Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao
Awake flexible intubation is the gold standard for difficult airway management but failures have been reported in up to 13% of cases. A novel technique called 'awake fibrecapnic intubation', developed in the Netherlands, is described here for the intubation of patients with head and neck cancer who have a difficult airway. After topical anaesthesia is administered, a flexible fibrescope is introduced into the pharynx. A special suction catheter is then advanced through the suction channel of this scope and then into the airway for the recording of carbon dioxide measurements. The catheter may also be used for oxygenation during the procedure. Spontaneous respiration is maintained in all patients. When four capnograms have been obtained, the flexible scope is railroaded over the catheter and after identification of tracheal rings or carina, the tracheal tube is placed. This new intubation technique is easier to learn than awake flexible intubation.
Differentiation between viable myocardium and scar tissue in segments with abnormal contraction has important consequences in the clinical management of patients with coronary artery disease. Positron emission tomography (PET) can identify viable tissue using 18F-fluorodeoxyglucose (FDG). However, application of PET for daily routine is limited. In this study, FDG uptake was visualized with single photon emission computed tomography (SPECT) and compared with regional perfusion assessed with thallium-201 (201Tl) SPECT. The scintigraphic findings were related to regional wall motion determined with two-dimensional echocardiography. Patients (n = 9) with wall motion abnormalities underwent FDG SPECT and resting 201Tl SPECT. To control the metabolic status patients were studied with a hyperinsulinaemic euglycemic clamp during FDG SPECT. Analysis of reconstructed data was performed visually and semiquantitatively using circumferential profiles. High-quality images were obtained. Eight 201Tl defects showed concordantly decreased FDG uptake (metabolism-perfusion matches) indicating scarred tissue, whereas six regions of hypoperfusion demonstrated a relatively increased FDG uptake (mismatches), suggesting viable myocardium. Semiquantitative analysis confirmed visual findings. Mean 201Tl and FDG activities were not significantly different in matching defects. In mismatches the mean FDG activity was 81 +/- 11% vs 64 +/- 9% mean 201Tl activity (P < 0.0001). In four of six segments with increased FDG uptake, two-dimensional echo revealed hypokinesia. Seven of eight regions with a matching defect in contrast were akinetic. Thus, in the areas with a mismatch contractility was preserved. We conclude that FDG uptake can be visualized with SPECT. Furthermore, our preliminary observations suggest that this approach can identify viable tissue.
We would like to thank our colleagues Howie and Urquhart for their valuable comments. Since we published our study, we have used a similar protocol. When high dose rocuronium is used for rapid sequence induction at our centre, we have the sugammadex ampoules ready for use in theatre and we calculate exactly the required dose for complete reversal of the rocuronium. We would again like to warn against a false feeling of security, when the medication is stored in a central store. As we clearly demonstrated with our simulation study, time and personnel are both lost when collecting emergency medication that is not directly available in theatre. All available medical personnel are needed at the bedside to help maintain oxygenation in a ‘cannot intubate, cannot ventilate situation’. Even in times of financial difficulties, managers should understand that patient safety comes first! No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.
To the Editor The results of the recent study by Gaitini et al.1 describing a nearly 100% success rate for a novel intubation technique with a VivaSight Single Lumen™ (SL; ETView Ltd, Misgav, Israel) tube and a Fastrach Laryngeal Mask Airway™ (FT-LMA; LMA North America, Inc., San Diego, CA), while impressive, was limited by the fact that, as admitted by the authors, only patients with normal airways were studied. We recently described a similar intubation method2 and believe that compared with other supraglottic airway devices (SADs) there are several drawbacks in using the FT-LMA. First, in contrast to other SADs, the rigid FT-LMA has a very sharp curve. To narrow the angle with which the VivaSight-SL exits the FT-LMA and hence to improve intubation success rate, the reversed curve technique, as previously described by Ye et al.,3 should be applied. Therefore, images are displayed upside down on the monitor. This obviously can impede anatomic orientation, which seems particularly undesirable in situations where conventional airway management has already failed. Second, the FT-LMA’s epiglottic elevating bar blocks the view on the glottis when the VivaSight-SL is advanced through it. Because of the epiglottic elevating bar, fiberoptic views through the FT-LMA are considered poorer compared with views through other SADs.4 Finally, we wonder whether the authors didn’t encounter any problems passing the VivaSight-SL’s mini universal serial bus connector through the FT-LMA. In a pilot study comparing different SADs as intubation conduits for the VivaSight-SL, we found this connector hardly fitted the FT-LMA’s internal diameter (Fig. 1, A and B). Occasionally we had to cut the video cable to remove the FT-LMA once the airway was secured.Figure 1: A, The VivaSight Single Lumen’s mini universal serial bus (USB) connector does not properly fit through the Fastrach Laryngeal Mask Airway (FT-LMA). B, Detail of the mini USB connector and the FT-LMA.Erik Michiel Koopman, MD Bastiaan van den Berg, MD Axel Schauer, MD, Dr Med Johannes Huitink, MD, PhD Department of Anesthesiology VU University Medical Center Amsterdam, The Netherlands [email protected]
In Brief Gene expression is increasingly used for diagnostic, prognostic, and therapeutic purposes in clinical practice. We tested the hypothesis that volatile anesthetics (VA) affect gene expression of tumor cells. Cells from the neuronal cell line SH-SY5Y and from the breast cell line MCF-7 were exposed ex vivo to enflurane, isoflurane, desflurane, halothane, sevoflurane, or nitrous oxide. Microarray gene expression profiles were studied. We observed significant differences in gene expression levels of cell cultures and response in time when exposed to different VA. Some genes used for predictive genetic fingerprints for breast cancer were affected by VA. Our findings suggest that VA modulate gene expression in breast and brain tumor cell cultures in a unique and time-dependent manner. Published ahead of print October 1, 2010
