Providing adequate ventilation may remain complex in patients with severe proximal laryngotracheal stenosis, especially when the airway is shared with the surgeon during tracheal resection surgery. ...We describe an effective alternative to standard endotracheal intubation using a Rüsch flexible intubation guide catheter.
In two patients undergoing tracheal repair surgery, we failed to insert a 5.0 inner diameter endotracheal tube (6.9 mm outer diameter) or a 6.0 mm outer diameter endoscope through the laryngotracheal stenosis. However, using indirect laryngoscopy, a 6.0 outer diameter Rüsch flexible intubation guide catheter was passed successfully through the vocal cords and then through the stenosis. Controlled ventilation was achieved by means of the Rüsch guide, provided with its two large Murphy's eyes. When the trachea was opened, the Rüsch guide was removed just enough for the surgeons to place a Montandon tracheal tube, at that point taking over ventilation. A 7.0 inner diameter endotracheal cuffed tube had been inserted onto the Rüsch guide and left pending upstream from the vocal cords. Once the posterior tracheal wall was sutured, this endotracheal cuffed tube was slid along the Rüsch guide through the vocal cords with the cuff placed beyond the tracheal sutures.
Controlled ventilation through the Rüsch flexible intubation guide catheter showed satisfying and stable ventilatory parameters in both patients. Inspiratory pressures of 25-30 mmHg were enough to reach adequate tidal volumes around 450 ml. End tidal CO
was kept between 35 and 40 mmHg (PaCO
showed similar values). Standard endotracheal intubation at the end of the tracheal resection was easy and safe thanks to the Rüsch guide still in place between the vocal cords.
We suggest an effective and reliable method using a Rüsch flexible intubation guide catheter for airway management in patients suffering from laryngotracheal stenosis in the setting of tracheal repair surgery.
Objectives This study evaluated the prognostic value of postoperative cardiac troponin-I (cTnI) in predicting all-cause mortality up to 3 months after normothermic congenital cardiac surgery. Design ...Prospective observational study. Setting University hospital. Participants All children ages 0 to 10 years. Interventions None. Measurements and Main Results cTnI was measured after the induction of anesthesia but before the surgery, at the pediatric intensive care unit arrival, and at 4, 12, and 24 hours postoperatively. Follow-up was extended up to 6 months. Overall, 169 children were analyzed, of whom 165 were survivors and 4 were nonsurvivors. cTnI levels were significantly higher in nonsurvivors only at 24 hours (p = 0.047). Children undergoing surgery with cardiopulmonary bypass (CPB) had significantly higher cTnI concentrations compared with those without CPB (p<0.001). Logistic regression analysis was performed on the 146 children in the CPB group with the following predictive variables: CPB time, postoperative cTnI concentrations, the presence of a cyanotic malformation, and intramyocardial incision. None of the variables predicted mortality. Postoperative cTnI concentrations did not predict 6 months' mortality. Only cTnI at 24 hours predicted the length of stay in the pediatric intensive care unit. Conclusions This study did not find that postoperative cTnI concentration predicted midterm mortality after normothermic congenital heart surgery. (ClinicalTrials.gov identifier: NCT01616394).
Abstract The existence of opioid-induced hyperalgesia (OIH), ie, nociceptive sensitization, caused by exposure to opioids remains difficult to appraise in perioperative setting because objective ...assessment is rare, evidence mostly relying on subjective measures like pain scores and postoperative analgesics use. Basic diagnostic criteria of OIH are still needed. Experimental studies have highlighted the pronociceptive effects of intraoperative high doses of opioids in term of latent hypersensitivity and long-term vulnerability to pain. The real question in daily clinical practice is then whether OIH prevention matters and which patients might be concerned. Until recently, OIH has been associated to intraoperative administration of high doses of opioids, mainly remifentanil, which increases acute postoperative pain and perhaps might cause the persistence of postsurgical pain. Recently, the existence of preoperative OIH has been demonstrated in chronic pain patients under chronic opioids intake and its exacerbation by the administration of intraoperative opioids has been suggested. Finally, the effect of long-term postoperative opioids intake on pain persistence after surgery or trauma certainly deserves to be questioned. Thereby, the prevention of perioperative OIH should extend up to several weeks after surgery and should include chronic postsurgical pain. The later point argues for the development of dedicated chronic postsurgical pain services.
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