Liposuction Complications in the Outpatient Setting: A National Analysis of 246,119 Cases in Accredited Ambulatory Surgery Facilities.

Background: Suction lipectomy (liposuction) is a popular cosmetic surgical procedure performed in the United States, but little has been documented regarding perioperative complications due to its outpatient nature. Objectives: This cross-sectional study aims to analyze the most common complications that accompany liposuction-related procedures and importantly estimate the total complication rate occurring at ambulatory surgical facilities. Methods: Adult patients who experienced liposuction-related complications from 2019 to 2021 were identified in the reporting database of the global surgery accreditation authority, the American Association for Accreditation of Ambulatory Surgery Facilities (QUAD A). Patients were then divided by complication type and procedure location. Demographics and facility-specific variables were analyzed. Descriptive statistics were performed. Results: Overall, 984 patients were included, with a mean age of 44 years (interquartile range [IQR] 37-53) and a median BMI of 28.7 kg/m2 (IQR 25.7-32.2). The overall confirmed complication rate was found to be 0.40% (984/246,119). Unplanned emergency department presentation was the most common complication overall (24%). Wound disruption was associated with the longest median procedure length (261 min), and venous thromboembolism was associated with the highest median BMI (30.1 kg/m2). The Southeast had the most complications (431), which accounted for 13/21 deaths (61.9%). Out of all complications, death was associated with the highest average annual case volume (241). Conclusions: Procedures that involve liposuction are associated with a variety of medical and surgical complications. Given the high frequency and variability in how liposuction is performed, a thorough assessment of complications is critical to improve the safety of this procedure.

A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists.

The American Society of Anesthesiologists' (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist's choice of pathway in the ASA's Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist's unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Difficult Airway Management in Adult Coronavirus Disease 2019 Patients: Statement by the Society of Airway Management.

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

Airway Management in an Anatomically and Physiologically Difficult Airway.

A "difficult airway" should be suspected in patients with any anatomical or physiologic abnormality that might result in the loss of the airway or significant cardiopulmonary compromise upon induction of general anesthesia. Historically, an awake intubation has often been the preferred approach for airway management in these patients. Here we describe a case in which an awake intubation was safely performed in a patient with both anatomical (i.e., laryngeal mass) and physiologic (i.e., pulmonary hypertension) abnormalities. Oxygenation, airway patency, and spontaneous breathing were well maintained with successful intubation on the first attempt. We recommend that the patient's physiologic state should always be considered in airway management planning.

Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis.

Exposure of healthcare providers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a significant safety concern during the coronavirus disease 2019 (COVID-19) pandemic, requiring contact/droplet/airborne precautions. Because of global shortages, limited availability of personal protective equipment (PPE) has motivated the development of barrier-enclosure systems, such as aerosol boxes, plastic drapes, and similar protective systems. We examined the available evidence and scientific publications about barrier-enclosure systems for airway management in suspected/confirmed COVID-19 patients. MEDLINE/Embase/Google Scholar databases (from December 1, 2019 to May 27, 2020) were searched for all articles on barrier enclosures for airway management in COVID-19, including references and websites. All sources were reviewed by a panel of experts using a Delphi method with a modified nominal group technique. Fifty-two articles were reviewed for their results and level of evidence regarding barrier device feasibility, advantages, protection against droplets and aerosols, effectiveness, safety, ergonomics, and cleaning/disposal. The majority of analysed papers were expert opinions, small case series, technical descriptions, small-sample simulation studies, and pre-print proofs. The use of barrier-enclosure devices adds to the complexity of airway procedures with potential adverse consequences, especially during airway emergencies. Concerns include limitations on the ability to perform airway interventions and the aid that can be delivered by an assistant, patient injuries, compromise of PPE integrity, lack of evidence for added protection of healthcare providers (including secondary aerosolisation upon barrier removal), and lack of cleaning standards. Enclosure barriers for airway management are no substitute for adequate PPE, and their use should be avoided until adequate validation studies can be reported.

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.

Effect of ancillary ligands on the DNA interaction of [Cr(diimine)3]3+ complexes containing the intercalating dipyridophenazine ligand.

The synthesis of photoluminescent Cr(III) complexes of the type [Cr(diimine)(2)(DPPZ)](3+) are described, where DPPZ is the intercalating dipyridophenazine ligand, and diimine corresponds to the ancillary ligands bpy, phen, DMP, and TMP (where bpy = 2,2'-bipyridine, phen = 1,10-phenanthroline, DMP = 5,6-dimethyl-1,10-phenanthroline, and TMP = 3,4,7,8-tetramethyl-1,10-phenanthroline). For TMP, DMP, and phen as ancillary ligands, the complexes have also been resolved into their Lambda and Delta optical isomers. A comparison of the photophysical and electrochemical properties reveal similar (2)E(g) --> (4)A(2g) (O(h)) emission wavelengths and lifetimes, and a variation of 110 mV in the (2)E(g) excited state oxidizing power. A detailed investigation has been undertaken of ancillary ligand effects on the DNA binding of these complexes with a range of polynucleotides. For all four complexes, emission is quenched by the addition of calf thymus B-DNA, with the emission lifetime data yielding bimolecular quenching rate constants close to the diffusion controlled limit. Equilibrium dialysis studies have established a general predilection for AT base binding sites, while companion experiments with added distamycin (a selective minor groove binder) provide evidence for a minor groove binding preference. For the case of [Cr(TMP)(2)(DPPZ)](3+), concomitant equilibrium dialysis and circular dichroism measurements have demonstrated very strong enantioselective binding by the Lambda optical isomer. The thermodynamics of DNA binding have also been explored via isothermal titration calorimetry (ITC). The ITC data establish that the primary binding mode for all four Cr(III) complexes is entropically driven, a result that is attributed to the highly favorable free energy contribution associated with the hydrophobic transfer of the Cr(III) complexes from solution into the DNA binding site.

Modulating effects of hypoxia and hypercarbia on glottic closing force.

OBJECTIVES: Aspiration has been identified as one of the independent risk factors for development of respiratory tract infections, the incidence of which varies from 10% to 65% in patients in intensive care units. The primary defense mechanism for protection of the lower airway is the glottic closure reflex (GCR), elicited by stimulation of the internal branch of the superior laryngeal nerve. This reflex, once considered highly stable, is now considered vulnerable to a growing number of clinical factors. This study was designed to explore the biomechanical effects of hypoxia and hypercarbia, common occurrences among critically ill patients, on the GCR. METHODS: Five adult male Yorkshire pigs were used in the study. Both internal superior laryngeal nerves were simultaneously stimulated with bipolar platinum-iridium electrodes. The glottic closing force (GCF) was then measured by placing a pressure transducer between the adducting vocal folds under 3 different protocols: protocol 1 (control), protocol 2 (hypoxia: partial pressure of arterial oxygen [PaO2] levels of 90, 70, and 50 mm Hg), and protocol 3 (hypercarbia: partial pressure of arterial carbon dioxide [PaCO2] levels of 60 and 70 mm Hg). Six readings were recorded under each experimental paradigm, and Student's t-test was applied to calculate the statistical significance against the control. RESULTS: Hypoxia reduced the GCF to 75%, 40%, and 29% of control for PaO2 levels of 90, 70, and 50 mm Hg, respectively, and hypercarbia reduced the GCF to 40% and 27% of control for PaCO2 levels of 60 and 70 mm Hg, respectively. CONCLUSIONS: This is the first study that highlights the biomechanical impact of hypoxia and hypercarbia on the GCR, providing a unified explanation for the increased incidence of life-threatening aspiration in critically ill patients with such alterations.

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.

The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.

BACKGROUND: Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster. METHODS: We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination. RESULTS: During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (+/-22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment. CONCLUSION: The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.

Effects of altered consciousness on the protective glottic closure reflex.

OBJECTIVES: The sphincteric function of the larynx, essential to lower airway protection, is most efficiently achieved through strong reflex adduction by both vocal folds. We hypothesize that central facilitation is an essential component of a bilateral brain stem-mediated adductor reflex and that its disturbance by altered consciousness or physiologic sleep could result in weakened sphincteric closure. METHODS: In 10 adult pigs the glottic closure response was evaluated under light and deep isoflurane anesthesia. The internal branch of the left superior laryngeal nerve was stimulated through bipolar platinum-iridium electrodes, and recording electrodes were positioned in the ipsilateral and contralateral thyroarytenoid muscles. The force of evoked glottic closure was measured with a pressure transducer positioned between the vocal folds. RESULTS: Consistent threshold responses (>90%) were obtained ipsilaterally from 0.5 to 2.0 minimal alveolar concentration (MAC) anesthesia. However, the contralateral reflex responses declined to 6.4% in successive trials as anesthetic levels approached 1.5 to 2.0 MAC. Furthermore, glottic closing force closely reflected these electromyographic changes, declining from 383 mm Hg at 0.5 to 1.0 MAC to 114 mm Hg at 1.5 to 2.0 MAC. CONCLUSIONS: Alteration of central facilitation by progressively deeper loss of consciousness abolishes a lower brain stem-mediated crossed adductor reflex, predisposing the subject to a weakened glottic closure response.

Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians.

STUDY OBJECTIVE: To determine the characteristics of prehospital tracheal intubation and the incidence of difficult-to-manage airways in out-of-hospital patients managed by emergency medicine physicians with anaesthesia training. METHODS: In a prospective study, conducted over a 4-year period, we evaluated all airway interventions performed by anaesthesia-trained emergency physicians. RESULTS: One thousand, one hundred and six out of 16,559 patients (6.8%) required tracheal intubation. Orotracheal intubation was attempted in 982, laryngoscopic aided nasotracheal intubation in 64 and blind nasotracheal intubation in 90 of the cases. Two techniques were used in 30 patients. Failure rates were 2.4, 8.1 and 25.6%, respectively. A Combitube or LMA was used in 2.0%. In one case of failed Combitube insertion successful needle cricothyrotomy was performed. In patients undergoing direct laryngoscopy, Cormack-Lehane laryngeal grade views I-IV were seen in 52.0, 28.8, 12.6 and 6.6% of cases, respectively. A difficult to manage airway (DMA) was reported in 14.8%, multiple intubation attempts in 4.3% and failed intubation in 2.0% of all cases. Grouping patients based on clinical presentation revealed a significantly higher incidence of DMA in trauma patients (18.6%) and during cardiopulmonary resuscitation (16.7%) than in the remaining patient group (9.8%). Intubation failed significantly more often in trauma (3.9%) than in the remaining patient group (1.1%). CONCLUSION: When compared to studies on laryngoscopy performed in the operating room, this study demonstrated a higher incidence of difficult and failed laryngoscopy, DAM, and high laryngeal grade views when patients were managed in a prehospital setting by anaesthesia trained physicians.