Airway Management Failure after Delayed Extubation in a Patient with Oral Malignant Melanoma Who Underwent Partial Mandibulectomy and Reconstruction with a Free Flap

Maxillofacial surgery may cause severe complications in perioperative airway management. We report a case of failed airway management in a patient who underwent segmental mandibulectomy, radical neck dissection, and reconstruction with a free flap. The patient was extubated approximately 36 hours after surgery. Approximately 7 hours after extubation, the patient complained of dyspnoea, and respiratory failure followed. Bag-mask ventilation, direct laryngoscopy, video laryngoscopy, and supraglottic airway access were ineffective. The surgical airway was secured with an emergency tracheostomy while performing cardiopulmonary resuscitation. However, the patient experienced permanent hypoxic brain damage. The airway of patients with oral cancer may be compromised postoperatively due to surgical trauma and bulky flap reconstruction. Patients should be closely monitored during the postoperative period to prevent airway failure. Early diagnosis and airway management before airway failure occurs are important. Medical staff should be aware of airway management algorithms, be trained to perform difficult airway management, and have the required equipment readily available.

Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials

Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.

Application of DOPS Checklists in Assessing the Skills of Emergency Bag Mask Ventilation and Endotracheal Tube Intubation

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Effects of airway management and tidal volume feedback ventilation during pediatric resuscitation in piglets with asphyxial cardiac arrest

To compare the effect on the recovery of spontaneous circulation (ROSC) of early endotracheal intubation (ETI) versus bag-mask ventilation (BMV), and expiratory real-time tidal volume (VTe) feedback (TVF) ventilation versus without feedback or standard ventilation (SV) in a pediatric animal model of asphyxial cardiac arrest. Piglets were randomized into five groups: 1: ETI and TVF ventilation (10 ml/kg); 2: ETI and TVF (7 ml/kg); 3: ETI and SV; 4: BMV and TVF (10 ml/kg) and 5: BMV and SV. Thirty breaths-per-minute guided by metronome were given. ROSC, pCO2, pO2, EtCO2 and VTe were compared among groups. Seventy-nine piglets (11.3 ± 1.2 kg) were included. Twenty-six (32.9%) achieved ROSC. Survival was non-significantly higher in ETI (40.4%) than BMV groups (21.9%), p = 0.08. No differences in ROSC were found between TVF and SV groups (30.0% versus 34.7%, p = 0.67). ETI groups presented lower pCO2, and higher pO2, EtCO2 and VTe than BMV groups (p < 0.05). VTe was lower in TVF than in SV groups and in BMV than in ETI groups (p < 0.05). Groups 1 and 3 showed higher pO2 and lower pCO2 over time, although with hyperventilation values (pCO2 < 35 mmHg). ETI groups had non significantly higher survival rate than BMV groups. Compared to BMV groups, ETI groups achieved better oxygenation and ventilation parameters. VTe was lower in both TVF and BMV groups. Hyperventilation was observed in intubated animals with SV and with 10 ml/kg VTF.

Anesthetic Management of Apert Syndrome: A Case Report

Apert syndrome is a rare autosomal dominant disease associated with abnormalities of skull, face and limbs. These patients present for different types of surgeries. To the anesthesiologists,they pose special challenge during airway management, manifesting as difficulty in bag-mask ventilation and increased incidence of airway obstruction. Here, we report a case of a child with Apert syndrome undergoing syndactyly release under general anesthesia, in whom severe bronchospasm and a failed bag-mask ventilation occurred during the emergence of anesthesia requiring re-insertion of laryngeal mask airway.

Midwives' Evaluation of a Neonatal Resuscitation in High- and Low-Resource Settings

Aim: To assess midwives' evaluation of a real-life neonatal resuscitation and their opinion on importance of resuscitation interventions.Methods: Multicenter, multi-country study.Setting: Beira Central Hospital (Mozambique) and Azienda Ospedale-Università di Padova (Italy).Subjects: Sixteen Mozambican midwives and 18 Italian midwives.Interventions: Midwives' assessment was evaluated by using a predefined score, which graded each resuscitation intervention (0–2 points) and summed to a total score for each step (initial steps, bag-mask ventilation, and chest compressions). All scores were compared with referral scores given by two expert neonatologists.Results: Both Mozambican and Italian midwives overestimated their performance regarding of initial steps taken during resuscitation, chest compressions, high-oxygen concentrations (p &lt; 0.01), and underestimated the importance of stimulation (p &lt; 0.05). Mozambicans overestimated suctioning (p &lt; 0.001). Participants agreed with experts about the importance of equipment preparation, using a warmer, drying the newborn, removing wet linen and heart rate assessment.Conclusion: Mozambican and Italian midwives overestimated the performance of a real-life neonatal resuscitation, with heterogeneous evaluation of the importance of several aspects of neonatal resuscitation. These findings may be useful for identifying educational goals.

Neonatal resuscitation: EN-BIRTH multi-country validation study

Background Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage. Methods The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017–2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation. Results Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5–40.8%, specificity 66.8–99.5%), BMV accuracy was higher (sensitivity 12.4–48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure. Conclusions Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.