Use of a video laryngoscope to facilitate removal of a long, sharp-pointed blade from the esophagus.

Initial management of ingested esophageal foreign bodies involves airway assessment, determination of the requirement for and timing of therapeutic intervention, risk mitigation during removal, and identification of all indicated equipment for retrieval. Long, sharp-pointed objects lodged in the esophagus require emergent attention and should be retrieved endoscopically, if perforation has not occurred. Inducing general anesthesia and rapidly securing the airway can minimize the risk of aspiration, mitigate any effects of tracheal compression, avoid the potential of exacerbating existing trauma, and provide optimal conditions for removal of long, sharp-pointed esophageal foreign bodies. Video laryngoscopy provides improved recognition of anatomical structures in both normal and difficult airways, enabling assessment for hypopharyngeal and glottic trauma resulting from foreign body ingestion. The indirect view of video laryngoscopy also facilitates the coordinated manipulation of the airway by both the anesthesiologist and the surgeon as they visualize the anatomy together while securing the airway and removing the foreign body.

Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study.

PURPOSE: The primary aim of this study was to compare the success rates of anesthesia providers vs trauma surgeons in their use of palpation to identify the cricothyroid membrane (CTM). The secondary aim was to explore whether prior training and experience performing surgical airways affected the success rates for identifying the CTM. METHODS: Four female adults participated in this prospective observational study. The participants had varying measurements of neck anatomy that were known or theorized to affect the accuracy of identifying the CTM location. For test purposes, the subjects were positioned with optimal neck extension via placement of a shoulder roll. Anesthesia providers (n = 57) and surgeons (n = 14) of various training levels and clinical experience marked the presumed CTM location on each subject. These palpation markings were then referenced against the ultrasound-confirmed CTM location, and the success rates for identifying the CTM were compared between groups. RESULTS: The overall success rate using palpation to identify the CTM was ≤ 50%, and there were no differences in success rates between the anesthesia providers and trauma surgeons (16% vs 26%, respectively; absolute difference, -10%; 95% confidence interval, -23 to 3; P = 0.15). Furthermore, there were no significant differences in the success rates for identifying the CTM based on either clinical experience or emergency surgical airway experience. CONCLUSION: The success rates for identifying the CTM using palpation were low and not significantly different for anesthesia providers and surgeons, collectively, as well as for the various levels of training. Anesthesiologists' ability to mark the CTM location correctly did not improve with years of experience.

Clinically relevant exaggerated pharmacodynamic response to dual antiplatelet therapy detected by Thromboelastogram(®) Platelet Mapping™.

Dual antiplatelet therapy (DAPT) is the standard of care for primary and secondary prevention strategies in patients with coronary artery disease after stenting. Current guidelines recommend that DAPT be continued for 12 months in patients after receiving drug eluting stents. Approximately 5% of these patients will present within this 12-month period for noncardiac surgery. This case report describes a clinically relevant exaggerated pharmacodynamic response to DAPT detected by preoperative assessment of platelet function. Based on the clinical history and physical exam and subsequent lab results, a general anesthetic was performed rather than a spinal anesthetic and the surgical procedure was changed. An exaggerated pharmacodynamic response to DAPT poses its own set of risks (unexpected uncontrolled bleeding, epidural hematoma following neuraxial block placement) that point-of-care aggregation testing may decrease or mitigate by altering clinical decision making. If the clinical history and physical exam reveal possible platelet dysfunction in patients receiving DAPT, preoperative platelet function testing should be considered.

Evaluation of Waste Anesthetic Gas in the Postanesthesia Care Unit within the Patient Breathing Zone.

Potential health hazards from waste anesthetic gases (WAGs) have been a concern since the introduction of inhalational anesthetics into clinical practice. The potential to exceed recommended exposure levels (RELs) in the postanesthesia care unit (PACU) exists. The aim of this pilot study was to assess sevoflurane WAG levels while accounting for factors that affect inhalational anesthetic elimination. In this pilot study, 20 adult day surgery patients were enrolled with anesthesia maintained with sevoflurane. Following extubation, exhaled WAG from the patient breathing zone was measured 8 inches from the patient's mouth in the PACU. Maximum sevoflurane WAG levels in the patient breathing zone exceeded National Institute for Occupational Safety and Health (NIOSH) RELs for every 5-minute time interval measured during PACU Phase I. Observed WAGs in our study were explained by inhalational anesthetic pharmacokinetics. Further analysis suggests that the rate of washout of sevoflurane was dependent on the duration of anesthetic exposure. This study demonstrated that clinically relevant inhalational anesthetic concentrations result in sevoflurane WAG levels that exceed current RELs. Evaluating peak and cumulative sevoflurane WAG levels in the breathing zone of PACU Phase I and Phase II providers is warranted to quantify the extent and duration of exposure.

Erroneous creation of a surgical airway through the thyrohyoid membrane.

This case report illustrates the importance of proper assessment, management, and creation of an emergent surgical airway. Assessment after the establishment of surgical airways should include confirmation of correct surgical site and appropriate location and depth of tracheostomy, tracheal tube, or catheter placement within the trachea. Supraglottic surgical airway access, as occurred in this case, can lead to laryngotracheal and esophageal injury. Early recognition and appropriate management of this complication can increase the likelihood of preservation of voice and airway function and minimize the extent of esophageal injury.