiviral mechanism of action is particularly beneficial in immunocompromised patients in comparison with other modalities, which require an efficient immune response in order to be successful.

Complications and Outcomes of Peritoneal Dialysis in Indian Subcontinent: Two Decades of Experience from a Single Centre

Introduction: Continuous Ambulatory Peritoneal Dialysis (CAPD) was first introduced in 1990. It is now being considered at per or even better than MHD in many centers in India. Regional Institute of Medical Sciences (RIMS),Imphal is a tertiary care hospital in Northeastern part of India which is surrounded by neighboring states and border states of Myanmar where communication, transport, renal health care system is least developed. Many patient used to die due to lack of availability of hemodialysis facility. Since September 2001, CAPD programme was started at RIMS hospital, Imphal to treat the patient of CKD in Manipur, other neighboring states and Myanmar. It has been already more than 21 years and 736 number of PD catheter insertion is done at RIMS till September 2022. Method(s): Tenckhoff catheters were implanted either trans-peritoneally by surgeon or percutaneously by the nephrologist under local anaesthesia. All the details data about the patients were collected and accumulated. Accumulation and collection of data is constantly done by designated analyzers in RIMS centers in order to be continually updated on the demographics of renal patients using PD. These data were constantly documented and analyzed to assess the outcome and complications of PD. A total of 736 CKD patients were implanted with CAPD catheter between September 2001 to September 2022 and their detail data were analysed. Result(s): Out of total 736 PD cases there were 276 episodes of peritonitis. 58.6% cases had single episode of peritonitis as in Table -1. Out of 276 episodes of peritonitis 27 cases were culture positive.The leading causative agent of peritonitis was Staphylococcus aureus (37% of culture positive cases). Staphylococcus epidermidis was responsible for 18.5% of culture positive episodes as shown in Table-2. The incidence of ESI was 0.03 per person-years.The most common infective organism was S. aureus which was responsible for 12 (52%) of cases Table-3. Out of total 736 PD cases 72 patients were shifted to HD over the twenty one -year period, refractory peritonitis was the most common cause of technique failure ( 41.6 %) (Table- 4). A total of 125(16.9%) patients among 736 had PD catheter tip migration of which 46% were surgically removed and re-inserted. Omentectomy was require in 14.4 % of patient due to omental wrap around PD catheter (Table 5). There were 443 admissions to the hospital by these PD patients during the study period, of which 173(39%)were due to peritonitis. Non-peritoneal infections were the second most common cause responsible for 98(22.1%) hospital admissions. The non-peritoneal infections included covid 19 pneumonia in 5 patients (Table 6). Out of 736 patients, 145 patients(14.7%) were continuing on PD and12 patients (1.6%)underwent renal transplantation(Table-8). Conclusion(s): Our study suggests that there has been considerable improvement in overall outcome and mortality in patients on PD over the 20 years period. Peritonitis is the most common complication associated with PD. Having a well-trained staff will decrease the complications. This modality of renal replacement therapy in terms of long-term survival and quality of life and should be encouraged at the national level. No conflict of interestCopyright © 2023

The British Society for Dermatological Surgery virtual surgery learning project

Dermatological surgery training across the UK has been severely affected by the COVID-19 pandemic, with reduced face-to-face clinical activity, trainee redeployment and suspension of specialist rotations. Simultaneously, the new dermatology curriculum implemented in August 2021 has set the bar for surgical competency even higher than previously, while surgical courses and meetings that trainees have relied upon to augment their skills and knowledge have had to be suspended. Achieving curriculum learning outcomes has therefore been very challenging, and has been highlighted at National Dermatology Trainee Meetings, as well as reflected in General Medical Council surveys. In response to these difficulties, the British Society for Dermatological Surgery (BSDS) and the British Association of Dermatologists have sought new ways of delivering aspects of surgical training and established the 'Virtual Surgery Learning Project' (VSLP). A pilot group of senior dermatological surgeons and a dermatology specialist trainee with interests in education and digital technology was set up to map the project in early summer 2021, to explore possible modules and secure technical support from an e-learning company with expertise in producing innovative virtual learning. Five key aspects of surgical training were identified: surgical anatomy of the head and neck, informed consent and medicolegal matters, local anaesthesia, preoperative assessment and biopsy techniques. Over 30 volunteers, comprising dermatology specialist trainees, Mohs fellows and consultants from across the country were then recruited to the project in September 2021 and divided into working groups to design the modules, each led by a consultant with an interest in medical education and/or skin surgery. The five virtual modules are each based on clinical cases encountered in daily practice. They have been developed with a key emphasis on interactive learning and innovative self-assessment features to consolidate teaching outcomes, encourage trainee engagement and facilitate deeper learning. Users can access the 45-60-min modules at their choosing on multiple platforms. The presentation will show the features of the modules, the interactivity and innovations they contain, as well as explore how the modules were developed. While not intended as a replacement for hands-on surgical experience, the VSLP goes a significant way in addressing the shortfall in surgical education and will remain a valuable learning resource, even once working patterns normalize. Furthermore, it is an important step in expanding and improving the BSDS digital education resources available to its membership and establishing a national collaborative surgical education project.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19. Copyright © 2022 Elsevier Ltd

Current Evidence Involving WALANT Surgery.

Wide-awake local anesthesia no-tourniquet (WALANT) surgery is an attractive option for hand surgeons, particularly during resource-scarce periods, as it eliminates dependence on main operating rooms or hospital-based procedures. The limited prepping or draping used for WALANT field sterility is as effective, if not more effective, than standard sterile prepping or draping. Patient anxiety surrounding WALANT surgery is similar to or less than that of general or local anesthesia with or without tourniquet. Patients use the same or lower amounts of postoperative narcotics after WALANT as compared to after the other anesthetic methods. Wide-awake local anesthesia no-tourniquet surgery saves significant costs for the same surgeries when performed under general or local anesthesia with or without tourniquet. There are very few complications associated with the WALANT method of anesthesia; rare case reports include vasovagal syncope and cardiac arrhythmia due to inadvertent intravascular injection of epinephrine.

Transiting Ureteric Stent Change under General Anaesthesia in Major Operation Theatre to a Procedure under Local Anaesthesia in Ambulatory Endoscopy Suite

Introduction &Objective: Patients with long term ureteric stents for urinary diversion need regular changes, done at intervals appropriate for their condition, type of stent and adjusted to stent encrustation risks. This is usually done under General Anaesthesia in the operating room. We present our series of patients on ureteric stents with change of stents done under local anaesthesia in the endoscopy suite as an outpatient day procedure. Method(s): Since July 2021, we started a stent change service for our patients on long term ureteric stents done solely by Urologists in the outpatient day procedure setting under Local anaesthesia. This is done in the outpatient endoscopy suite away from the operating theatre, with flexible cystoscopy aided by fluoroscopy. We review our series of ureteric stent changes including indications and technical success rate of stent change. Result(s): 56 patients underwent stent change under local anaesthetic from 7th July 2021 to 16th Feb 2022, with mean age of 75 years old (range 55 to 97). 24(42%) were male and 32(57%) female. 9 patients had bilateral stents changed (16%), with the rest unilateral. Etiology wise, 34 (61%) had strictures, 13 (23%) had stones, and 9 (16%) had extraluminal compression. Mean duration from the last stent change was 4.6 months (SD = 1.38) based on clinical condition and stent type. 54 (96%) of patients had successful stent changes. The two patients with unsuccessful stent changes had failed retrograde wire access, one with tight extraluminal compression and the other with severe stent encrustation. Advantages of the new service for the patients include avoiding risks of sedation or general anaesthesia, and procedure performed as day surgery with decreased duration of hospital stay, particularly in this time of COVID-19 pandemic. From a resource point of view, this has freed up operating theatre space and anaesthetist manpower to focus on Urological procedures needing general anaesthesia, decreasing waiting time for higher acuity cases. Conclusion(s): Moving flexible cystoscopy guided ureteric stent change from major operation theatre under general anaesthesia to an ambulatory endoscopy center setting under local anaesthesia is a feasible and safe option for patients with long-term ureteric stents. It avoids risk of general anaesthesia, is potentially cost saving and conserves hospital resources.

Impact of COVID-19 Pandemic on Hepatobiliary and Pancreatic Surgical Services

Introduction: The hepato-pancreato-biliary (HPB) unit had to scale down the clinical workload and reallocate resources to combat COVID-19. We report local audit evaluating the impact of COVID-19 on the unit and its impact on cancer surgery. Method(s): We performed a comparative audit of the HPB team surgical workload for January-June 2019 (baseline) and 2020 (COVID-19). Elective and emergency cases performed under general anesthesia were audited. Elective cases included hernia surgeries, biliary surgeries (cholecystectomy and complex biliary resections), liver, and pancreatic resections. Emergency cases included cholecystectomies and laparotomies performed for general surgical indications. We excluded endoscopy and procedures done under local anaesthesia. Result(s): Elective surgical workload decreased by 42.3% during the COVID-19 pandemic (n=200 (2019) vs. 347 (2020)). Hernia surgery decreased by 63.9% (n=155 (2019) vs. 56 (2020)) and cholecystectomy by 40.3% (n=144 (2019) vs. 86 (2020)). Liver and pancreatic resection volume increased by 16.7% (n=30 (2019) vs. 35 (2020)) and 111.1% (n=9 (J 2019) vs. 19 (2020)). The emergency surgical workload reduced by 40.9% (n=193 (2019) vs. 114 (2020)). Conclusion(s): Reallocation of resources due to the COVID-19 pandemic did not adversely impact elective HPB oncology work. With prudent measures in place, essential surgical services can be maintained during a pandemic. Copyright © 2022

TRACHEOBRONCHIAL ASPIRATION IN THE ELDERLY

CASE: A 68-year-old male with a past medical history of hypertension and null smoking history presented with insidious onset dyspnea for the past three days. On physical exam, he had inspiratory rhonchi and was hypoxic, saturating to 88% in room air, requiring 6L oxygen. Laboratory studies were unremarkable, including a negative COVID PCR test. Chest X-ray demonstrated right-sided hilar prominence, and CT of the chest revealed an 8 mm endobronchial. On the day of his bronchoscopy evaluation, the patient expectorated a brownish undercooked pea while receiving nebulizer treatment and repeat chest CT revealed the resolution of the previous endobronchial lesion. IMPACT/DISCUSSION: Foreign body aspiration (FBA) has a bimodal presentation with a second peak in adults above 50 years. Although FBA most commonly presents with abrupt onset cough and dyspnea, the immediate presentation may not be evident in the geriatric population given the lack of cough reflex and cognitive decline. A retrospective study performed with data from 140 patients with FBA noted that 44.3% of patients did not present to the emergency in the first 24 hours of aspiration. Physical exam findings depend on the location of foreign body(FB) dislodgement, but around half the time, the exam could be unremarkable. A radiograph could reveal the object if the aspirated FB is radiopaque;hence a negative radiograph does not rule out the diagnosis of FBA. However, when present, the most common radiographic findings are inspiratory-expiratory abnormalities. High clinical suspicion is required to diagnose FBA to prevent chronic respiratory manifestations. An undiagnosed FB could travel distally and present as pneumonia, bronchiectasis, atelectasis, asthma/COPD-like illness. However, our patient presented with an endobronchial mass that was suspicious for malignancy. We found a similar presentation described by Bader et al. in a case about a 41-year-old woman who underwent chest CT for chronic cough, revealing a mass lesion in the right main bronchus. Bronchoscopic examination showed no growth;instead, the team found a plastic foreign body. The patient admitted aspirating this plastic object in her early 20s. If FBA is suspected, bronchoscopy is the study of choice to evaluate the airway, and extraction of FB can be performed with flexible or rigid bronchoscopy. Although flexible bronchoscopy requires only local anesthesia and a rigid bronchoscopy requires general anesthesia, the latter is safer in preventing damage to the airway. Given that each case of FBA can present unique challenges and might occasionally need endotracheal intubation or tracheostomy, only experts should perform bronchoscopic extraction of FB. CONCLUSION: In this COVID era, it is very reasonable to be anchored to a diagnosis of COVID for every patient who presents with dyspnea. FBA should be one of the differential diagnoses for geriatric patients presenting with newonset respiratory symptoms even when no physical or radiographic signs are evident.

WALANT: A Discussion of Indications, Impact, and Educational Requirements.

Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.

Optimization of Carpal Tunnel Syndrome Using WALANT Method.

As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.

Management of Symptomatic Inguinal Hernia under Local Anesthesia in Covid Pandemic Our Experience

Background: Health care burden has increased since the pandemic of Covid-19 has emerged. The healthcare resources are limited currently and majority surgeries have been postponed because of the current pandemic. Therefore, the main concern of carrying out any surgery at current point is mainly in those patients that are landing in emergency. Symptomatic inguinal hernia being a common presentation in emergency can be dealt by applying local anesthesia. Objective: To evaluate the outcome (in terms of efficacy and safety) of local anesthesia for managing symptomatic inguinal hernia in a tertiary care hospital during current Covid-19 pandemic. Methodology: It was a descriptive study.60 males were enrolled with inguinal hernia of age 30-60 years. IV line was secured and local anesthesia was administered under aseptic measures. Lichtenstein repair, a mesh technique was applied in all patients for treating the inguinal hernia. Patients were evaluated postoperatively after 2 hours and 6 hours for any complications. Results: Mean age of the patients was 38.2±10.542, Mean time to eat was 3.85 ±3.138. Mean time to ambulate was 4.37 ±2.51. Mean pain score was 5.78± 2.131 postoperatively and after 6 hours it was 2.24 ±0.84. Indirect hernia was present in 74% patients whereas direct hernia was present in 26%. 6.67% patients had nausea/vomiting, 3.3% developed hematoma and 1.67% had wound infection. Conclusion: Local anesthesia is effective in all patients who have to undergo inguinal hernia surgery, in terms of efficacy and safety.

Description of WALANT technique in forefoot surgery in time of COVID-19

Most of the time forefoot surgery requires the use of a tourniquet, and therefore, the surgery is usually performed with either a popliteal block or an ankle block. Surgical departments have traditionally relied on an anesthesiol-ogist to perform these procedures. The elective nature of the forefoot surgery and the lack of surgical anaesthetists due to the COVID-19 pandemic have become mandatory to find alternatives to continue performing these surgeries in order to avoid an increase of waiting lists. The foot and ankle wide-awake local anaesthesia with no tourniquet (WALANT) technique is an adaptation from the one used for hand surgery. This technique requires no sedation, no regional or general anaesthesia, and the patient is fully conscious during the operation. WALANT technique con-sists of administration of lidocaine and epinephrine for local anaesthesia and vasoconstriction. This technique allows the surgeon to perform the surgery with the patient fully awake and without a tourniquet. In addition, this gives the advantage to perform an intraoperative as-sessment of function. WALANT for foot and ankle surgery is a suitable, safe, and cheap technique. Taking into con-sideration the lack of anaesthetists, operating rooms, and hospital resources observed during SARS-CoV-2 epidemic, this technique represents an acceptable alternative to consider in order to be able to continue performing se-lected cases of foot and ankle surgery.