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The novel coronavirus disease 2019 (COVID-19) pandemic presents unique challenges for surgical management of laryngotracheal stenosis. High viral concentrations in the upper aerodigestive tract, the ability of the virus to be transmitted by asymptomatic carriers and through aerosols, and the need for open airway access during laryngotracheal surgery create a high-risk situation for airway surgeons, anesthesiologists, and operating room personnel. While some surgical cases of laryngotracheal stenosis may be deferred, patients with significant airway obstruction or progressing symptoms often require urgent surgical intervention. We present best practices from our institutional experience for surgical management of laryngotracheal stenosis during this pandemic, including preoperative triage, intraoperative airway management, and personal protective measures.

Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures.After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4-17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves.Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55-0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67-0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82-0.87]).Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness.

Although rare, cannot intubate and cannot oxygenate situations are challenging acute events. The development of management algorithms, standardized equipment provisions, and appropriate clinical training in the application of front-of-neck access techniques are necessary to optimize procedural success to ensure adequate oxygenation. The OxyTain algorithm is an institutionally developed protocol to manage cannot intubate and cannot oxygenate events. With proper implementation, this unique process aligning the cannula cricothyroidotomy and scalpel bougie as primary and secondary techniques, respectively, can potentially optimize procedural success. This algorithmic approach is trained routinely among our anesthesia providers, while the equipment is standardized throughout our anesthetizing locations.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Purpose: As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to the anesthesia and surgical teams that require careful consideration to ensure optimal patient care. Airway management and other head and neck procedures risk exposure to mucosal surfaces, secretions, droplets, and aerosols that may harbor the SARS-CoV-2 virus. This review provides guidance on optimal practice approaches for performing patient evaluation and management of head and neck procedures with the shared goal of providing safe and effective patient care while minimizing the risk of viral transmission. Methods: The scientific literature was evaluated, focusing on strategies to reduce risk to health care workers involved in airway management and head and neck surgery. The search strategy involved curating consensus statements and guidelines relating to COVID-19 or prior coronavirus outbreaks in relation to aerosol-generating procedures (AGPs) and other high-risk procedures, with the search restricted to the scope of head and neck anesthesia. A multidisciplinary team analyzed the findings, using iterative virtual communications through video conference, telephone, email, and shared online documents until consensus was achieved, loosely adapted from the Delphi technique. Items without consensus were so indicated or removed from the manuscript. Results: Health care worker infection and deaths during the COVID-19 pandemic and prior outbreaks mandate robust standards for infection control. Most head and neck anesthesiology procedures generate aerosols, and algorithms may be modified to mitigate risks. Examples include preoxygenation before induction of anesthesia, rapid sequence induction, closing circuits expeditiously, and consideration of apneic technique for surgical entry of airway. Rescue measures are also modified, with supraglottic airways elevated in the difficult airway algorithm to minimize the need for bag mask ventilation. Personal protective equipment for AGPs include fit-tested N95 mask (or purified air positive respirator), gloves, goggles, and gown for patients with known or suspected COVID-19. Meticulous donning and doffing technique, minimizing personnel and room traffic, diligent hand hygiene, and social distancing all can decrease risks. Perioperative management approaches may differ from commonly employed patterns including avoidance of techniques such as jet ventilation, high-flow nasal oxygen and instead utilizing techniques with a closed ventilatory circuit and secured endotracheal tube, minimizing open suctioning, and preventing aerosolization at emergence. Recommendations are made for the following head and neck procedures and considerations: primary airway management; high-flow nasal oxygen delivery; jet ventilation for laryngotracheal surgery; awake intubation; transnasal skull base surgery; tracheostomy; and use of personal protective equipment. COVID-19 testing may facilitate decision making, but it is currently often unavailable and urgency of surgical treatment must be considered. Conclusions: During pandemics, head and neck anesthesia and surgical teams have a duty to not only provide high quality patient care but also to ensure the safety of the health care team. Several specific perioperative approaches are recommended that have some variance from commonly employed practices, focusing on the reduction of AGP to minimize the risk of infection from patients with known or suspected COVID-19 infection.

Objective The objective of this study was to develop a child-friendly biofeedback mediated relaxation device called “BrightHearts”. Methods Qualitative data were collected at a tertiary pediatric hospital to inform an iterative design process. Clinicians participated in expert group interviews to identify practical considerations which would facilitate the use of BrightHearts during procedures and provide feedback on prototype designs. Children aged 7-18 years participated in interactive exhibitions of the prototypes and were interviewed about their experience using BrightHearts. Results Twenty-four clinicians participated in 6 group interviews. Thirty-nine children participated in interactive exhibitions and 21 were interviewed. Clinicians placed high value on the following factors in the management of procedural pain: providing children with an element of control, the use of relaxation techniques, the use of portable electronic devices such as iPads (Apple Inc Cupertino CA). They highlighted the need for BrightHearts to be cost effective, portable and capable of engaging childrens’ interest. They confirmed the utility of developing a biofeedback assisted relaxation device for children. Based on the factors identified by clinicians BrightHearts was developed as an iPad app paired with a wireless heart rate monitor. The BrightHearts heart rate biofeedback application displays a digital geometric artwork which responds to changes in heart rate. Children aged 7 to 17 years understood the concept of biofeedback and operate the app by slowing their heart rate. Conclusion The BrightHearts app can be used to teach children biofeedback assisted relaxation. Ongoing studies are evaluating its efficacy for the management of procedural pain in children. This article is protected by copyright. All rights reserved.