Awake versus Asleep Anesthesia in Deep Brain Stimulation Surgery for Parkinson's Disease: A Systematic Review and Meta-Analysis.

INTRODUCTION: Deep brain stimulation (DBS) is a well-established surgical therapy for patients with Parkinsons' Disease (PD). Traditionally, DBS surgery for PD is performed under local anesthesia, whereby the patient is awake to facilitate intraoperative neurophysiological confirmation of the intended target using microelectrode recordings. General anesthesia allows for improved patient comfort without sacrificing anatomic precision and clinical outcomes. METHODS: We performed a systemic review and meta-analysis on patients undergoing DBS for PD. Published randomized controlled trials, prospective and retrospective studies, and case series which compared asleep and awake techniques for patients undergoing DBS for PD were included. A total of 19 studies and 1,900 patients were included in the analysis. RESULTS: We analyzed the (i) clinical effectiveness - postoperative UPDRS III score, levodopa equivalent daily doses and DBS stimulation requirements. (ii) Surgical and anesthesia related complications, number of lead insertions and operative time (iii) patient's quality of life, mood and cognitive measures using PDQ-39, MDRS, and MMSE scores. There was no significant difference in results between the awake and asleep groups, other than for operative time, for which there was significant heterogeneity. CONCLUSION: With the advent of newer technology, there is likely to have narrowing differences in outcomes between awake or asleep DBS. What would therefore be more important would be to consider the patient's comfort and clinical status as well as the operative team's familiarity with the procedure to ensure seamless transition and care.

Anaesthesia Management for Neurosurgery in a Patient With Congenital Lung Agenesis.

Congenital lung agenesis is a rare congenital abnormality associated with an absence or under-development of either one or both lungs, and its presentation in adulthood is even rarer. We describe a 40-year-old female patient with a history of congenital agenesis of the right lung and a high-grade glioma in the frontal region of the brain presenting for craniotomy and excision of the tumor in an MRI suite. Lung protective strategies of ventilation were utilized intraoperatively. The remote location of the MRI suite made access to extra manpower support challenging. The patient was managed uneventfully and discharged stable to the high-dependency unit. Our case describes how congenital lung agenesis poses a unique set of challenges for anaesthetic management, particularly in neurosurgical patients, and provides guidance to a multidisciplinary team approach.

Local anesthesia versus general anesthesia for surgical drainage of chronic subdural hematoma: a systematic review and meta-analysis.

PURPOSE: The optimal anesthetic technique for surgical drainage of chronic subdural hematoma (CSDH) is still uncertain. We performed this systematic review and meta-analysis to determine if local anesthesia with or without sedation (LA) or general anesthesia (GA) results in better outcomes for surgical drainage of CSDH. METHODS: We searched PubMed, EMBASE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for randomized controlled trials (RCTs) and prospective or retrospective studies that compared GA vs LA for adult patients undergoing surgical drainage of CSDH and reported at least one outcome of interest. Primary outcomes of interest included total duration of surgery, recurrence rate, and length of hospital stay (LOS). Secondary outcomes included intraoperative adverse events, postoperative complications, and postoperative mortality. RESULTS: Eight studies (1,542 patients; 926 LA; 616 GA) were included-two were RCTs and six were observational studies. Pooling the estimates of all available studies, we found that LA was associated with a decreased mean LOS by about two days (95% confidence interval [CI], -3.47 to -0.77; P = 0.01; low certainty of evidence) as well as a lower risk of postoperative complications (odds ratio, 0.31; 95% CI, 0.17 to 0.58; P = 0.004; very low certainty of evidence). There was no significant difference in terms of duration of surgery, recurrence rate, intraoperative adverse events, or mortality. The quality of the observational studies was poor to fair, largely because of heterogeneity among the studies. Among the RCTs, one had a low risk of bias and one was deemed to be at high risk of bias. CONCLUSIONS: Local anesthesia with/without sedation for surgical drainage of CSDH may be associated with a shorter LOS, and lower postoperative complications. As most of our included studies were observational in nature, our results should be interpreted as summaries of unadjusted group comparisons. In view of the low certainty of evidence, higher quality evidence is required to corroborate these findings. STUDY REGISTRATION: PROSPERO (CRD42022333388); first submitted 1 June 2022.

RéSUMé: OBJECTIF: La technique anesthésique optimale pour le drainage chirurgical de l'hématome sous-dural chronique (HSDC) demeure incertaine. Nous avons réalisé cette revue systématique et méta-analyse pour déterminer si l'anesthésie locale (AL) avec ou sans sédation ou l'anesthésie générale (AG) entraînait de meilleurs devenirs suite à un drainage chirurgical de l'HSDC. MéTHODE: Nous avons effectué des recherches dans les bases de données PubMed, EMBASE, Scopus, le registre central Cochrane des études contrôlées et ClinicalTrials.gov afin d'en extraire les études randomisées contrôlées (ERC) et les études prospectives ou rétrospectives qui comparaient l'AG à l'AL chez une patientèle adulte bénéficiant d'un drainage chirurgical de l'HSDC et qui rapportaient au moins un résultat d'intérêt. Les critères d'évaluation principaux d'intérêt comprenaient la durée totale de la chirurgie, le taux de récidive et la durée du séjour à l'hôpital. Les critères d'évaluation secondaires comprenaient les événements indésirables peropératoires, les complications postopératoires et la mortalité postopératoire. RéSULTATS: Huit études (1542 patients, 926 AL, 616 AG) ont été incluses, dont deux ERC et six études observationnelles. En regroupant les estimations de toutes les études disponibles, nous avons constaté que l'AL était associée à une diminution de la durée moyenne de séjour d'environ deux jours (intervalle de confiance [IC] à 95 %, −3,47 à −0,77; P = 0,01; faible certitude des données probantes) ainsi qu'à un risque plus faible de complications postopératoires (rapport de cotes, 0,31; IC 95 %, 0,17 à 0,58; P = 0,004; très faible certitude des données probantes). Il n'y avait pas de différence significative en termes de durée de la chirurgie, ni de taux de récidive, d'événements indésirables peropératoires ou de mortalité. La qualité des études observationnelles était médiocre à passable, en grande partie en raison de l'hétérogénéité entre les études. Parmi les ERC, l'une présentait un faible risque de biais et l'autre a été considérée comme présentant un risque élevé de biais. CONCLUSION: L'anesthésie locale avec ou sans sédation pour le drainage chirurgical de l'HSDC peut être associée à une durée de séjour hospitalier plus courte et à des complications postopératoires plus faibles. Étant donné que la plupart des études incluses étaient de nature observationnelle, nos résultats doivent être interprétés comme des résumés de comparaisons de groupes non ajustées. Compte tenu de la faible certitude des données probantes, des données de meilleure qualité sont nécessaires pour corroborer ces conclusions. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022333388); soumis pour la première fois le 1er juin 2022.

Diagnosis of bone cement implantation syndrome using point of care ultrasound examination.

Once regarded as a rare complication, the potentially fatal bone cement implantation syndrome (BCIS) has been increasingly reported. BCIS can present as transient desaturation, hypotension, cardiac dysrhythmias, and cardiovascular collapse. Diagnosis of BCIS is often clinical and confirmed with computed tomography (CT) imaging postoperatively. However, point of care ultrasound (POCUS) examination could be a helpful and timely tool to clinch the diagnosis in a sudden cardiovascular collapse. We present a case of Grade 3 BCIS where POCUS examination revealed a massive clot in the right atrium, which supports the diagnosis.

Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic.

Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.

RéSUMé: Le 11 mars 2020, l'Organisation mondiale de la Santé déclarait que la nouvelle maladie du coronavirus 2019 (COVID-19) était une pandémie en raison de sa propagation mondiale rapide. En salle d'opération, dans le cadre des mesures de réponse aux épidémies, les anesthésiologistes doivent prendre des précautions supplémentaires et adapter les pratiques anesthésiques au cas par cas selon chaque patient. Plus particulièrement, en minimisant les nombreuses interventions générant des aérosols pendant la réalisation de l'anesthésie générale, les anesthésiologistes peuvent réduire l'exposition aux sécrétions respiratoires des patients et le risque de transmission virale périopératoire aux travailleurs de la santé et aux autres patients. Afin d'éviter toute manipulation des voies aériennes, il convient d'envisager la réalisation d'une anesthésie régionale si une chirurgie est prévue chez un patient sous enquête de COVID-19 ou confirmé, ou chez tout patient posant un risque infectieux. L'anesthésie régionale comporte des avantages en matière de maintien de la fonction respiratoire et ce, tout en évitant la production d'aérosols et par conséquent la transmission virale. Cet article explore les considérations pratiques et les mesures recommandées pour réaliser une anesthésie régionale dans ce groupe de patients, en se concentrant sur les mesures de surveillance visant à garantir la sécurité des patients et du personnel soignant, la protection des équipements et la prévention des infections. Ce faisant, nous espérons répondre à des interrogations qui pourraient avoir des implications à plus long terme dans la manière dont nous pratiquerons la prévention de la contagion en anesthésie, avec une pertinence toute particulière pour cette nouvelle ère de maladies infectieuses émergentes et de nouveaux pathogènes. Le coronavirus du syndrome respiratoire aigu sévère 2 (SARS-CoV-2) n'est pas le premier et ne sera certainement pas le dernier nouveau virus qui entraînera des épidémies mondiales. En disposant d'un plan bien conçu d'anesthésie régionale pour prendre en charge ces patients dans cette nouvelle ère, les meilleures issues possibles seront assurées tant pour le patient que pour l'équipe de prise en charge périopératoire.

Fibreoptic intubation in airway management: a review article.

Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.

Direct and indirect low skill fibre-optic intubation: A randomised crossover manikin study of six supraglottic airway devices.

BACKGROUND AND AIMS: Fibre-optic intubation (FOI) through supraglottic airway devices (SADs) is useful in the management of the difficult airway. We compared two methods of FOI through seven SADs in a randomised crossover manikin study to assess each device's performance and discuss implications on SAD selection. METHODS: Thirty anaesthetsiologists, 15 seniors and 15 juniors, each performed low skill FOI (LSFOI) with seven SADs using both 'direct' and 'indirect' methods. The order of method and device used were randomised. The primary end point was success rate of intubation; secondary end points were time taken for intubation, incidence of difficulties with direct and indirect LSFOI and operator device preference. Statistical analysis was with univariable analysis and comparison of proportions. RESULTS: Data from six devices were analysed due to a protocol breach with one SAD. There was no difference in intubation success rate across all SADs and intubation methods. Intubation time was significantly shorter in AmbuAuragain than other SADs and shorter with the direct method of LSFOI than the indirect method (mean difference of 6.9 s, P = 0.027). Ambu Auragain had the least SAD and bronchoscope-related difficulties. Seniors had significantly shorter mean intubation times than juniors by 11.6 s (P = 0.0392). The most preferred SAD for both methods was AmbuAuragain. CONCLUSION: Low skill FOI consistently achieves a high intubation success rate regardless of experience, choice of method, or SAD used. SAD design features may significantly affect the performance of low skill FOI.

Identification of individuals by trait prediction using whole-genome sequencing data.

Prediction of human physical traits and demographic information from genomic data challenges privacy and data deidentification in personalized medicine. To explore the current capabilities of phenotype-based genomic identification, we applied whole-genome sequencing, detailed phenotyping, and statistical modeling to predict biometric traits in a cohort of 1,061 participants of diverse ancestry. Individually, for a large fraction of the traits, their predictive accuracy beyond ancestry and demographic information is limited. However, we have developed a maximum entropy algorithm that integrates multiple predictions to determine which genomic samples and phenotype measurements originate from the same person. Using this algorithm, we have reidentified an average of >8 of 10 held-out individuals in an ethnically mixed cohort and an average of 5 of either 10 African Americans or 10 Europeans. This work challenges current conceptions of personal privacy and may have far-reaching ethical and legal implications.

Awake tracheal intubation in a patient with a supraglottic mass with the Bonfils fibrescope after failed attempts with a flexible fibrescope.

Awake intubation with a flexible fibrescope is usually done electively in patients with a known difficult airway. Herein, we describe the case of an elective awake tracheal intubation that was performed on a patient with a large, obstructive supraglottic mass. The intubation was successfully performed using the Bonfils fibrescope after several failed attempts with a flexible fibrescope. This case highlights the usefulness of the Bonfils fibrescope and the limitations of the flexible fibrescope in certain clinical situations.

A comparison between the Bonfils Intubation Fiberscope and McCoy laryngoscope for tracheal intubation in patients with a simulated difficult airway.

BACKGROUND: The Bonfils Intubation Fibrescope (Bonfils) and the McCoy laryngoscope (McCoy) are airway devices designed to assist tracheal intubation in difficult cases. Individually, both the Bonfils and McCoy have demonstrated superiority to the Macintosh laryngoscope in a simulated difficult airway. In this study, we compared the Bonfils with the McCoy laryngoscope in patients whose tracheal intubation had been intentionally hindered. Our primary hypothesis was that there is a significant difference in the rate of success for tracheal intubation when using the Bonfils or McCoy laryngoscope in patients with an intentionally hindered airway. METHODS: Patients undergoing elective surgery and requiring general anesthesia and endotracheal intubation were randomized to have intubation performed with either the Bonfils or McCoy laryngoscope. All patients were fitted with a hard cervical collar to simulate a difficult airway. Data collected included the success rate of endotracheal intubation, the time taken for intubation, the number of attempts required, the use of further aids to intubation, hemodynamic variables, and the incidence of adverse events. The primary end point was the relative rate of successful tracheal intubation. Categorical outcome measures were compared using the χ test, or Fisher exact test where appropriate, and the Mann-Whitney U test or unpaired Student t test where data were continuous. For the nonnormally distributed data, log transformation was adopted, and t test was performed if normalcy was achieved. RESULTS: Sixty adult patients were recruited and randomized into 2 groups of 30 patients each. There was no difference in the rate of successful intubation between groups (95% confidence interval [CI], -11.6% to 11.6%), with a 100% success rate achieved in both groups. We found no statistically significant differences between groups in the time taken for intubation (P = 0.32, 95% CI, 0.90-1.41) and percentage of single attempts (P = 0.47, 95% CI, -30.3% to 9.7%). However, further aids to intubation were required more frequently when using the McCoy laryngoscope (P < 0.001, 95% CI, 0.17-0.46), with 18 patients in the McCoy group requiring the use of an elastic bougie, and no patients in the Bonfils group requiring any aids. There were no significant differences found in the rates of adverse events. CONCLUSIONS: In the hands of trained operators, there appears to be no clinically significant difference in success, time to intubation, or adverse outcomes, when comparing the Bonfils with the McCoy laryngoscope, in the setting of a simulated difficult airway. The choice to use either device should remain based on appropriate patient selection, available aids, individual operator's experience, and economic circumstances.

Difficult intubation in a patient with vallecular cyst.

Although rare, vallecular cysts can have catastrophic consequences in an anaesthetised patient if airway management is inappropriate. We report a case of difficult intubation in a 46-year-old man with a vallecular cyst, and detail the methods and strategies for successful endotracheal tube insertion. Following a review of the current literature, we also discuss airway management options in adult patients with vallecular cysts.

Clinical uses of the Bonfils Retromolar Intubation Fiberscope: a review.

The Bonfils Retromolar Intubation Fiberscope is a rigid, straight fiberoptic device with a 40-degree curved tip, which facilitates targeted intubation. Bonfils, using a retromolar approach to intubate tracheas of children with Pierre Robin syndrome, was first described in 1983. After an initial steep learning curve, the Bonfils becomes a useful device in the management of normal and difficult airways. The advantages lie in its performance as an optical intubating stylet, which allows visualization from the tip of the endotracheal tube during intubation. The slim profile makes it useful in patients with limited mouth opening and cervical spine movement. Unlike the flexible fiberoptic bronchoscope, its rigid structure improves maneuverability and allows insertion past soft tissue obstructions. Endoscopic orientation of the Bonfils is better than the flexible fiberoptic bronchoscope, and it is also portable, durable, and simple to set up. The main difficulty experienced by Bonfils users is common to all fiberoptic scopes, limited view due to blood, secretions, fogging, and tissue contact. Additionally, nasal intubation is not possible with the Bonfils, and direct trauma and barotrauma are possible. Although the intubation success rate is high, it is still very much operator dependent. Time to intubation is inferior to conventional laryngoscopy, and its expense may be an issue in some centers. In conclusion, the Bonfils is an effective tool for management of the difficult airway after initial training.

Optimal reproductive allocation in annuals and an informational constraint on plasticity.

In this computational study, we examined optimal reproductive allocation schedules in annual plants whose season lengths vary in predictability. We discuss relationships among season-length predictability, the form of the optimal allocation schedule, the degree of plasticity reflected in the optimal reaction norm, and the competitive consequences of plasticity and bet-hedging. We used an evolutionary algorithm to search the allocation-schedule space for optima, given different distributions of season length. The resulting schedules maximize geometric-mean fecundity under their selecting distributions. We then examined the relative fitness of these schedules in simulated competition among reaction norms optimized for different degrees of season-length predictability. Gradedness of optimal schedules decreases with increasing season-length predictability, and reaction norms comprising highly graded schedules reflect lesser plasticity than norms comprising schedules that are less graded. In simulations, competitively successful genotypes were those that reflected plasticity appropriate to the season-length predictability. Informational constraints in the form of low season-length predictability select for low plasticity and high bet-hedging in allocation. Because an environmental cue must mediate the relationship between environment and fitness, plasticity in reproductive allocation ought to be understood not as a direct response to the selective environment, but rather to cues that are correlated with relevant environmental parameters.

Anesthetic management for a five-day separation of craniopagus twins.

UNLABELLED: Craniopagus twinning is a rare form of the already uncommon entity of conjoint twins. With advances in medical technology and expertise, future attempts at surgical separation of these increasingly complex cases are likely to occur. Despite this, medical literature on the anesthetic management of these cases is sparse. The following case report details the anesthetic management and planning leading to and including the 5-dy separation of 11-mo-old craniopagus twins. The report emphasizes the importance of teamwork, communication, and advanced planning required in cases such as this. IMPLICATIONS: The following case report documents the anesthetic planning and management leading to and including a 5-day separation of twins joined at the head. This case report also details the difficulties encountered during the unique combination of a rarely performed procedure and a long operating time.