Should we take precautions to avoid respiratory compromise while delaying CPAP resumption following transsfenoidal surgery? An alternative approach in a patient with severe obstructive sleep apnea: case report.

BACKGROUND: We describe a patient with severe obstructive sleep apnea scheduled for transsfenoidal surgery. Early postoperative use of continuous positive airway pressure (CPAP) was considered unsafe because increased risk of intracranial complications. METHODS: Aiming to bypass the upper airway obstruction and thus avoid CPAP, a 6-mm nasopharyngeal airway was introduced by the surgical team under endoscopic vision. In the postoperative period and during follow-up, patient and his family did not complain about apnea/hypopnea episodes and nasopharyngeal airway was tolerated comfortably. CONCLUSION: We recommend this technique as an alternative in obstructive sleep apnea patients undergoing transsfenoidal surgery.

Haemodynamic Response to Four Different Laryngoscopes.

OBJECTIVE: In this prospective randomized study, we aimed to evaluate the effect of tracheal intubation with four different laryngoscopes [Macintosh direct laryngoscope-classic laryngoscope (CL), McCoy (MC), C-Mac video-laryngoscope (CM) and McGrath video-laryngoscope (MG)] on haemodynamic responses in patients with a normal airway. METHODS: One hundred and sixty patients were included. Succeeding haemodynamic measurements were performed immediately after intubation (T2) and for 5 min with 1-min intervals (T3-T4-T5-T6-T7). The primary outcome was the heart rate (HR) and systolic blood pressure (SBP) change triggered by the four different laryngoscopes. The intubation time, the number of intubation attempts, need for stylet or additional manipulation, glottic view and traumatic complications caused by intubation procedure were recorded as secondary outcomes. RESULTS: HR values significantly increased with the completion of laryngoscopy and intubation at T2 for the CL, MC and CM groups. Lesser fluctuation in HR and SBP was observed in the MG group. Intubation time was significantly shorter in the MG group (p<0.001). There was no statistically significant difference between the groups regarding the number of intubation attempts, need for stylette and glottic view. Fewer patients in the MG and CM groups experienced a moderate and severe sore throat than in the other two groups. Shorter intubation time and lesser sore throat incidence were observed in the MG group. CONCLUSION: MG offers less haemodynamic stimulation than CL, MC, and CM. Our findings showed that tracheal intubation with MG is advantageous in preventing cardiovascular stress responses with short intubation time and less sore throat incidence.

Comparison of Ultrasound-Guided Axillary Brachial Plexus Block Properties in Diabetic and Nondiabetic Patients: A Prospective Observational Study.

PURPOSE: Patients with diabetes mellitus (DM) type 2 may have subclinical peripheral nerve neuropathy. We performed this study to compare the differences in duration of axillary brachial plexus blocks in patients with type 2 DM and without DM (NODM). Our hypothesis was that the sensory block duration would be prolonged in patients with DM. METHODS: A total of 71 patients who were scheduled for elective forearm and/or hand surgery were enrolled in this study. Before surgery, they received ultrasound-guided axillary brachial plexus blocks with a mixture of 10 mL lidocaine 2% and 20 mL bupivacaine 0.5%. After surgery, all patients received 1 g paracetamol every 6 hours as needed. The primary end point was sensory block duration. Secondary end points were motor block duration, time until first pain (numeric rating scale [NRS] 4 or greater), highest NRS pain scores, and rescue analgesic consumption (NRS 4 or greater) through the first 2 postoperative days. RESULTS: In all, 67 patients completed the study: 22 in the DM group and 45 in the NODM group. Sensory and motor block durations were longer in the DM group than in the NODM group (mean [range], 773.5 [479-1155] vs 375 [113-900] minutes, and 523 [205-955] vs 300 [110-680] minutes). Time until first pain was 855 (590-1,285) minutes in the DM group and 500 (200-990) minutes in the NODM group. The highest NRS scores were also significantly lower in the DM group at 6 and 12 hours. Paracetamol consumption was lower in the DM group through the first 2 postoperative days. CONCLUSIONS: The presence of DM was associated with longer duration of the sensory block after axillary brachial plexus block. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Ultrasound-Guided Bilateral Thoracic Paravertebral Blocks as an Adjunct to General Anesthesia in Patients Undergoing Reduction Mammaplasty: A Historical Cohort Study.

BACKGROUND: This study investigates whether ultrasound-guided thoracic paravertebral blocks would improve postoperative analgesia in patients undergoing bilateral reduction mammaplasty. METHODS: After obtaining ethics committee approval, data of 70 patients who underwent bilateral reduction mammaplasty were reviewed. Sixty-four patients' data were evaluable; 30 were in the general anesthesia group and 34 were in the thoracic paravertebral block group. Data such as time to first pain, intraoperative fentanyl requirement, postoperative numeric rating scale scores, number of patients who required tramadol in the postoperative care unit, and rescue analgesic consumption through the first 2 postoperative days were analyzed. RESULTS: Time to first pain was 311 minutes (range, 0 to 1605 minutes) and 20 minutes (range, 0 to 120 minutes) in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Fentanyl requirement was 52.94 ± 11.94 µg and 115 ± 29.79 µg in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Numeric rating scale scores were lower in the thoracic paravertebral block group through the first 2 postoperative hours (p < 0.001), and only two of 34 patients required tramadol in the postoperative care unit (p < 0.001). On postoperative day 1, both metamizole sodium (p < 0.001) and paracetamol (p = 0.018), and on day 2, only metamizole sodium (p < 0.001) consumption was lower in the thoracic paravertebral block group. CONCLUSION: Adding ultrasound-guided thoracic paravertebral blocks to general anesthesia postponed time to first pain and reduced analgesic consumption in patients undergoing bilateral reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.