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Three patients underwent laryngeal and tracheal surgeries under apneic conditions using transnasal humidified rapid-insufflation ventilatory exchange. Transcutaneous carbon dioxide (CO2) levels were recorded throughout the apneic period to detect rates of CO2 rise. Conventional airway management was initiated after 15 minutes of apnea with either tracheal intubation or jet ventilation. No patient experienced oxygen desaturation <97%. The average rate of transcutaneous CO2 rise (1.7 mm Hg/min) was higher than previously reported using this technique. This suggests a need for further investigation into the utility of transnasal humidified rapid-insufflation ventilatory exchange for airway surgery and adequate ventilation during apnea.

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Background: This study compared the Macintosh blade direct laryngoscope, Glidescope, C-Mac d-Blade, and McGrath MAC X-blade video laryngoscopes in 2 cadaveric models with severe cervical spinal instability. We hypothesized that the Glidescope video laryngoscope would allow for intubation with the least amount of cervical spine movement. Our secondary endpoints were glottic visualization and intubation success. Methods: In total, 2 fresh cadavers underwent maximal surgical destabilization from the craniocervical junction to the cervicothoracic junction by a neurosurgical spine specialist, with subsequent neutral positioning of the heads with surgical head fixation devices. On each cadaver, 8 experienced anesthesiologists performed four intubations with the 4 laryngoscopes in random order. Lateral radiographic measurements determined vertebral displacement during intubation. Results: Cervical spine displacements were not significantly different amongst video laryngoscopes. Cormack-Lehane Grade 1 views were achieved with all attempts with each of the 3 video laryngoscopes; intubation attempts with the Macintosh blade achieved only grade 3 or grade 4 views. Intubation was successful every time with a video laryngoscope but only during 1 of 16 intubation attempts with the Macintosh blade. Conclusions: In a cadaveric model with maximally destabilized cervical spines, cervical spine movement was observed during attempted laryngoscopy using each of 3 video laryngoscopes, although there was no significant difference between the laryngoscopes. Given cervical spine displacement occurred, these video laryngoscopes do not prevent cervical spine motion during laryngoscopy. However, with improved glottic visualization and intubation success, video laryngoscopes are superior to the Macintosh blade in both cervical spine safety and intubation efficacy in the model studied.

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Postpartum hemorrhage is a leading cause of maternal and fetal mortality. Although rare, peripartum splenic rupture (PSR) is a lethal cause of bleeding due to variable presentation and delayed diagnosis. A 22-year-old gravida 2, para 0, abortus 1 (G2P0A1) woman presented for premature rupture of membranes and was diagnosed with Influenza A and chorioamnionitis. She underwent emergent cesarean delivery under general anesthesia. Postoperatively, her condition worsened despite treatment for presumed sepsis. She was taken to the operating room for an exploratory laparotomy, and a splenectomy was performed for splenic rupture. We discuss management, risk factors, challenges, and importance of prompt treatment of PSR.

Increasing numbers of patients have impalpable and aberrant laryngeal anatomy (obesity pandemic and improved postsurgical survival are two causes). In the event of a can't intubate can't oxygenate scenario, the Difficult Airway Society (DAS) advises 'blunt dissection with fingers' to identify the impalpable larynx for front of neck access (FONA), and also that every patient should have an airway assessment including for FONA as part of preoperative planning. 1 Importantly, blunt dissection is not typically part of anaesthetists' skill set, with it not being routinely included in any training or simulation. This is in stark contrast to sonography, and airway anatomy can be seen and marked by rapid bedside assessment. With the evolution in safety standards over recent years, it is also important to remember that inadequate preparation may be considered indefensible and historical techniques (e.g. landmark central line insertion) have become more unacceptable. Improving anaesthetist familiarity with airway ultrasound (US) offers a noninvasive solution, as pre-emptive scanning mitigates the need for blunt dissection in the event of emergency FONA.A pilot of a novel teaching programme was conducted. Eight anaesthetic registrars with no prior airway US experience, and two volunteers (one male, one female) were recruited. The volunteers were obese, but with palpable cricoids. The volunteers were examined before the session. Consent was obtained, but ethical approval was deemed not necessary.Pre-course material comprising approximately 5 min reading was issued; completion was confirmed on arrival. A 10-min training session was conducted against a mastery learning checklist using one of the authors as the training model. This included identifying and marking the level of the cricothyroid membrane and the midline. Participants then used US on one volunteer and palpation on the other in order to place a circular 4 mm diameter dot on where the cricothyroid membrane was thought to be. An assessment was made of speed (s), accuracy (mm), and self-rated confidence (0e10) for each attempt. The order of volunteer and technique were randomised, and each participant had not previously examined either volunteer.Identification by palpation was associated with substantially more inaccuracy (8.5 mm vs 0.5 [0e25 vs 0e5] (median [range]). The US method took an average of an additional 42 s, but interestingly gave lower confidence scores (5.5 vs 6.1 [2e7 vs 3e9]). Overall, 75% of participants stated they will change their practice as a result of this pilot, and all participants indicated that they would welcome regular airway sonoanatomy refreshers.This work highlights the current lethal combination of overconfidence and inaccuracy of landmark cricothyroidotomy. This work demonstrates the feasibility of a novel teaching as a short low-cost intervention. The additional time (42 s) taken in airway assessment at the planning stage of an airway strategy to improve the accuracy of incision is a worthwhile investment. The principles of DAS air...