SummaryThe Pentax-AWS Ò airway scope system is a rigid indirect video laryngoscope with integrated tube guidance. Laryngoscopy and intubation are visualised using a built in LCD monitor which displays the view obtained by a CCD camera mounted in the tip of the laryngoscope. We describe its clinical performance in 320 patients. The Pentax-AWS significantly improved the laryngeal view compared to the Macintosh laryngoscope. Forty-six patients (14%) who were classified as Cormack Lehane glottic view grade 3 or 4 using the Macintosh laryngoscope were classified as grade 1 (45 cases) or 2a (1 case) using the Pentax-AWS airway scope. Laryngeal views measured by percentage of glottic opening score were improved significantly using the Pentax-AWS. Intubation using the Pentax-AWS was successful in all cases, 96% at the first and 4% at the second attempt. The mean (SD) time required to place the tracheal tube was 20 (10) s. The Cormack Lehane grade obtained with the Macintosh blade did not affect the total time to correctly position the tube using the Pentax-AWS. Intubation difficulty scale (score = 0 in 305 patients, score = 1 in 14 and score = 2 in one patient) indicates that tracheal intubation was performed easily in most cases. The Pentax-AWS not only improves the laryngeal view, but its tube guide also facilitates rapid, easy and reliable tracheal intubation under vision. It can be useful in routine anesthesia care and may be advantageous in the situation of unanticipated difficult intubation.

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Patient: Male, 60Final Diagnosis: Hepatocellular carcinomaSymptoms: NoneMedication: —Clinical Procedure: HepatectomySpecialty: SurgeryObjective:Unusual clinical courseBackground:Carbon dioxide (CO2) is believed to be the safest gas for laparoscopic surgery, which is a standard procedure. We experienced severe cerebral infarction caused by paradoxical CO2 embolism during laparoscopic liver resection with injury of the hepatic vessels despite the absence of a right-to-left systemic shunt.Case Report:A 60-year-old man was diagnosed with hepatocellular carcinoma in the right hepatic lobe secondary to alcoholic liver disease. We planned the laparoscopy-assisted liver resection. During the surgery, the root of the right hepatic vein was injured. A 1.5-cm hole was accidentally made in the right hepatic vein, while mobilizing the right hepatic lobe laparoscopically. End-tidal CO2 dropped from 39 to 15.5 mmHg, and systemic blood pressure dropped from 121 to 45 mmHg, returning to normal with the administration of inotropes. The transesophageal echocardiography revealed numerous bubbles in the left atrium and ventricle. The Bispectral Index monitoring system showed low brain activity, suggesting cerebral infarction due to paradoxical gas embolism. The hepatectomy was completed by conversion to open laparotomy. The patient went into a coma and suffered quadriplegia after surgery, despite the cooling of his head and the administration of Thiamylal. Brain MRI revealed cerebral infarction in the broad area of the cerebral cortex right side predominantly, with poor blood flow confirmed by the brain perfusion single-photon emission CT. Rehabilitation was gradually achieved with Botox injections.Conclusions:Cerebral infarction by paradoxical gas embolism is a rare complication in laparoscopic surgery, but it is important to be aware of the risk and to be prepared to treat it.

Sugammadex, a modified gamma-cyclodextrin, has changed clinical practice of neuromuscular reversal dramatically. With the introduction of this selective relaxant binding agent, rapid and reliable neuromuscular reversal from any depth of block became possible. Sugammadex can reverse neuromuscular blockade without the muscarinic side effects typically associated with the administration of acetylcholinesterase inhibitors. However, what remained unchanged is the incidence of residual neuromuscular blockade. It is known that sugammadex cannot always prevent its occurrence, if appropriate dosing is not chosen based on the level of neuromuscular paralysis prior to administration determined by objective neuromuscular monitoring. Alternatively, excessive doses of sugammadex administered in an attempt to ensure full and sustained reversal may affect the effectiveness of rocuronium in case of immediate reoperation or reintubation. In such emergent scenarios that require onset of rapid and reliable neuromuscular blockade, the summary of product characteristics (package insert) recommends using benzylisoquinolinium neuromuscular blocking agents or a depolarizing agent. However, if rapid intubation is required, succinylcholine has a significant number of side effects, and benzylisoquinolinium agents may not have the rapid onset required. Therefore, prior administration of sugammadex introduces a new set of potential problems that require new solutions. This novel reversal agent thus presents new challenges and anesthesiologists must familiarize themselves with specific issues with its use (e.g., bleeding risk, hypermagnesemia, hypothermia). This review will address sugammadex administration in such special clinical situations.

Background: There is a possibility that physiological changes in respiratory mechanics

To the editor: Both the Airway Scope (Pentax-AWS system; AWS; Pentax, Tokyo, Japan) and the Airtraq (ATQ; Prodol Meditec, Vizcaya, Spain) are anatomically shaped new intubation devices which provide an indirect view of the glottis without requiring the laryngoscopist's line of sight [1][2][3]. They both have a tube channel in the right side of the blade which holds the endotracheal tube (ETT) and directs it towards the vocal cords. Japan is the fi rst country to have obtained approval for the clinical use of both these devices, and we have noticed that many anesthesiologists confuse the AWS with ATQ.Although the two devices have very similar blade confi gurations, the tip positions for elevating the epiglottis are different. According to the manufacturer's manual, the AWS tip position should be inserted posterior to the epiglottis, directly elevating it out of the way (Miller-type approach), whereas it is recommended that the ATQ tip be placed in the vallecula for indirect lifting of the epiglottis (Macintosh-type approach). For the ATQ, the Miller-type approach is also possible as an alternative. But for the AWS, there is no description of an alternative (Macintosh-type) approach.These different approaches indicate that the routes that the blade passes through are different for each device. The AWS tip should be pass through a posterior route, in that the blade is inserted along the palate and posterior pharyngeal wall to facilitate passage behind the epiglottis, with the insertion being similar to that of a laryngeal mask airway. On the other hand, the recommended ATQ approach uses an anterior route, in that the blade tip glides on the tongue surface to the base of the tongue and is to be inserted into the vallecula.We performed intubation with both devices, using two different approaches with each device. After the obtaining of institutional ethical committee approval, 15 anesthesiologists performed intubation on a manikin intubation trainer (Airsim Multi; TruCorp, Belfast, UK). Intubation with the recommended technique for each device was successful in all attempts. However, AWS intubation using a Macintosh-type approach failed in 12 of 15 attempts due to ETT impingement onto the epiglottis, whereas ATQ intubation using the Millertype approach was successful in 15 of 15 attempts including 3 in which ETT impingement onto the arytenoid occurred, and Fig. 1. Difference between the Pentax Airway Scope (AWS) and the Airtraq (Prodol Meditec) (ATQ). Two blades holding the endotracheal tube (ETT) in the channel are shown. The TT advanced from the AWS blade (upper panel) seems to go upward, so there is no space between the ETT and the blade tip, resulting in frequent impingement onto the epiglottis when using the Macintosh-type (Mac) approach for intubation. Therefore, only the Miller-type (Mil) approach should be used for ATQ intubation. The ETT advanced from the ATQ blade (lower panel) seems to go downward, so there is a space between the ETT and the tip (white arrow), which contributes to successful ETT placement d...

We used target-controlled infusion (TCI) of dexmedetomidine (DEX) for awake intubation under sedation in 5 patients who had a risk of pulmonary aspiration or difficult airway. Dexmedetomidine level was escalated stepwise until the patients developed tolerance to laryngoscopy. The target DEX concentrations at the time of intubation were 2.10-5.95 ng/ml and were higher than those clinically used for sedation in the intensive care unit (ICU). Chin lift was applied in 1 case, and therefore no assisted ventilation was required and pulse oxygen saturation was maintained at >98% throughout the procedure. Simple pharmacological interventions for blood pressure changes induced by increased target plasma DEX concentrations were needed in 4 cases. However, hemodynamics was stable, and no cardiovascular drug was needed after tracheal intubation. Conditions at laryngoscopy were excellent in all cases, and conditions at tracheal intubation were good except in 1 case. Reflex to intubation was preserved in all cases, and coughing was observed in all cases. The patients had no memory of discomfort and/or intubation. Although further investigations are needed, this method may be useful for awake intubation under sedation.