Efficacy of Phrenic Nerve Block and Suprascapular Nerve Block in Amelioration of Ipsilateral Shoulder Pain after Thoracic Surgery: A Systematic Review and Network Meta-Analysis.

Background and Objectives: Ipsilateral shoulder pain (ISP) is a common complication after thoracic surgery. Severe ISP can cause ineffective breathing and impair shoulder mobilization. Both phrenic nerve block (PNB) and suprascapular nerve block (SNB) are anesthetic interventions; however, it remains unclear which intervention is most effective. The purpose of this study was to compare the efficacy and safety of PNB and SNB for the prevention and reduction of the severity of ISP following thoracotomy or video-assisted thoracoscopic surgery. Materials and methods: Studies published in PubMed, Embase, Scopus, Web of Science, Ovid Medline, Google Scholar and the Cochrane Library without language restriction were reviewed from the publication's inception through 30 September 2022. Randomized controlled trials evaluating the comparative efficacy of PNB and SNB on ISP management were selected. A network meta-analysis was applied to estimate pooled risk ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Results: Of 381 records screened, eight studies were eligible. PNB was shown to significantly lower the risk of ISP during the 24 h period after surgery compared to placebo (RR 0.44, 95% CI 0.34 to 0.58) and SNB (RR 0.43, 95% CI 0.29 to 0.64). PNB significantly reduced the severity of ISP during the 24 h period after thoracic surgery (WMD -1.75, 95% CI -3.47 to -0.04), but these effects of PNB were not statistically significantly different from SNB. When compared to placebo, SNB did not significantly reduce the incidence or severity of ISP during the 24 h period after surgery. Conclusion: This study suggests that PNB ranks first for prevention and reduction of ISP severity during the first 24 h after thoracic surgery. SNB was considered the worst intervention for ISP management. No evidence indicated that PNB was associated with a significant impairment of postoperative ventilatory status.

A Comparison of the external anatomical landmark and the radiological landmark for obtaining the optimal depth of a right internal jugular venous catheter in pediatric cardiac patients.

BACKGROUND: The external anatomical landmark and the radiological landmark have been introduced to provide estimation of the depth of right internal jugular venous catheter during insertion. AIMS: This study aimed to compare the accuracy, agreement, and reliability of the external anatomical landmark and the radiological landmark, confirmation being by transesophageal echocardiography. METHODS: This prospective observational study was conducted in children ages 1-15 years. The catheter was placed at the superior vena cava and the right atrium junction guided by transesophageal echocardiography. The catheter depth derived from the transesophageal echocardiography, the external anatomical landmark, and the radiological landmark was recorded. The optimal zone of the catheter tip was 5 mm below and 10 mm above the superior vena cava and the right atrium junction. Accuracy was assessed by the difference between the transesophageal echocardiography and the external anatomical landmark or the radiological landmark. Agreement with Bland-Altman plots and correlation were tested. RESULTS: Eighty participants, median age of 3 years, were enrolled. The median (IQR) differences between the depth of the transesophageal echocardiography and the external anatomical landmark or the radiological landmark were 0.30 (0, 0.70) and 0.10 (-0.20, 0.90) cm, respectively. Bland-Altman plots demonstrated good agreement between the depths. The catheter tips were located in the optimal zone more frequently with the external anatomical landmark than the radiological landmark (94.7% vs 64.5%). The external anatomical landmark showed a stronger correlation to transesophageal echocardiography than the radiological landmark (r = .95 vs .83). CONCLUSION: Both the external anatomical landmark and the radiological landmark enabled accurate estimation of the central venous catheter depth close to the superior vena cava and the right atrium junction. The external anatomical landmark is of more potential use than the radiological landmark in clinical practice.

Cardiovascular effects of volatile induction and maintenance of anesthesia (VIMA) and total intravenous anesthesia (TIVA) for laryngeal mask airway (LMA) anesthesia: a comparison study.

OBJECTIVE: To compare changes of heart rate and blood pressure in patients that underwent LMA anesthesia with VIMA or TIVA technique. MATERIAL AND METHOD: A hundred healthy patients, age 16 to 60 years were enrolled. They were randomized into two groups. Patients in group V (VIMA) were induced with 8% sevoflurane until loss of eyelash reflexes then controlled ventilation for five minutes before LMA insertion. Group T (TIVA) patients were given propofol to reach the affected site concentration of eight mcg/mlfor the LMA insertion. Bloodpressure and heart rate were recorded before induction, immediately before and after LMA insertion then every two minutes until surgical incision. RESULTS: Decreased SBP from baseline in group T was significantly more than group V in each period of time (D1-D7). DBP in group T decreased more than group V significantly only at eight and ten minutes after LMA insertion. The incidence of decreasing SBP > 20% from baseline was more significant in group T than group V. No significant difference of changed HR was found. Coughing during LMA insertion occurred in eight patients (16%) in group T and in three patients (6%) in group V (p = 0.11). CONCLUSION: Induction with propofol by effective site concentration of eight mcg/ml significantly decreased SBP more than with 8% sevoflurane. Both techniques provided smooth LMA insertion without serious complication.

Kinking of catheters during translaryngeal jet ventilation: a bench model investigation of eight devices.

OBJECTIVE: To evaluate oxygen flow through several transtracheal devices in native and right angle kinked states. MATERIAL AND METHOD: Eight catheter-over-needle, and two oxygen conveyance devices (Enk Flow Modulator 10 L/min flow and Manujet III Jet device 15, 30, 50 psi) were examined. Oxygen flow from each catheter was measured five times with three insufflation patterns [continuous insufflation, one second insufflation/one second pause (1:1), one second insufflation/three second pause (1:3)] in both native, and 90 degree kinked condition. RESULTS: During continuous insufflation, all but the 20G catheter delivered flows of more than 7 L/m with all conveyance pressures. With a 1:1 insufflation/pause ratio, catheters smaller than 16G were able to deliver 7 L/min flow only with driving pressures of 30 and 50 psi. With a 1:3 insufflation ratio, no catheter could deliver adequate flow with 15 psi (manujet) or with the Enk Flow modulator Only the Cook catheter and 14G Ravussin were capable at 30 psi. Only the Cook Transtracheal Jet Ventilation Catheter could deliver adequate flow in kinked position, but only at 50 psi. CONCLUSION: Needle-catheters designed for vascular access are marginally capable of effective TJV. The Cook Transtracheal Jet Ventilation catheter proved to be the most robust device in the kinked state, but only when combined with a high-pressure oxygen conveyance system.

Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation.

BACKGROUND: Development of a perioperative plan for management of patients with airway pathology is a challenge for the anesthesiologist. Lack of comprehensive information regarding the architecture of airway lesions often leads the clinician to consider techniques of awake intubation (AI) to avoid catastrophic outcomes in this population. In one uncontrolled trial, endoscopic visualization of the airway lesion was included in the preoperative anesthetic assessment for planning of airway management. We sought to determine whether visual inspection of airway pathology would change the anesthesiologist's approach to the management of these patients. METHODS: Patients presenting for elective diagnostic or therapeutic airway procedures were included in the study. After a standard examination of the airway, a management plan was recorded. Before entering the operating room, and after brief preparation of the nares with a vasoconstrictor and local anesthetic, the patients underwent a preoperative endoscopic airway examination (PEAE) and a final airway management plan was recorded and implemented. Four or more months after the procedure, video recordings of the PEAE were reviewed without other patient identifiers and a remote PEAE plan was recorded, to test for operator bias. RESULTS: One hundred thirty-eight patients were studied. Although AI was initially planned in 44 patients, only 16 of these patients underwent preinduction airway control after PEAE (P > 0.05). Additionally, of the 94 patients for whom the initial plan was airway control after the induction of anesthesia, 8 patients were found to have unexpectedly severe airway pathology on PEAE, and also underwent AI. There was no significant difference between the post-PEAE airway management plan and the remote plan recorded 4 or more months later. CONCLUSIONS: In 26% of the patients studied, PEAE affected the planned airway management. We believe that PEAE can be an essential component of the preoperative assessment of patients with airway pathology; airway visualization reduces the number of unnecessary AIs while providing superior information about the airway architecture. PEAE could be applied to other populations of patients at risk for airway control failure with the induction of anesthesia.

Airway management in a patient with Goldenhar syndrome: a case report.

Children with Goldenhar syndrome are known to present airway management challenges for the anesthesiologist. We present the case of a 10-year-old child with Goldenhar syndrome, in whom a flexible Laryngeal Mask Airway (Intavent Orthofix, Ltd, Maidenhead, UK) was successfully used for eye surgery.