Polytrauma patient with lateral thoracic spondyloptosis: case report and literature review

Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation.

BACKGROUND: Patients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (AirtraqⓇ; Prodol Meditec) and nonchanneled (McGrathⓇ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated. OBJECTIVE: Our aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway. METHODS: A prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18-60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted. RESULTS: Mean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0-1 for group M and median IDS score of 1; IQR 0-2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A. CONCLUSIONS: The performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

Neuroanesthesia practice during COVID-19: A single-center experience

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.

Maintaining Prehospital Intubation Success with COVID-19 Personal Protective Precautions.

BACKGROUND: Tracheal intubation is a high-risk intervention for exposure to airborne infective pathogens, including the novel coronavirus disease 2019 (COVID-19). During the recent pandemic, personal protective equipment (PPE) was essential to protect staff during intubation but is recognized to make the practical conduct of anesthesia and intubation more difficult. In the early phase of the coronavirus pandemic, some simple alterations were made to the emergency anesthesia standard operating procedure (SOP) of a prehospital critical care service to attempt to maintain high intubation success rates despite the challenges posed by wearing PPE. This retrospective observational cohort study aims to compare first-pass intubation success rates before and after the introduction of PPE and an altered SOP. METHODOLOGY: A retrospective observational cohort study was conducted from January 1, 2019 through August 30, 2021. The retrospective analysis used prospectively collected data using prehospital electronic patient records. Anonymized data were held in Excel (v16.54) and analyzed using IBM SPSS Statistics (v28). Patient inclusion criteria were those of all ages who received a primary tracheal intubation attempt outside the hospital by critical care teams. March 27, 2020 was the date from which the SOP changed to mandatory COVID-19 SOP including Level 3 PPE - this date is used to separate the cohort groups. RESULTS: Data were analyzed from 1,266 patients who received primary intubations by the service. The overall first-pass intubation success rate was 89.7% and the overall intubation success rate was 99.9%. There was no statistically significant difference in first-pass success rate between the two groups: 90.3% in the pre-COVID-19 group (n = 546) and 89.3% in the COVID-19 group (n = 720); Pearson chi-square 0.329; P = .566. In addition, there was no statistical difference in overall intubation success rate between groups: 99.8% in the pre-COVID-19 group and 100.0% in the COVID-19 group; Pearson chi-square 1.32; P = .251.Non-drug-assisted intubations were more than twice as likely to require multiple attempts in both the pre-COVID-19 group (n = 546; OR = 2.15; 95% CI, 1.19-3.90; P = .01) and in the COVID-19 group (n = 720; OR = 2.5; 95% CI, 1.5-4.1; P = <.001). CONCLUSION: This study presents simple changes to a prehospital intubation SOP in response to COVID-19 which included mandatory use of PPE, the first intubator always being the most experienced clinician, and routine first use of video laryngoscopy (VL). These changes allowed protection of the clinical team while successfully maintaining the first-pass and overall success rates for prehospital tracheal intubation.

DON'T CUT THE NECK: A NOVEL OPTION FOR DEFINITIVE RESCUE AIRWAY

SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: COVID-19 has resulted in many patients presenting in severe hypoxemic respiratory failure without the ability to achieve adequate oxygenation despite non-invasive positive pressure ventilation prior to attempting endotracheal intubation. Recently, the American Academy of Anesthesiology (AAOA) released an updated 2022 guideline addressing difficult airway management. Though evidence is limited, the use of a combination maneuvers with a supraglottic airway and lighted stylet yielded a greater than 75% intubation success rate after failed direct laryngoscopy [1]. The following case emphasizes a novel definitive airway rescue option for an anatomically and physiologically difficult airway, complicated by an inability to ventilate and oxygenate in the setting of severe hypoxemic respiratory failure. CASE PRESENTATION: The patient is a 58 year old, morbidly obese (BMI-58) female with severe COVID-19 pneumonia and severe refractory hypoxemia on Bi-Level non-invasive ventilation (inspiratory pressure 20, expiratory pressure 15, 100% fraction inspired oxygen) complicated by an acute complete opacification of the left hemi-thorax and right pneumothorax with oxygen saturation (SpO2) of 80%. Rapid sequence induction was attempted, however failed despite multiple maneuvers. Due to continued deterioration of the patient's oxygenation, a laryngeal mask airway (LMA) was placed with improvement of the patient's oxygen saturation. A single-use disposable bronchoscope was then placed through the LMA with successful navigation through the vocal cords and direct visualization of the tip within the right main-stem bronchus. Using trauma shears, the handle of the bronchoscope was cut away from the insertion tube. The LMA was then retracted (Fig. 1) and forceps were utilized to maintain position of the insertion tube (Fig. 2) during this maneuver. The video laryngoscope blade was then reinserted into the oropharynx for visualization of the insertion tube coursing through the vocal cords. Using the insertion tube from the single-use bronchoscope as a stylet, intubation was successfully accomplished by inserting a 7.5mm ETT over the insertion tube under direct visualization with the video laryngoscope (Fig. 3). DISCUSSION: Single use bronchoscope devices have been successfully used for planned awake intubations [2] as well as confirmation of endotracheal tube placement [3] after emergent intubation. The novel technique described above can be a useful measure to facilitate intubation under direct visualization in complicated airway scenarios without the need for a surgical airway. CONCLUSIONS: This technique offers a number of advantages to include direct visualization of the airway, navigational capability of bronchoscopy and confirmation of placement with video laryngoscopy. The combination of these techniques can be considered as an alternative prior to pursuing an invasive surgical option. Reference #1: Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O'Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung;2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31–81 doi: https://doi.org/10.1097/ALN.0000000000004002 Reference #2: Kristensen MS, Fredensborg BB. The disposable Ambu aScope vs. a conventional flexible videoscope for awake intubation – a randomised study. Acta Anaesthesiol Scand. 2013 Aug;57(7):888-95. doi: 10.1111/aas.12094. Epub 2013 Mar 15. PMID: 23495767 Reference #3: Mitra A, Gave A, Coolahan K, Nguyen T. Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting. World J Emerg Med. 2019;10(4):210-214. doi: 10.5847/wjem.j.1920-8642.2019.04.003. PMID: 31534594;PMCID: PMC6732169 DISCLOSURES: No relevant r lationships by John Levasseur No relevant relationships by Lauren Sattler No relevant relationships by Tyson Sjulin

General anaesthesia for operative obstetrics

General anaesthesia in obstetrics is reducing. Obstetric surgery is often urgent, requiring effective team communication and a rapid, focused preoperative assessment. Physiological changes of pregnancy increase the incidence of aspiration, desaturation and failed intubation. In addition, the rapidly evolving circumstances add additional stress impacting on performance. Hypotension from aortocaval compression is common and minimized by left lateral tilt or uterine displacement. Rapid sequence induction with tracheal intubation remains gold standard but supraglottic devices are advocated in the event of failed intubation. Awareness remains relatively common and adequate depth of anaesthesia should be maintained and monitored. Complications are more common in obese pregnant patients, whilst women with pre-eclampsia are at particular risk of hypertensive responses to intubation and extubation, intravenous opiates can ameliorate this. Improved multidisciplinary communication on the delivery suite allows for pre-emptive assessment of patients at risk of requiring an operative delivery. With diminishing individual experience of general anaesthesia in obstetrics and delivery suite often being covered by junior doctors, simulation exercises can improve confidence, performance and team working.

Anaesthetic management of a parturient with Klippel-Trenaunay syndrome

Introduction: Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disease which is characterised by capillary, venous and lymphatic malformations. We describe the anaesthetic management of a 36 year old parturient with COVID-19 and KTS, who underwent an elective caesarean section. Very few such cases have been described and the multi-system nature of condition poses various challenges to both the obstetrician and the anaesthetist. Case Report: We had a 36-year-old woman who had experienced three previous normal vaginal deliveries and an elective caesarean section (CS) four years previously under general anaesthetic(GA) at 36 weeks gestation. She was told by a vascular surgeon that she was not suitable for regional anaesthesia. There was no recent imaging of her back to rule out arteriovenous(AV) malformations. Her past history included gastric bypass surgery under GA two years ago. She also had depression, varicose veins and three previous deep venous thrombosis andwas on prophylactic lowmolecularweight heparin. She had tested positive for COVID-19 4 days previously, and had mild symptoms of cough and sore throat. After a multi-disciplinary discussion involving an obstetrician, vascular surgeon, haematologist and anaesthetist, a decision was made to proceed with GA despite recent COVID-19, because of the possibility of AV malformations, in agreement with the patient. After securing two wide bore cannulae and adequate preoxygenation, a modified Rapid Sequence Induction was performed, and a tracheal tube was secured. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. After delivery of the baby, oxytocin 5U, followed by an infusion, midazolam, morphine, ondansetron and dexamethasone were administered. Extubation was performed when the patient was fully awake. In recovery, further opioids were given for pain. There were no concerns for the newborn. Estimated blood loss was 200 mL. Discussion: Gestation and its physiology may further exacerbate the manifestations of KTS, with increased obstetric risk. The success in the management of these patients requires the participation of a multidisciplinary team, consisting of obstetrician, anaesthetist, urologist, haematologist and vascular surgeon, with appropriate collaboration among the professionals involved. Periodic imaging and clotting tests are recommended to evaluate the evolution of vascular malformations in the pelvis, uterus and vagina, and identify neuraxial changes, to guide the safest way of delivery and anaesthesia.

Intubation Performance with Stylet and Preloaded Bougie for Rapid Sequence Intubation in Patients Undergoing General Anaesthesia: A Randomised Clinical Trial

Introduction: Rapid sequence induction requires quick and single attempt intubation to secure airway without any untoward complications. As the number of attempts increase, risk of desaturation and aspiration increase which is potentially life threatening. In such circumstances, miscalculation may cost loss of time which may prove fatal. Various adjuncts and techniques have been devised to prevent such calamities. Aim: To compare ease of intubation with angulated stylet versus distally preloaded bougie for rapid sequence intubation in elective general anaesthesia procedures. Materials and Methods: This randomised trial was conducted in 100 patients belonging to 18-60 years of age from November 2019 to October 2020. Patients were intubated using rapid sequence including cricoid pressure by either styletted endotracheal tube (Group S) or distally preloaded bougie (Group B), for surgeries performed under general anaesthesia. The primary outcome was to determine mean time to intubation (TTI) and number of attempts, while secondary outcomes were haemodynamic responses to intubation and complications. Data comparison between independent groups in this normally distributed data was done using student -t test while intragroup analysis was done using chi-square test. Results: A total of hundred patients were randomized into two groups- group S (mean age: 41.12 years) and group B (mean age: 37.34 years), of 50 patients each. Number of intubation attempts with stylet were single in 82%, two in 18% cases while with preloaded bougie, it was 80% and 14%, respectively (p-value=0.196). Time to intubation was 22.16 seconds (group S) versus 33.78 seconds (group B) (p-value <0.05). The haemodynamic assessments revealed that tachycardia, hypertension and increased End tidal carbon dioxide (EtCO2) was seen for 10 minutes immediately post induction in both the groups, though the intergroup difference was non significant. The incidence of sore throat was higher with stylet than bougie, though non-significant (p-value=0.118). Conclusion: Stylet should be preferred for ease of intubation in rapid sequence inductions. However, the insertion and removal of stylet must be done cautiously to prevent postoperative sore throat.

The aerosol box for intubation in coronavirus disease 2019 patients: an in-situ simulation crossover study.

The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early-generation box and a latest-generation box) on intubations in patients with severe coronavirus disease 2019 with an in-situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early-generation box (median (IQR [range]) 42.9 (32.9-46.9 [30.9-57.6])s vs. 82.1 (45.1-98.3 [30.8-180.0])s p = 0.002) and the latest-generation box (52.4 (43.1-70.3 [35.7-169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first-pass success. With the early-generation and latest-generation boxes, 9 (75%) and 10 (83%) participants obtained first-pass success, respectively. One breach of personal protective equipment occurred using the early-generation box and seven breaches occurred using the latest-generation box. Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.