Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

[Airway management of COVID-19 patients: a survey on the experience of 1125 physicians in Spain]. / Manejo de vía aérea en pacientes COVID-19: una encuesta sobre la experiencia de 1125 médicos en España.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists.The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision.Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and physicians. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Tranexamic acid in cardiac surgery: Are low doses enough?

OBJECTIVES: Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS: A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS: There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002). CONCLUSIONS: Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.

Tranexamic acid in cardiac surgery: Are low doses enough? / Ácido tranexámico en cirugía cardíaca: ¿las dosis bajas son suficientes?

OBJECTIVES: Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS: A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS: There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P=.014) and ID (P=.040) but more fresh frozen plasma than group ID (P=.0002). CONCLUSIONS: Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.

The erector spinae plane block (ESPB) in the management of chronic thoracic pain. Correlation of pain/analgesia areas and long term effect of the treatment in three cases.

The erector spinae plane block (ESPB) is a technique that is used both as perioperative analgesia and in the management of chronic pain. This has been described recently and is being a resource increasingly used for its easy implementation and low rate of complications. However, the correlation between pain and analgesia, as well as its long-term effect on chronic pain, should be studied. We present a series of 3 cases in which the effectiveness of the ESPB in patients with chronic chest pain was evaluated. The block was performed in all cases by depositing 20ml of 0.2% Ropivacaine in the fascial plane of the erector spinae muscle. The pain was measured using a numerical scale prior to the block, at 30minutes and a month. The areas were marked on the skin with different colours for comparison.

Usefulness of diaphragmatic ultrasound in the early diagnosis of phrenic nerve palsy after shoulder surgery in the prevention of post-operative respiratory complications. / Utilidad de la ecografía diafragmática en el diagnóstico precoz de parálisis frénica tras cirugía de hombro para prevenir complicaciones respiratorias postoperatorias.

Phrenic nerve block is a complication that can occur after brachial plexus anaesthesia above the clavicle. The main consequence of this blockage is ipsolateral diaphragmatic paralysis, which can sometimes lead to the appearance of post-operative respiratory complications. A case is presented on a woman, who after having undergone a total shoulder prosthesis, presented with dyspnoea in the post-operative recovery unit. A diaphragmatic ultrasound was performed that enabled a rapid diagnosis to be made of a complete paralysis of the ipsolateral hemi-diaphragm. Given the suspicion of phrenic nerve block, ultrasound has proven to be a rapid diagnostic tool with high sensitivity and specificity. Its use can anticipate the possible development of immediate complications, and act as a guide in choosing the appropriate therapeutic strategy for each case in an early manner. In this case it enabled us to treat early with oxygen therapy, interscalene catheter removal, and intensive surveillance.

Intubation in two patients with difficult airway management and tracheal stenosis after tracheostomy in thoracic surgery. / Intubación en dos pacientes con vía aérea difícil y estenosis traqueal tras traqueostomía en cirugía torácica.

Lung isolation in thoracic surgery is a challenge, this is even more complex in the presence of unknown tracheal stenosis (TS). We report two cases of unknown TS and its airway management. TS appears most frequently after long term intubation close to the endotracheal tube cuff or in the stoma of tracheostomy that appears as a consequence of the granulation tissue after the surgical opening of the trachea. Clinical history, physical examination, difficult intubating predictors and imaging tests (CT scans) are crucial, however most of tracheal stenosis may be unnoticed and symptoms depend on the degree of obstruction. In our cases, the patients presented anatomical changes due to surgery and previous tracheostomy that led to a TS without symptoms. There is scarce literature about the intubation in patients with previous tracheostomy in thoracic surgery. In the first case, a Univent® tube was used using a flexible fiberscope but an acute tracheal hemorrhage occurred. In the second case, after intubation with VivaSight SL® in an awake patient, the insertion of a bronchial blocker was performed through an endotracheal tube guided by its integrated camera without using flexible fiberscopy.

Proposal for an algorithm for the management of the patient's airway after smoke inhalation. / Propuesta de algoritmo para el manejo de la vía aérea del paciente tras inhalación de humo.

Smoke inhalation represents the leading cause of mortality and morbidity in burns patients. Given the injuries that can occur in the airway after this exposure, it is imperative to evaluate the need for orotracheal intubation in the emergency department and even in the place of first assistance by healthcare workers. Since the clinical signs are poor predictors of the severity of the lesion, in selected cases, it is advisable to perform a diagnostic fibroscopy. We present a case report of a patient with a smoke inhalation lesion in which the fibroscopy was determinant to proceed to intubation, and we propose an algorithm of action for the management of the airway in this type of patients.

Regional analgesia in postsurgical critically ill patients. / Analgesia regional en el paciente crítico posquirúrgico.

Regional analgesia intrinsically, based on its physiological effects, is routinely used for the perioperative treatment of pain associated with surgical procedures. However, in other areas such as the non-surgical treatment of acute pain for patients in a critical condition, it has not been subjected to specific prospective studies. If we confine ourselves to the physiological effects of the nerve block, in a situation of stress, the indications for regional anaesthesia in this group of patients extend to the management of a wide variety of medical as well as postsurgical conditions, of trauma patients and of other painful procedures performed in the patient's bed. The critical patient certainly must be analyzed individually as their own primary conditions is of vital importance, as well as any associated conditions they have developed that can potentially increase the risk of systemic toxicity or morbidity, such as, coagulopathies, infection, immunosuppressive states, sedation and problems associated with mechanical ventilation. This review aims to assess the role of regional analgesia in critically ill patients, placing it within the algorithm decision tree of the professional responsible for patients in critical care units, all based on the evidence of potential benefits according to the published literature.

[Proposed difficult airway teaching methodology. Presentation of an interactive fresh frozen cadaver model]. / Propuesta de metodología docente en vía aérea difícil. Presentación de un modelo interactivo de cadáver fresco congelado.

BACKGROUND AND OBJECTIVE: The aim of this paper is to present a methodology based on the use of fresh-frozen cadavers for training in the management of the airway, and to evaluate the degree of satisfaction among learning physicians. MATERIAL AND METHODS: About 6 fresh-frozen cadavers and 14 workstations were prepared where participants were trained in the different skills needed for airway management. The details of preparation of the cadavers are described. The level of satisfaction of the participant was determined using a Likert rating scale of 5 points, at each of the 14 stations, as well as the overall assessment and clinical usefulness of the course. RESULTS: The mean overall evaluation of the course and its usefulness was 4.75 and 4.9, out of 5, respectively. All parts of the course were rated above 4 out of 5. The high level of satisfaction of the course remained homogeneous in the 2 editions analysed. The overall satisfaction of the course was not finally and uniquely determined by any of its particular parts. CONCLUSION: The fresh cadaver model for training physicians in techniques of airway management is a proposal satisfactory to the participant, and with a realism that approaches the live patient.

[New options in the treatment of painful shoulder syndrome]. / Nuevas alternativas en el tratamiento del síndrome de hombro doloroso.

Shoulder pain is a common complaint in clinical practice in Primary Care and affects 20% of the general population. The usual form of treatment is based on NSAIDs, rest, rehabilitation and, as an alternative, a local injection into the joint. There are also radiofrequency techniques on the suprascapular nerve in the cases of refractory pain to these therapies. Radiofrequency can be used in two ways: Conventional Radiofrequency, using high temperatures to the target tissue with the aim of producing a thermal neurolysis and Pulsed Radiofrequency where the temperatures are lower and produces a temporary non-destructive blockage; the latter being the most common technique in the management of shoulder pain. Although the analgesic mechanism of action of Radiofrequency is unknown, recent studies have shown that it is safe, effective and Lasting. Radiofrequency of the suprascapular nerve is a valid, effective and with few complications in the treatment of shoulder pain refractory to other therapies.

[Prophylaxis for hypotension during cesarean section under spinal anesthesia: a randomized trial comparing hydroxyethyl starch 130/0.4 to ephedrine]. / Prevención de la hipotensión arterial en cesáreas con anestesia subaracnoidea. Estudio prospectivo, aleatorizado comparativo entre hidroxietilalmidón 130/0,4 y efedrina.

BACKGROUND AND OBJECTIVE: Spinal anesthesia is the technique of choice for scheduled or emergency cesarean section, but the prevalence of hypotension is high in this setting. Our aim was to compare the efficacy of a colloid (6% hydroxyethyl starch [HES] 130/0.4) to ephedrine for preventing hypotension. PATIENTS AND METHODS: Patients undergoing elective or emergency cesarean section (in non-life-threatening situations) were enrolled. Patients were randomized to 3 groups for prophylaxis. The first ephedrine group received 5 mg of ephedrine intravenously (EPHE-5); the second ephedrine group received 10 mg of the drug intravenously (EPHE-10); and the HES group received 500 mL of HES 130/0.4 in rapid infusion n 15 minutes. We recorded systolic and diastolic blood pressures and heart rate after 10 minutes in the operating room and 2, 5, 10, 15, 20, and 30 minutes after injection of the anesthetic. We also assessed the sensory and motor blockades on both sides 2, 5, 10, 15, 20, and 30 minutes after injection. Neonatal status was assessed by Apgar score and umbilical cord blood gas analysis. RESULTS: Ninety-six patients, 33 in each ephedrine group and 30 in the HES group, were enrolled. Blood pressure decreased similarly in all 3 groups (36% EPHE-5 group, 36% EPHE-10 group and 40% HES group); no significant between-group differences were observed. Nor were there significant differences in the percentages of patients requiring bolus doses of ephedrine to treat hypotension (23% in the HES group vs 33% in the EPHE-5 group and 27% in the EPHE-10 group) or in the cumulative doses of ephedrine. Neonatal status was also similarly satisfactory in all 3 groups. CONCLUSIONS: HES 130/0.4 is as useful for hypotension prophylaxis as 5-mg or 10-mg intravenous doses of ephedrine. HES 130/0.4 might be a substitute for sympathomimetic agents if adverse effects are predicted or contraindications to the use of such drugs are present.

[Postoperative pain management for patients who are long-term users of opioid]. / Manejo perioperatorio del dolor en el paciente en tratamiento crónico con opiáceos.

Pain is one of the most common reasons for seeking medical care and the frequency of prescription of opioid analgesics by both primary care physicians and specialists has increased. It is therefore unsurprising that many patients with chronic pain who must undergo scheduled or emergency surgery will be on long-term medication, including opioids. Managing postoperative pain, even with high doses of drugs, seems to be more difficult in regular users of such analgesics, possibly because of an apparent association of opioid use with increased tolerance and hyperalgesia. Postoperative pain relief should be carefully tailored in these cases by means of a management plan worked out along with the patient. Adjuvants may be particularly useful; the most thoroughly studied adjuvants are nonsteroidal anti-inflammatory drugs and ketamine. Regional anesthesia offers a particularly attractive approach when long-term users of opioids must undergo surgery.

Ultrasound-guided transversus abdominis plane block for spinal infusion and neurostimulation implantation in two patients with chronic pain.

OBJECTIVE: This case report describes an ultrasound approach to the transversus abdominis plane (TAP) local anesthetic block. This block induces sensory blockade in the lower half of the abdomen where the pulse generator or the infusion pump is to be housed in a subcutaneous pocket, and therefore provides an alternate to general anesthesia or administration of high-dose local anesthetics. CASE REPORT: We report two cases of neuromodulation procedures-implantation of an internal morphine pump for severe somatic pain refractory to other therapies and placement of a double-stimulator generator for dorsal column stimulation in a patient diagnosed with postoperative failed-back syndrome. We successfully used ultrasound-guided TAP block to achieve ipsilateral sensory block of dermatomes T9-L1 in the context of a monitored anesthesia care multimodal approach. CONCLUSION: TAP block can be a potentially useful substitute to general anesthesia or local anesthesia for the pocket formation in neuromodulation techniques, and it provides adequate anesthesia of the abdominal wall. This block is potentially an important addition to the monitored anesthesia care protocol.