Comparison of Airtraq® Laryngoscope, Bonfils Endoscope and Fiberoptic Bronchoscope for Awake Tracheal Intubation: A Randomized, Controlled Trial

Over the last decades several indirect laryngoscopes have been developed to provide a significant better glottic view and improved the success rate in difficult intubations. Some case reports describe the use of indirect laryngoscopes for awake tracheal intubations under preserved spontaneous breathing. However, randomized clinical studies comparing indirect laryngoscopy to the standard of fiberoptic intubation under spontaneous breathing are rare. Therefore, we compared the intubation with the Airtraq® laryngoscope and the Bonfils endoscope, to the standard fiberoptic intubation in patients with an expected difficult intubation under local anesthesia and sedation. 150 patients with an expected difficult intubation were randomized to one of the three devices. All intubation attempts were performed under local anesthesia and sedation. We evaluated success rate, time for intubation and the satisfaction of anesthesiologists and patients. Fiberoptic intubation was significantly more successful (100%) than intubation with an Airtraq® laryngoscope (88%) or the Bonfils endoscope (88%). Time for intubation was quickest with the Airtraq® laryngoscope and significantly shorter than fiberoptic intubation (p=0.044). There was no difference in satisfaction of the anesthesiologists and none of the patients had a negative recall to one of the techniques. An expected difficult intubation can be managed using the Airtraq® laryngoscope or the Bonfils endoscope in 88% and shows the same satisfaction of anesthesiologists and patient. We conclude that these techniques represent an acceptable alternative for an awake tracheal intubation under sedation and preserved spontaneous breathing.

Transient Ischemic Attack in a Hemophilia Patient with Severe Preeclampsia after Preoperative Administration of Tranexamic Acid and Factor VIII Replacement for Cesarean Section

Hemophilia A in females accounts for few cases due to hemophilia A and B having X-linked recessive inheritance patterns. Hemostatic changes in pregnancy include an increase in coagulation factors and von Willebrand activity, placing hemophilia patients at an increased risk for Postpartum Hemorrhage (PPH). General recommendations include considering pharmacologic prophylaxis, including tranexamic acid and factor replacement when necessary. The ultimate goal is to prevent uncontrolled bleeding during vaginal or operative delivery. Benefits of prophylactic therapies must be weighed with relevant risk profiles of each intervention. We present a case where a parturient with hemophilia prophylactically treated with TXA and FVIII experienced a transient ischemic attack. We discuss the background information known regarding tranexamic acid and factor replacement, and the subsequent recommendations for their use in this patient population. We consider recommendations to expand the multidisciplinary team incorporated in the assessment and planning for the peripartum care of such a patient.

Transversus Abdominis Plane Block in Robotic Gynecologic Oncology Surgery

Objective: Although minimally invasive surgery decreases opiate requirements compared to laparotomy, achieving adequate postoperative pain relief continues to be a concern. We aimed to determine the efficacy of transversus abdominis plane block on postoperative opiate use, pain levels, and time of discharge following robotic hysterectomy for surgeries performed by our division of gynecologic oncology. Design: This is a retrospective analysis of patients who underwent robotic hysterectomy. Methods: After induction of general anesthesia, patients received transversus abdominis plane block and underwent robotic hysterectomy. Patients who did not receive the transversus abdominis plane block received local analgesia. A non-narcotic pain control regimen was used pre- and postoperatively and supplemented with narcotic analgesics as needed. Length of stay, pain levels (score of 0-10), and opioid consumption were reviewed and compared between the two groups. Results: Following power calculation, 140 patients were studied: 70 received a transversus abdominis plane block and were matched to 70 patients who received local anesthesia. All patients received our Enhanced Recovery Pathway. After controlling for age, BMI, total surgical time, and number of ports, there were no differences in pain scores at 1 hour (p = 0.13) and at discharge (p = 0.06), time to discharge (p = 0.09), amount of opioids required (p = 0.11), or time to void (p = 0.07). Conclusions: This study demonstrated that when well-established Enhanced Recovery Pathway is utilized, transversus abdominis plane block was equivalent to local anesthesia in reducing postoperative opioid consumption and pain scores.

What do we know about SARS-Cov-2 and Anesthesia Management?

In general, COVID-19 is an acute disease, and the most common symptoms at onset are fever, dry cough, and fatigue, partly with nausea, diarrhea, or other gastrointestinal symptoms [1,2]. Also it has association with neurological symptoms, cardiovascular involvement, and hypercoagulability [3-13]. Anesthesiologists are confronted with these patients not only in intensive care but also in the operating room. In this brief review we focused on what do we know about COVID-19, and how to manage anesthesia and operating room when surgery is needed under the light of our experience and expertise in the field.

The Effect of Virtual Reality on Anxiety and Pain in Patients Undergoing Gynecological Surgery (VRAP-G); a Randomized Controlled Trial

Background: Lack of postoperative acute pain management is associated with increased morbidity, longer recovery time, more opioid use and subsequently increased health care costs. There is increasing evidence that Virtual Reality (VR) is effective in the reduction of acute pain. Alternative methods to reduce postoperative pain and multimodal analgesia are necessary for acute postoperative pain management and to reduce opioid use and their adverse effects. The aim of this study is to explore the effect of VR on pain in the postoperative period after elective gynecological surgery. Methods and Design: The study concerns a non-blinded, single center, randomized controlled trial. Eligible women fulfilling the inclusion criteria and receive elective gynecological surgery in the Zuyderland Medical Center will be randomized for participation. The study population will be randomly divided into the intervention group (VR-group) or the standard care- group. The intervention group can choose for an immersive guided relaxation VR experience or an interactive VR experience during the pre- and postoperative period additional to the usual standard care. The participants randomized to the standard caregroup will receive only the usual standard care pre-and postoperative. The primary outcome is postoperative pain measured on a Numeric Rating Scale (NRS). A total of 30 patients have to be included in each group. This means that a total of 60 women will have to be included in this study. Secondary outcomes are; evaluating pre-and postoperative anxiety, pain catastrophizing, analgesic use, length of hospital stay between both groups and to explore tolerability, feasibility and satisfaction of VR use. Discussion: This study will provide insight as to whether in women who receive gynecological surgery, VR is an effective method to reduce postoperative pain and subsequently opioid use.

Use of Stellate Ganglion Local Anesthetic Blockade for Treatment of Complex Regional Pain Syndrome Type-II of the Upper Extremity: A Case Report of One Patient’s Experience after Traumatic Hand Injury

Background: Complex Regional Pain Syndrome (CRPS) is a neuropathic pain syndrome associated with edema, muscle weakness, and hyperhidrosis. It can be precipitated by fracture, surgery, and spinal cord injury and usually involves the ipsilateral and sometimes contralateral extremity. Case Details: A 47-year-old male with CRPS Type-II involving the upper extremity had severe neuropathic pain that was limiting his ADLs despite medical, physical and occupational therapy. This case discusses the use of stellate ganglion block in the treatment of upper extremity CRPS Type-II. Conclusion: Stellate ganglion blockade is an effective adjuvant therapy in the treatment of CRPS Type-II when conservative therapy has failed to provide improvement in pain, highlighting a need for a multimodal therapeutic strategy. Keywords: Stellate ganglion block; Chronic pain; Complex regional pain syndrome type-II; Bupivacaine