Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

[Airway management of COVID-19 patients: a survey on the experience of 1125 physicians in Spain]. / Manejo de vía aérea en pacientes COVID-19: una encuesta sobre la experiencia de 1125 médicos en España.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists.The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision.Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and physicians. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Intubation in two patients with difficult airway management and tracheal stenosis after tracheostomy in thoracic surgery. / Intubación en dos pacientes con vía aérea difícil y estenosis traqueal tras traqueostomía en cirugía torácica.

Lung isolation in thoracic surgery is a challenge, this is even more complex in the presence of unknown tracheal stenosis (TS). We report two cases of unknown TS and its airway management. TS appears most frequently after long term intubation close to the endotracheal tube cuff or in the stoma of tracheostomy that appears as a consequence of the granulation tissue after the surgical opening of the trachea. Clinical history, physical examination, difficult intubating predictors and imaging tests (CT scans) are crucial, however most of tracheal stenosis may be unnoticed and symptoms depend on the degree of obstruction. In our cases, the patients presented anatomical changes due to surgery and previous tracheostomy that led to a TS without symptoms. There is scarce literature about the intubation in patients with previous tracheostomy in thoracic surgery. In the first case, a Univent® tube was used using a flexible fiberscope but an acute tracheal hemorrhage occurred. In the second case, after intubation with VivaSight SL® in an awake patient, the insertion of a bronchial blocker was performed through an endotracheal tube guided by its integrated camera without using flexible fiberscopy.

[Proposed difficult airway teaching methodology. Presentation of an interactive fresh frozen cadaver model]. / Propuesta de metodología docente en vía aérea difícil. Presentación de un modelo interactivo de cadáver fresco congelado.

BACKGROUND AND OBJECTIVE: The aim of this paper is to present a methodology based on the use of fresh-frozen cadavers for training in the management of the airway, and to evaluate the degree of satisfaction among learning physicians. MATERIAL AND METHODS: About 6 fresh-frozen cadavers and 14 workstations were prepared where participants were trained in the different skills needed for airway management. The details of preparation of the cadavers are described. The level of satisfaction of the participant was determined using a Likert rating scale of 5 points, at each of the 14 stations, as well as the overall assessment and clinical usefulness of the course. RESULTS: The mean overall evaluation of the course and its usefulness was 4.75 and 4.9, out of 5, respectively. All parts of the course were rated above 4 out of 5. The high level of satisfaction of the course remained homogeneous in the 2 editions analysed. The overall satisfaction of the course was not finally and uniquely determined by any of its particular parts. CONCLUSION: The fresh cadaver model for training physicians in techniques of airway management is a proposal satisfactory to the participant, and with a realism that approaches the live patient.

[Continuous infusion of baclofen and an antibiotic for treating meningitis related to refilling of an intrathecal infusion pump reservoir]. / Infusión continua de baclofeno con antibiótico para el tratamiento de meningitis asociada a relleno del reservorio de la bomba de perfusión intratecal.

Baclofen via intrathecal infusion pump is a widely used treatment severe spasticity. Complications are rare and usually mild, though they can also be serious. The sudden discontinuation of intrathecal baclofen may have significant adverse effects. We report the case of a 59-year-old man with chronic spasticity and torsion dystonia who developed meningitis due to Staphylococcus epidermidis due to contamination of the intrathecal, infusion pump reservoir during refilling. It was decided to treat the patient by administering vancomycin through the pump, together with the baclofen. We believe that changing the intrathecal perfusion pump is not necessary as the first measure to take in these cases. Combined infusion of baclofen and an antibiotic through the pump makes it possible to maintain antispastic treatment, sterilize the pump reservoir and tubes, and effectively treat infections that develop during use of these systems.

[Electron microscopy of the lesions produced in the human dura mater by Quincke beveled and Whitacre needles]. / Microscopia electrónica de las lesiones producidas en la duramadre humana por las agujas de bisel Quincke y Whitacre.

INTRODUCTION: Comparisons of Quincke needles and non traumatic "pencil point" needles in recent years have reported lower rates of post dural puncture headache using the later type. Our new understanding of the morphology of the human dura mater motivated us to study dural lesions caused by the Whitacre 25 G and Quincke 26 G needles, using scanning electron microscopy with the aim of determining whether there is an anatomic basis for the different outcomes. METHOD: The dura mater from three fresh cadavers of individuals aged 65, 70 and 72 years were punctured 40 times at an angle of 90 degrees each time. The Whitacre 25 G needle was used for 20 punctures and the Quincke 26 G needle was used for the other 20. Half the punctures were performed with the bevel in the parallel alignment and the other half with the bevel perpendicular to the spinal column. Fifteen min after causing the punctures, specimens were fixed in solutions of glutaraldehyde phosphate buffer and dehydrated in acetone. After critical point removal of the acetone, after the specimens were treated with carbon and metallized with gold. The lesions were examined externally and internally and expressed as the ratio of area of lesion to diameter of the needle that had caused them. RESULTS: Whitacre needle: each lesion consisted in the superimposition of multiple damaged layers that started to close individually. After 15 min the outermost layers were 90% closed and the innermost ones had closed entirely. Layers in the arachnoid surface of the dura mater had closed from 86 to 88%, while deeper layers in the thick part had closed 97 to 98%. Quincke needle: lesions were V-shaped or half-moon shaped, much like the opening formed by a can opener, on both the external and internal surfaces. Alignment of the bevel of the needle parallel to the spinal column did not lead to a different shape of puncture. After 15 min the lesions had closed 94 to 95% on the epidural surface and 95 to 96% on the arachnoid side, a difference attributable to the retraction of the arachnoid layers over the spinal column. CONCLUSION: Non traumatic beveled dural needles, termed "pencil point needles", only partially separate dural fibers, and lesions caused by these needles develop in a more complex way. The Quincke 26G needle produced a puncture that is morphologically different from that caused by the Whitacre 25G needle, although lesions produced by both types close more than 94% after 15 min. We believe the size of the lesion caused by these needles does not explain the difference in post dural puncture headache due to loss of spinal fluid.