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Background & Objective: Regional anesthesia (RA) blocks are most commonly performed in large academic hospitals and has been shown to reduce postoperative pain. The lack of RA blocks in rural hospitals leaves a large subset of the population without availability of this service. In North Carolina, there is an increased need for these services in small community hospitals. This study examined RA nerve block success rates for total knee, hip, and shoulder arthroplasty procedures. We hypothesized that through proper mentorship, general anesthesiologists could provide safe and efficacious RA blocks at a small, community hospital. Methodology: An Institutional Review Board (IRB) approved retrospective study was performed at Lexington Medical Center (LMC), in Lexington, North Carolina part of Wake Forest Baptist Health. We analyzed 307 patients who underwent total joint arthroplasty (195 knee, 69 hip and 43 shoulder replacements) at LMC. Demographics, type of blocks, block success, and intraoperative analgesics used were also recorded. VAS was used to assess postoperative pain. Results: We found an overall success rate of 96.3% for all joints; 95.2%-femoral or 98.9%-adductor canal, 90.4%-lumbar plexus, 100%-interscalene block for knee, hip and shoulder arthroplasties respectively. 283/307 (92.2%) patients reported a verbal pain score between 0-2 in the PACU. There was a significantly higher mean fentanyl dose/h in patients that did not receive a lumbar plexus block for hip procedures. Conclusion: The results of our study support that general anesthesiologists can provide rural communities with quality, specialized regional anesthesia care safely, and at an equivalent level to that of anesthesiologists specialized in RA blocks at large academic institutions. [ABSTRACT FROM AUTHOR]

Objective: The primary aim of our study was to develop an alternative airway exam to calculate the size and shape of the tongue, the unoccupied area of the oral cavity, and the ratio of unoccupied area to the entire oral cavity in patients with thyroid disease. A secondary aim was to compare the ratio of unoccupied area of the oral cavity to the Mallampati classification. Methodology: An IRB-approved prospective observational study was performed at Wake Forest Baptist Health in patients undergoing thyroid/parathyroid surgery who were 18 and older, and had an anticipated difficult airway indicated either by the physical exam, previous history, or planned use of a specialized airway device. Awake intubations or tracheostomies were excluded. Demographic data were collected including the airway exam (Mallampati classification, oral aperture, thyromental distance, neck range of motion) and a picture of the oral cavity with the tongue protruding was captured. Digital imaging analysis was performed with ImageJ to measure the area of the tongue, the unoccupied area of the oral cavity, and the entire oral cavity area. The ratio of unoccupied area to the entire oral cavity was calculated and correlated to the Mallampati classification. Results: Eleven patients undergoing thyroid surgery were included in analysis. There was a wide variation in the size and shape of the tongue, leading to different unoccupied areas of the oral cavity and different ratios of unoccupied area to the entire oral cavity area. There was a negative correlation between Mallampati class and the ratio of unoccupied area (r = -0.696). Unoccupied area ratios < 18 were correlated with Mallampati III/IV while that > 36 were correlated with Mallampati I; the distinction between Mallampati I and II was harder to define. Conclusion: We found that the ratio of unoccupied area to that of the entire oral cavity may be classified similarly to the Mallampati class and may quantify the distinction between Mallampatis I and III. The use of digital imaging to measure the size and shape of the tongue and the unoccupied area of the oral cavity may provide a quick and reliable alternative method to predict difficult intubation. [ABSTRACT FROM AUTHOR]

Objective: Current predictive airway tests focus on the tongue, but are subjective in nature and vary largely depending on the clinician performing them. We aimed to develop a method using digital imaging to quantify the size and shape of the tongue and the area left unoccupied in the oral cavity. Our goal was to develop an alternative airway assessment that was precise and objective. Methodology: Photographs were taken by our clinical research team. A total of 9 photographic images were taken and analyzed by 7 members via ImageJ software obtained from the National Institute of Health (NIH) to measure the size and shape of the tongue using an area measurement (in cm2), the area of the teeth, the area of the unoccupied space, the area of the entire oral cavity (minus lips). The ratio of the unoccupied area to the entire oral cavity was calculated by dividing the area of the unoccupied area by the area of the entire oral cavity and multiplying by 100. In addition, intra- and inter-rater reliabilities were also measured to assess the precision of the objective exam. Results: A wide variety of sizes and shapes of tongues in the oral cavity was found. The ratio of the unoccupied area to the entire oral cavity ranged from 19.7 to 47.8. We also found a high precision defined by intra- and inter-rater reliability of 1.638×10-4 and 3.347×10-4, respectively. Conclusion: Due to the variation in the sizes and shapes of the tongues, the unoccupied area left in the oral cavity differed among the images analyzed. Therefore, the ratio of the unoccupied area to the entire oral cavity varied extensively. Overall, our alternative method may allow for a more precise, objective airway assessment. [ABSTRACT FROM AUTHOR]

Objective: Pitt-Hopkins Syndrome (PTHS) is characterized by cognitive dysfunction, developmental delays, seizures, and several anatomical abnormalities. These abnormalities may have an impact on airway and anesthetic management. In rare syndromes, many variants exist with potentially different interactions between the children's medications used for treating their condition and anesthetic agents. The study's aim was to develop a survey for the parents of patients with PTHS to determine their perception related to airway and anesthetic management. Further, in order to obtain an in depth point of view on their children's experiences we examined the parents' perspective. Methodology: A survey (paper and web-based) consisting of 31 questions was developed and distributed at the Pitt-Hopkins Research Foundation Scientific Symposium and Family Conference in Dallas, Texas from November 3-5, 2016. The survey questions were developed after an extensive literature review of PTHS supplemented with input from certain families of patients with PTHS. The focus of the survey was to obtain the parents' perception related to airway and anesthetic management and additionally, their perspective of overall care using follow-up telephone calls and interviews to develop narratives. Results: We received 32 survey responses (31 paper and 1 web). Five were not analyzed since the children had not received either sedation or general anesthesia. The parents' perceptions related to airway and anesthetic management were as follows: 22 of 27 (81.4%) patients did not report any complications related to airway management. There were no reported episodes of aspiration even though 23 of 27 (85.2%) patients suffered from GI issues: either upper (reflux), lower (constipation), or both. Sixty-three percent (17/27) of respondents reported poor quality of emergence, while 26% (7/27) described delayed emergence. We found there were many different variants of patients with PTHS regarding their verbal, cognitive, and ambulatory abilities, leading to a wide variety of experiences with anesthetics obtained from parents' interviews and narratives. Conclusion: Our study found a low incidence of problems with airway management in children with Pitt-Hopkins syndrome. Their problems with anesthetic care were specifically related to poor quality of emergence, though the exact etiology was not clear. Their perspective in the form of narratives offered more insight into their fears, frustrations, and expectations for their children's care. We obtained valuable information on their experiences after discharge, which is usually not available on the medical records or hospital documentation charts. [ABSTRACT FROM AUTHOR]

There are many anatomical, physiopathological, and cognitive changes that occur in the elderly that affect different components of airway management: intubation, ventilation, oxygenation, and risk of aspiration. Anatomical changes occur in different areas of the airway from the oral cavity to the larynx. Common changes to the airway include tooth decay, oropharyngeal tumors, and significant decreases in neck range of motion. These changes may make intubation challenging by making it diffcult to visualize the vocal cords and/or place the endotracheal tube. Also, some of these changes, including but not limited to, atrophy of the muscles around the lips and an edentulous mouth, affect bag mask ventilation due to a diffcult face-mask seal. Physiopathologic changes may impact airway management as well. Common pulmonary issues in the elderly (eg, obstructive sleep apnea and COPD) increase the risk of an oxygen desaturation event, while gastrointestinal issues (eg, achalasia and gastroesophageal reflux disease) increase the risk of aspiration. Finally, cognitive changes (eg, dementia) not often seen as related to airway management may affect patient cooperation, especially if an awake intubation is required. Overall, degradation of the airway along with other physiopathologic and cognitive changes makes the elderly population more prone to complications related to airway management. When deciding which airway devices and techniques to use for intubation, the clinician should also consider the difficulty associated with ventilating the patient, the patient's risk of oxygen desaturation, and/or aspiration. For patients who may be diffcult to bag mask ventilate or who have a risk of aspiration, a specialized supralaryngeal device may be preferable over bag mask for ventilation. Patients with tumors or decreased neck range of motion may require a device with more finesse and maneuverability, such as a flexible fiberoptic bronchoscope. Overall, geriatric-focused airway management is necessary to decrease complications in this patient population. [ABSTRACT FROM AUTHOR]

Background & Objective: Pediatric sub-specialty procedures are usually performed in large hospitals by specialists. We aimed to develop a protocol in pediatric patients undergoing bilateral myringotomies (BMT) or tonsillectomies and/or adenoidectomies (T&A) in a rural community hospital. Methodology: An IRB-approved, prospective study was performed at Lexington Medical Center to examine the safety (S), emergence (E), and efficacy (E) (SEE) of an anesthetic protocol in patients under 7 y of age undergoing BMT or T&A. A non-specialist anesthesiology-based team performed the protocol related to SEE. Results: Out of 60 patients enrolled in the study, 4 (6.6%) desaturated (lowest SpO2 87%), and 6 (10%) had poor quality of emergence from anesthesia. The mean times for induction, emergence, and surgery for BMT were 4.8 ± 1.3, 4.2 ± 2.2, and 3.9 ± 1.0 min respectively. The mean times for induction-intubation, emergence-extubation, and surgery for T&A were 9.0 ± 2.9, 12.1 ± 6.8, and 14.6 ± 5.8 min respectively. Conclusion: The development of a clinical research program and study protocol was achieved for pediatric ENT procedures at a rural hospital. We found that Lexington Medical Center had a low incidence of desaturation, good quality of emergence from anesthesia, and efficacy. [ABSTRACT FROM AUTHOR]

Background: Simple endoscopies such as esophagogastroduodenoscopy (EGD) and colonoscopies are common procedures that require the use of sedation or general anesthesia. The risk of airway complications for these procedures depends on the type of medications administered. Wide variation exists in reported rates of airway complications for endoscopic procedures. This retrospective study analyzed airway interventions and desaturations during simple endoscopy procedures performed by anesthesia-based teams (ABT) using propofol in a rural hospital. Methodology: An IRB approved retrospective study was conducted at Wake Forest Baptist Lexington Medical Center (LMC). Patients over age 18 who underwent an EGD, colonoscopy, or both from July to December 2017 were included. Demographics, comorbidities, airway interventions, incidence of desaturation, the mean doses of propofol, and duration of procedures were recorded. Results: Five hundred and thirteen patients underwent simple endoscopies (130 EGD, 320 colonoscopies, and 63 EGD/colonoscopy) at LMC. No patients required rescue intubation. One (0.2%) patient required BMV, three (0.6%) required a nasal airway, and three (0.6%) required an oral airway. 44 patients desaturated; 11 (25%) were severe and 33 (75%) moderate. Conclusion: We found that simple endoscopies performed by ABT had a low rate of airway interventions; however, the incidence of desaturation was higher than reported by other non-anesthesia-based teams and/or when clinicians used propofol for the endoscopies. [ABSTRACT FROM AUTHOR]

Objective: Cornelia de Lange syndrome (CdLS) is characterized by multiple anatomic malformations, which may affect airway and anesthetic management. The study's objective was to collect information from families of CdLS patients regarding their perception of their airway and anesthesia experiences and associated complications. This would allow anesthesiologists to evaluate the families' perspective in order to create a better approach to treating patients. Methodology: A web-based, 24 question survey was solicited via the CdLS Foundation's quarterly newsletter (circulation 4,000) It was followed up, via phone, Skype, and e-mail, with questions targeting intubation, ventilation, oxygenation, aspiration, and complications during surgery and procedures requiring sedation. A paper version of the survey was distributed to families and caregivers of the patients at the 2014 CdLS Foundation National Family Conference. The focus of the survey was to obtain the families'/caregivers' perception related to airway and anesthetic management experiences and perspectives regarding overall clinical care. Results: We received 70 survey responses (52 web, 18 paper). 23 of the CdLS patients were adults, while 47 were pediatric patients. Fifty-one respondents (72.9%) reported difficulty breathing due to anatomical reasons. Compared to adults, pediatric CdLS patients were reported to have more airway complications with a significantly higher incidence of oxygen desaturation (19.2% vs. 0.0%). Cardiac arrest occurred in 12.8% of pediatric CdLS patients. Thirty-one (44.3%) respondents reported complications caused by the anesthetic or analgesic medication. The most commonly reported complication was unfavorable emergence from anesthesia (52.9%). Upon follow up, we found that a large number of parents did not complete responses due to their lack of understanding or awareness. The perspectives from both caregivers and families illustrated the need to develop patient centered approach for patients with CdLS. Conclusion: Our study found that CdLS patients experienced extensive problems during airway and anesthetic management. In addition, certain complications were found more frequently in pediatric patients such as, cardiac arrest and difficult intubation. We found that the families were very involved and knowledgeable about their children's care. However, there was still a lack of awareness in certain areas of airway and anesthetic management. The value of their perspective highlighted the need for a more focused patient centered care for CdLS patients and their families. [ABSTRACT FROM AUTHOR]

Background: Multiple techniques have been described for anesthetizing the lower glottis and trachea prior to awake fiberoptic intubation. The primary aim of this study is to evaluate whether direct application of local anesthetic to the lower airway via an epidural catheter under direct vision is equally efficacious when compared to use of a transtracheal block in adult patients with an anticipated difficult airway., Methods: Patients age >18 years requiring awake fiberoptic intubation who underwent upper and lower airway topicalization were observed prospectively. Following topicalization of the upper airway, patients underwent either a transtracheal block or had their trachea and lower glottis anesthetized under direct vision via dispersion of local anesthetic through a multi-orifice epidural catheter. Choice of technique was at the discretion of the attending anesthesiologist. The primary outcome was defined as the degree of coughing observed at the time of intubation based on a 4-point ordinal scale., Results: Awake intubations in 88 patients were observed with 44 patients undergoing transtracheal block and 44 patients undergoing the epidural catheter technique. Degree of coughing with intubation was similar for each approach with a coughing score of (0, IQR (0,1)) versus (0, IQR (0,1)) in the epidural catheter and transtracheal groups respectively (p = 0.385). Duration of procedure was less in the transtracheal group (1.35 ± 1.54 min) vs. epidural catheter approach (2.86 ± 2.20 min) (p< 0.001)., Conclusion: The epidural catheter and transtracheal approach appear to be equally effective at preventing coughing with intubation during awake fiberoptic intubation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, McCutchen et al.)

Background: Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality., Methods: A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions., Results: Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users., Conclusions: Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2020 International Anesthesia Research Society.)

Background: In-training examinations (ITEs) are commonly used by residency programs to measure competency in their respective fields. It has been demonstrated that success on the ITE is correlated to First Time Pass Rate (FTPR) on the boards. Therefore, it is important to motivate residents to perform well on these exams. Previous studies indicate positive incentivization may contribute to improvement on examinations. The objective of our study was to determine whether introduction of a positive incentive could improve resident performance on the ITE and/or FTPR on the advanced certifying exam., Methods: A positive incentive was introduced in 2017 (certificate of commendation, curriculum vitae honor, public recognition, and $500 in their books/travel allowance) to residents who achieved the target score on the ITE (80th percentile). A survey was then provided to these residents to determine which incentives contributed most to their motivation., Results: Before the incentivization, 21 (15.1%) of the previous 149 senior residents reached the target score on the annual ITE. After incentivization, this improved to 28 (30.9%) of 81 ( P = .0056). The FTPR on the advanced certifying exam was 90% before incentivization and 97.6% after ( P = .14). The survey found that the primary motivators were extra funding, honor on their curriculum vitae, and public recognition., Conclusions: We found that our residents had significant improvements on the annual ITE after the introduction of positive incentives. This incentivization may be easily implemented by program directors in their respective medical residencies to increase examination performance., Competing Interests: Conflicts of interest: The authors have no conflicts or competing interests to disclose., (© 2020 Society for Education in Anesthesia.)