The most frequent causes of airway obstruction during the use of laryngeal mask airway (LMA) devices are related to a superficial plane of anesthesia or misposition. However, uncommon causes must also be considered. This case report presents a patient scheduled for elective surgery, encountering unexpected difficulties during airway management due to a previously undiagnosed giant vocal cord polyp. The steps for managing a difficult airway were followed correctly finally leading to awakening the patient to prevent a potentially dangerous “can’t intubate, can’t ventilate” scenario.This case emphasizes the importance of thorough preoperative airway assessment, early recognition of airway difficulties and the strategic use of awake intubation techniques in complex airway management situations.

Skeletal dysplasias and short stature are a heterogeneous group of pathologies in which achondroplasia is the most common presentation. The presence of bone deformities leads to thoracic and airway changes that can complicate ventilation and airway management. Most individuals with skeletal dysplasia present spinal abnormalities that increase the difficulty of administering neuraxial anaesthesia. In pregnant patients, physiological and anatomical changes further complicate obstetric and anaesthesia management.We report the case of a patient with skeletal dysplasia and short stature who was admitted to our hospital in week 34.3 of her pregnancy due to labour and respiratory difficulties. It was decided to perform an emergency caesarean section due to the disproportionate size of the foetal head with respect to the pelvis. We also review the different anaesthesia techniques described in the literature, and discuss their potential advantages and difficulties.

Las displasias esqueléticas con talla baja representan un grupo heterogéneo de afecciones, siendo la acondroplasia la más frecuente. La presencia de deformidades óseas determina alteraciones torácicas y de vía aérea que pueden dificultar su abordaje y ventilación. Asimismo, la mayoría presentan alteraciones vertebrales que dificultan las técnicas neuroaxiales. En el caso de la paciente embarazada, se suman alteraciones fisiológicas y anatómicas que pueden complicar aún más el manejo obstétrico y anestésico.Se presenta el caso de una gestante de 34,3 semanas con displasia esquelética y talla baja que ingresa en nuestro hospital por trabajo de parto y alteraciones respiratorias, decidiendo finalización mediante cesárea urgente ante la desproporción entre el tamaño pelviano y la cabeza fetal. Se realiza, además, una revisión de las diferentes técnicas anestésicas descritas en la literatura, con sus potenciales ventajas y dificultades asociadas.

La Sección de Vía Aérea de la Sociedad Catalana de Anestesiología, Reanimación y Terapéutica del Dolor (SCARTD) presenta la actualización de las recomendaciones para la evaluación y manejo de la vía aérea difícil con el fin de incorporar los avances técnicos y los cambios observados en la práctica clínica desde la publicación de la primera edición en 2008.

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its Latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines. (C) 2019 Published by Elsevier Espana, S.L.U. on behalf of Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor.

BACKGROUND:In the POISE-2 (PeriOperative ISchemic Evaluation 2) trial, perioperative aspirin did not reduce cardiovascular events, but increased major bleeding. There remains uncertainty regarding the effect of perioperative aspirin in patients undergoing vascular surgery. The aim of this substudy was to determine whether there is a subgroup effect of initiating or continuing aspirin in patients undergoing vascular surgery.METHODS:POISE-2 was a blinded, randomized trial of patients having non-cardiac surgery. Patients were assigned to perioperative aspirin or placebo. The primary outcome was a composite of death or myocardial infarction at 30 days. Secondary outcomes included: vascular occlusive complications (a composite of amputation and peripheral arterial thrombosis) and major or life-threatening bleeding.RESULTS:Of 10 010 patients in POISE-2, 603 underwent vascular surgery, 319 in the continuation and 284 in the initiation stratum. Some 272 patients had vascular surgery for occlusive disease and 265 had aneurysm surgery. The primary outcome occurred in 13·7 per cent of patients having aneurysm repair allocated to aspirin and 9·0 per cent who had placebo (hazard ratio (HR) 1·48, 95 per cent c.i. 0·71 to 3·09). Among patients who had surgery for occlusive vascular disease, 15·8 per cent allocated to aspirin and 13·6 per cent on placebo had the primary outcome (HR 1·16, 0·62 to 2·17). There was no interaction with the primary outcome for type of surgery (P = 0·294) or aspirin stratum (P = 0·623). There was no interaction for vascular occlusive complications (P = 0·413) or bleeding (P = 0·900) for vascular compared with non-vascular surgery.CONCLUSION:This study suggests that the overall POISE-2 results apply to vascular surgery. Perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications. Registration number: NCT01082874 ( http://www.clinicaltrials.gov).

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Intensive Care Medicine

OBJECTIVES:Von Frey monofilaments (VFM) and Electronic von Frey are used as quantitative sensory testing to explore mechanical hyperalgesia. The aim of the study was to determine VFM and Electronic von Frey reproducibility and the time required for testing undamaged areas in volunteers and surgical in-hospital patients. METHODS:Prospective study in 2 groups of individuals without neurological disorders and not receiving treatments that alter sensorial response. Group 1 was formed by 30 healthy volunteers and group 2 by 28 patients after knee arthroplasty who received unilateral femoral block as postoperative analgesia. Testing was performed by 2 trained investigators in the forearm and abdominal wall and repeated 24 hours later. Pain threshold was determined as the VMF or the pressure rate applied with the Electronic von Frey referred to as unpleasant. The time used in each test was measured. Intraobserver and interobserver reproducibility were analyzed by means of Kappa and Lin coefficients. RESULTS:Intraobserver and interobserver reproducibility for VFM was only fair or moderate in both groups (Kappa<0.6). Intraobserver reproducibility for Electronic von Frey was good in Group 1 (Lin 0.61 to 0.8) and almost perfect in Group 2 (Lin>0.8). No differences were found between the 2 tested areas. Time used was 6.03 and 3.16 minutes for VFM and Electronic von Frey, respectively. DISCUSSION:Exploration of mechanical allodynia in postoperative patients requires rapid and reliable quantitative sensory testing. Electronic von Frey was more reliable and rapid than VFM in exploring mechanical pain thresholds in undamaged areas in volunteers and patients. Further studies are required to confirm whether these results can be extrapolated to areas affected by surgery.

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Intensive Care Medicine

This study sought to examine ketamine exposures reported to US poison centers over the past 16 years and identify trends in exposures and outcomes.A retrospective review was performed of all cases involving ketamine exposures reported to US poison centers and entered into the National Poison Data System from 2000 to 2015. Cases were divided into those involving ketamine alone and those involving ketamine and other agents. Data collected included: age, sex, form of ketamine used, reason for exposure, and outcome.A total of 3109 cases were evaluated. 1595 (51%) reported ketamine to be the only substance exposure, while 1514 (49%) involved multiple substances with ketamine. For single agent exposures, more involved males (67%) between the ages of 16–25 years (49%). Single agent ketamine exposures peaked between 2000 and 2002, fell consistently until 2008; then rebounded to previous peak levels through 2015. Intentional exposures (65% of all cases) were the most common reason for single agent ketamine exposures. 53% of ketamine-only cases resulted in minor effects, with two deaths. In contrast, ketamine exposures with multiple agents resulted in outcomes judged as moderate or worse in 62% of cases, including 20 deaths.Single-agent ketamine exposures reported to US poison centers have rebounded to historical peaks in recent years. More deaths and serious outcomes were reported in ketamine exposures involving multiple substances.