Airway Management for Acute and Reconstructive Burns: Our 30-year Experience.

Airway management in both acute and reconstructive burn patients can be a major challenge for evaluation, intubation, and securing the airway in the setting of altered airway structure. Airway evaluation in both acute and reconstructive patients includes examination for evidence of laryngeal and supraglottic edema and structural changes due to trauma and/or scarring that will impact the successful approach to acquiring an airway for surgical procedures and medical recovery. The approach to acquiring a successful airway is rarely standard laryngoscopy and often requires fiberoptic bronchoscopy and a variety of airway manipulation techniques. Tracheostomy should be reserved for those with classic requirements of ventilatory and/or mechanical failure or severe upper airway burns. Even securing an airway for surgical procedures, especially with patients suffering injuries involving the head and neck, can be nonstandard and requires creative and flexible approaches to be successful. After much trial and error over the past 30 years in a large burn center, our multidisciplinary team has learned many valuable lessons. This review will focus on our current approach to safe airway management in acute and reconstructive burn patients.

Evaluating the Role of Anesthesia on Intraoperative Blood Loss and Visibility during Endoscopic Sinus Surgery: A Meta-analysis.

BACKGROUND: Previous studies and meta analyses have led to incongruent and incomplete results respectively when total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) are compared in endoscopic sinus surgeries in regards to intraoperative bleeding and visibility. OBJECTIVE: To perform a more comprehensive meta-analysis on randomized controlled trial (RCTs) comparing TIVA with IA in endoscopic sinus surgery to evaluate their effects on intraoperative bleeding and visibility. METHODS: A systematic review and meta-analysis of studies comparing TIVA and IA in endoscopic sinus surgery for chronic rhinosinusitis was completed in May 2020. Utilizing databases, articles were systematically screened for analysis and 19 studies met our inclusion criteria. The primary outcome included intraoperative visibility scores combining Boezaart, Wormald and Visual Analogue Scale (VAS). Secondary outcomes included rate of blood loss (mL/kg/min), estimated total blood loss (mL), Boezaart, Wormald scores, VAS, heart rate, and mean arterial pressure (MAP). RESULTS: 19 RCTs with 1,010 patients were analyzed. TIVA had a significantly lower intraoperative bleeding score indicating better endoscopic visibility (Boezaart, VAS, and Wormald) than IA (-0.514, p = 0.020). IA had a significantly higher average rate of blood loss than TIVA by 0.563 mL/kg/min (p = 0.016). Estimated total blood loss was significantly lower in TIVA than IA (-0.853 mL, p = 0.002). There were no significant differences between TIVA and IA in the mean heart rate (-0.225, p = 0.63) and MAP values (-0.126, p = 0.634). The subgroup analyses revealed no significant difference between TIVA and IA when remifentanil was not utilized and whenever desflurane was the IA agent. CONCLUSION: TIVA seemed to have superior intraoperative visibility scores and blood loss during endoscopic sinus surgery when compared to IA. However, the results are not consistent when stratifying the results based on the use of remifentanil and different inhaled anesthetics. Therefore, the conclusion cannot be made that one approach is superior to the other.

Comparison of steroid-releasing stents vs nonabsorbable packing as middle meatal spacers.

BACKGROUND: A randomized controlled trial was held to compare nonabsorbable packs to steroid-eluting absorbable stents as middle meatal spacers after endoscopic sinus surgery in patients with chronic rhinosinusitis (CRS). METHODS: CRS patients were randomly assigned to receive either nonabsorbable Merocel packs wrapped in non-latex glove material (packing type A) or Propel steroid eluting stents (packing type B). Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores were collected preoperatively and postoperatively during the initial 4 debridements up to 3 months. Recording of the nasal endoscopy was also collected during all postoperative visits. In addition, Lund-Kennedy scores and middle turbinate lateralization scores, using a new visual analogue scale, were compared between the 2 types of packing. RESULTS: Forty CRS patients were prospectively enrolled in this institutional review board (IRB)-approved study. Patients with packing type A had significantly lower middle turbinate lateralization scores at their first (∼10 days) postoperative visit (p = 0.02 and p = 0.04, for left and right sides, respectively). This difference disappeared by later postoperative visits (from 20 days to 3 months). Overall, patients receiving packing type A had significant lower SNOT-22 scores at 20 days postsurgery (p = 0.05). This difference also disappeared at 1 and 3 months postoperation. There were no statistically significant differences in Lund-Kennedy scores. CONCLUSION: In this study, nonabsorbable packing materials showed significant superior middle meatal spacing capacities as evidenced by greater middle turbinate medialization capability at the first postoperative visit. Additionally, patients with this type of packing saw improvements in their SNOT-22 scores at the 20-day postoperative visit. This study showed that there was no significant improvement in postoperative outcomes with drug-eluting stents when compared to nonabsorbable packing.

Respiratory Volume Monitoring Reduces Hypoventilation and Apnea in Subjects Undergoing Procedural Sedation.

INTRODUCTION: The use of monitored anesthesia care for endoscopic procedures increases the risk of respiratory depression, necessitating careful monitoring of patient ventilation. We examined the effectiveness of an impedance-based respiratory volume monitor (RVM) in improving the safety of patients undergoing upper and lower gastrointestinal endoscopies under total intravenous anesthesia. We hypothesized that feedback from the RVM would allow anesthesiologists to maintain adequate ventilation, which would reduce the duration of respiratory depression (ie, hypoventilation and apnea) compared to a blinded control group. METHODS: Sixty-five subjects were enrolled in a randomized controlled trial and monitored with a noninvasive impedance-based RVM, which displayed respiratory traces and calculated expiratory minute ventilation (V̇E), tidal volume (VT), and breathing frequency (f) measurements. Prior to induction of anesthesia, a baseline V̇E measurement (V̇E-baseline) was taken as a measurement of normal breathing. V̇E was monitored throughout the procedure for signs of hypoventilation and apnea. Hypoventilation was defined as V̇E < 40% V̇E-baseline, and apneas were defined as V̇E = 0 for > 15 s. RESULTS: Sixty-five subjects were randomly assigned to either a control (n = 38) or RVM intervention group (n = 27). Subjects in the intervention group had a higher V̇E% for the entire procedure (P = .045), as well as the third and fourth quartile of the procedure compared to the control group (P = .01). Likewise, subjects in the RVM intervention group spent significantly less time below 40% V̇E-baseline compared to the control group throughout the entire procedure (12 ± 15% vs 32 ± 24%, respectively) (P < .001). The median number of apneas per subject was greater in the control group (median 2, interquartile range 1-2, maximum 4) compared to the RVM intervention group (median 1, interquartile range 1-2, maximum 3) (P = .037). CONCLUSIONS: The control group had a higher incidence of hypoventilation and apnea compared to the RVM intervention group. Respiratory monitoring using the RVM can potentially be a useful tool for identifying early signs of respiratory depression and for titrating anesthetics to maintain adequate ventilation while minimizing patient risk.