Nasogastric tube intubation of a patient under general anesthesia with an endotracheal tube in place can pose a challenge to the most experienced anesthesiologist. Physiologic and pathologic variations in a patient’s functional anatomy can present further difficulty. While numerous techniques to the difficult nasogastric tube intubation have been described, there is no consensus for a standard approach. Therefore, selecting the most appropriate approach requires a working knowledge of the techniques available, mindful consideration of individual patient and clinical factors, and the operator’s experience and preference. This article reviews the relevant literature regarding various approaches to the difficult nasogastric tube intubation with descriptions of techniques and results from comparative studies if available. Additionally, we present a novel approach using a retrograde technique for the difficult intraoperative nasogastric tube intubation.

BackgroundThe off-label use of recombinant activated factor VII (rFVIIa) for intractable bleeding is associated with a risk of thrombotic events. The objective of this study was to evaluate the incidence and predictors of rFVIIa-related thrombotic events and its efficacy in the reduction of transfusion requirements during various surgeries.MethodsNinety-two cases received rFVIIa for uncontrollable bleeding despite medical and surgical hemostasis. The incidence and risk factors of thrombotic events were analyzed. Blood products transfused in the 24 h before and after rFVIIa injection were calculated. Subgroup analysis was performed to see which types of surgeries benefited most from rFVIIa.ResultsThe main indication for rFVIIa administration was uncontrollable bleeding during cardiothoracic surgery followed by coagulopathy due to liver failure followed by neurosurgical procedures. Requirements of blood products after rFVIIa decreased significantly by 45 % (p = 0.012), 52 % (p = 0.0001), and 75 % (p = 0.0001) for red blood cells, plasma, and cryoprecipitate, respectively. Subgroup analysis showed that cardiothoracic surgery was the sole group that benefited from rFVIIa with a reduction in transfusion of red blood cells (p = 0.013), plasma (p = 0.0001), and cryoprecipitate (p = 0.0001). Thrombotic events occurred in 9.8 % of the cases mostly on the arterial side (89 %) and have not contributed to mortality.ConclusionrFVIIa can significantly reduce transfusion requirements when given for intractable bleeding during cardiothoracic surgery at the expense of thrombotic events in approximately one tenth of the cases. Further prospective studies are necessary to study if this effect of rFVIIa is translated to a favorable outcome.Electronic supplementary materialThe online version of this article (doi:10.1007/s40268-015-0093-9) contains supplementary material, which is available to authorized users.

In this study, lingual traction was shown to be a valuable maneuver for facilitating fiber-optic bronchoscope-guided intubation in the management of patients with anticipated difficult airways.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

Background: Systemic intraoperative lidocaine has been seen to decrease postoperative pain following abdominal surgery, but few studies have examined its use in morbidly obese patients. Objective: We sought to evaluate the safety and effects of intravenous lidocaine in obese patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) surgery. Methods: Setting: University-affiliated, private hospital, United States. In this preliminary prospective, double-blinded, and placebo-controlled safety study, we enrolled 21 patients and 20 completed the study. Ten patients were randomly assigned to the study group and received a continuous infusion of lidocaine intravenously from induction of general anesthesia until the end of the operation. Ten other patients were assigned to the control group and received a dextrose placebo intravenously over the same time period. Subjects were followed for 24 hours postoperatively. The primary endpoint was the presence of symptoms of lidocaine toxicity at 1 hour postoperatively. Exploratory outcomes were adverse events, visual analog scale (VAS) pain scores, opioid consumption, time to first passage of flatus and bowel movement, and length of hospital stay. Results: No significant differences were seen between groups for overt signs of lidocaine toxicity or adverse events, opioid consumption, postoperative pain scores, time to first passage of flatus or first bowel movement, or length of hospital. We identified a trend towards less opioid consumption in patients receiving lidocaine. We were underpowered to detect statistical differences due to our pilot study design; addressing safety as the primary outcome measure as opposed to efficacy. Conclusions: In this study, intravenous lidocaine in RYGB surgery was found to be safe without differences in postoperative pain or adverse effects.