In laparoscopic nephrectomy patients, early post-operative pain is associated with 30-day infectious complications.
Why is this important?
Indications for the use of laryngeal mask airways (LMAs) increasingly challenge our airway choice for surgical procedures where endotracheal intubation has been the norm. Thyroid surgery, with its limited anaesthetic access to the airway and potential for airway obstruction, has not typically been a first choice for LMA use.
Proponents point to avoiding muscle relaxants and reducing throat pain and laryngeal trauma as the main benefits.
What did they do?
Gong and team randomised 138 ASA 1 & 2 adults to either flexible (reinforced) LMA or intubation with an ETT (7.0 or 7.5 mm). Notably any patients with surgical complexity or BMI > 30 kg/m2 were excluded. The study was single-blinded.
The researchers reported the upper 95%-CI for estimated mean difference in peak airway pressure as +0.96 cmH2O, and for endtidal-CO2 +1.99 mmHg – neither of which are clinically significant.
They concluded that flexible-LMA was non-inferior to ETT in terms of PAP and ET-CO2.
The relevance of this study to most thyroid surgical patients is however limited at best. Not only were common groups of patients excluded (ie. BMI > 30) but one of the major arguments for LMA use (avoiding muscle relaxants) was irrelevant: all patients were paralysed with rocuronium.
Further, in 7% of the LMA cases severe air-leak occured and the surgical team were asked to cease or reduce tracheal traction.
Although the journal editors conclude in their Key Points that "FLMA is a safe alternative for experienced anesthesiologists in thyroid surgery" this seems quite a stretch given that this small study was neither powered for safety and only investigated airway ventilation performance as a narrow surrogate for acceptability.
Additionally the authors themselves highlight very real surgical concerns that LMA use can distort pharyngeal anatomy with serious consequences.
Not dissimilar to arguments for LMA use in GA caesarean section, the use of an LMA for thyroid surgery edges toward 'just because we can, does not mean we should'.
Ultrasound-guided peripheral nerve blocks may yield better sensory and motor block, reduce supplementation & minor complications. Use of ultrasound alone is faster than when using with nerve stimulation.
Compared to direct laryngoscopy, videolaryngoscopy is associated with fewer failed intubations, improved glottic view and less trauma, but no consistent improvement in first-pass success, attempts, or respiratory complications.
For non-mastectomy breast surgery the PECS II block is no better than surgical local infiltration.
Using a flexible reinforced laryngeal mask is non-inferior to endotracheal intubation for thyroid surgery when considering only peak airway pressure and end-tidal CO2.
Current evidence is too limited to conclude any significant difference between phenylephrine and noradrenaline for managing CS hypotension due to spinal anaesthesia.
Fascinating introspection from an experienced psychiatrist on the ways the pandemic has subtly (and perhaps not-so-subtly) changed his interactions with patients and his perspective on his role as caregiver.
"...among the many unknown — and potentially positive — outcomes of the pandemic, one may be the more widespread realization that “acting like a doctor” ideally involves less acting and more authenticity."
Automated robotic intubation of the trachea is feasible.
Pre-operative anaemia is associated with increased mortality, prolonged hospital stay and return to theatre in patients having emergency laparotomy.