Time to adapt in the pandemic era: a prospective randomized non -inferiority study comparing time to intubate with and without the barrier box.

BACKGROUND: The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Devices such as barrier boxes are being considered as potential adjuncts to full PPE's to limit the aerosol spread. Usage of the barrier box raises concerns of delay in time to intubate (TTI). We designed our study to determine if using a barrier box with glidescope delays TTI within acceptable parameters to make relevant clinical conclusions. METHODS: Seventy-eight patients were enrolled in this prospective non-inferiority controlled trial and were randomly allocated to either group C (without the barrier box) or the study group BB (using barrier box). The primary measured endpoint is time to intubate (TTI), which is defined as time taken from loss of twitches confirmed with a peripheral nerve stimulator to confirmation of end-tidal CO 2. 15 s was used as non-inferiority margin for the purpose of the study. We used an unpaired two-sample single-sided t-test to test our non- inferiority hypothesis (H 0: Mean TTI diff ≥15 s, H A: Mean TTI diff < 15 s). Secondary endpoints include the number of attempts at intubation, lowest oxygen saturation during induction, and the need for bag-mask ventilation. RESULTS: Mean TTI in group C was 42 s (CI 19.2 to 64.8) vs. 52.1 s (CI 26.1 to 78) in group BB. The difference in mean TTI was 10.1 s (CI -∞ to 14.9). We rejected the null hypothesis and concluded with 95% confidence that the difference of the mean TTI between the groups is less than < 15 s (95% CI -∞ to 14.9,p = 0.0461). Our induction times were comparable (67.7 vs. 65.9 s).100% of our patients were intubated on the first attempt in both groups. None of our patients needed rescue breaths. CONCLUSIONS: We conclude that in patients with normal airway exam, scheduled for elective surgeries, our barrier box did not cause any clinically significant delay in TTI when airway manipulation is performed by well-trained providers. The study was retrospectively registered at clinicaltrials.gov (NCT04411056) on May 27, 2020.

Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center.

Transcarotid artery revascularization (TCAR) procedure is a novel hybrid surgical modality in treating carotid stenosis. Understanding the various steps of the TCAR and the unique challenges involved in the anesthetic management is essential for the successful conduct of anesthesia. In this article, we discuss the overview of the key issues relevant to the anesthetic management and strategies from our experience. We present the data on anesthetic management and outcomes of 40 patients who underwent TCAR procedure at our institute between June 2018 and February 2020. Electronic medical records were retrospectively reviewed and relevant demographic, clinical, and laboratory data were collected. All our patients had general anesthesia with an endotracheal tube utilizing standard American Society of Anesthesiology (ASA) monitoring along with intra-arterial blood pressure monitoring and cerebral oximetry. The mean age of our patients was 73.6 ± 7.58 years. Fifteen (37.5 %) patients had significant co-morbidities, thus classified as ASA 4 and 10 (25%) patients were on at least three antihypertensives (beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, loop diuretics, thiazides). Thirty-four (85%) patients were considered to have symptomatic carotid stenosis which was the predominant indication for the TCAR procedure. Patients who had episodes of transient ischemic attack (TIA) or a cerebrovascular accident (CVA) documented by a computerized tomography (CT) scan of the brain and/or residual weakness are considered symptomatic. Thirty-six (90%) of our patients received a bolus dose of 0.2 - 0.4 mg of glycopyrrolate for maintaining heart rate of around 70 beats per minute (BPM) and 38 (95%) received phenylephrine infusion during the carotid clamp to maintain blood pressure between 140 and 160 mm Hg systolic or at patients' baseline. Twenty-one (52.5%) patients needed antihypertensives such as hydralazine ( 10-20 mg) or beta-blockers such as labetalol (10-20 mg) at the time of emergence from anesthesia to mitigate hemodynamic response during extubation. The mean blood loss was 74 ml ± 33.19 ml, and none of our patients received blood transfusion during the perioperative period. The mean duration of anesthesia was 202.6 ± 27.85 minutes, and the mean length of hospital stay was 1.5 ± 0.97 days. A thorough preoperative examination with specific attention to the preoperative neurological deficits and cardiopulmonary reserve is important for the meticulous management of intraoperative hemodynamics. Intraoperative administration of glycopyrrolate and the use of vasopressors to maintain optimal hemodynamics to ensure cerebral perfusion during the perioperative period should be considered. The anesthetic goals of carotid revascularization (TCAR) are perioperative hemodynamic stability and early evaluation of neurological status in the immediate postoperative period.